Secular Trends in Tuberculosis during the Second Epidemiological Transition: A Swiss Perspective

Advances in Anthropology

2013. Vol.3, No.2, 78-90

Published Online May 2013 in SciRes (http://www.scirp.org/journal/aa) http://dx.doi.org/10.4236/aa.2013.32011

Secular Trends in Tuberculosis during the Second

Epidemiological Transition: A Swiss Perspective

Kara L. Holloway1, Renata Henneberg1, Miguel de Barros Lopes2, Kaspar Staub3,

Karl Link3, Frank Rühli3, Maciej Henneberg1

1Biological Anthropology and Comparative A na t omy Research Unit, University of Adelaide,

Adelaide, Australia

2Pharmacy and Medical Sciences , University of South Australia, Adelaide, Australia

3Centre for Evolutionary Medicine, Institute of Anatomy, University of Zürich, Zürich, Switzerland

Email: kara.holloway@adelaide.edu.au

Received January 17th, 2013; revised Fe bruary 23rd, 2013; accep ted March 1st, 2013

mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, pro-

vided the original work is properly cited.

The second epidemiologic transition is defined as “the age of receding pandemics”, wherein mortality de-

clines, life expectancy increases, and population growth occurs. The major causes of death also shifted

from predominantly acute infectious diseases to degenerative and “man-made” diseases (Omran, 1983).

The aim of this study was to determine the timing of the transition in Zürich (Switzerland) and to investi-

gate patterns of tuberculosis mortality during this period. This is one of the first studies to specifically in-

vestigate the timing of the second transition in Zürich, Switzerland. The data sources for this study were

Swiss records of mortality from the Staatsarchiv (Canton Archives), Stadtarchiv (City Archives) and a

published volume of State Statistics (Historische Statistik der Schweiz). The changes in mortality through

time were addressed for all causes of death in the city of Zürich for the years 1893 to 1933 that is, the

time including the second epidemiological transition. After 1933 the structure of the mortality data collec-

tion changed as the responsibility was transferred away from the canton archives. Mortality from tuber-

culosis was then examined in greater detail and compared with changes in living standards as well as

population density occurring at the time.

Keywords: Tuberculosis; Second Epidemiological Transition; Switzerland

Introduction

An Overview of Tuberculosis

Tuberculosis is an ancient disease and has been one of the

biggest causes of death among societies throughout history

(Kaufmann & Britton, 2008). Tuberculosis occurs in individu-

als infected with a bacterium called Mycobacterium tuberculo-

sis and who cannot control the organism effectively due to a

lowered immunity (North & Jung, 2004). Tuberculosis is usu-

ally transmitted by inhalation of aerosols generated primarily

by coughing (Cole, Eisenach, McMurray, & Jacobs Jr., 2005).

However, ingestion of contaminated meat and dairy products is

a route of infection for the related bacterium, Mycobacterium

bovis, which predominantly infects cattle but can cause infection

in humans (Waddington, 2004; Wilbur, Farnbach, Knudson, &

Buikstra, 2008).

Mycobacterium tuberculosis does not always cause disease;

in fact only approximately 10% of infected individuals suffer

pathological signs and symptoms (Wilbur et al., 2008). A pa-

tient can even be asymptomatic and thus appear to be “cured”

for long periods of time, yet may show signs and symptoms

later in life. Since M. tuberculosis spreads mostly through the

respiratory tract, the common pathological signs and symptoms

include coughing, difficulty breathing, bloody sputum, weak-

ness, lethargy, loss of appetite and weight, night sweats, pallor

and chest pain (Dormandy, 1999; Wilbur et al., 2009). Tuber-

culosis can affect any part of the body and with time, the bacte-

ria can disseminate from soft tissues of the lungs to the other

parts of the body, including the bones (Wilbur et al., 2008).

In Europe, tuberculosis was likely responsible for 20% to

25% of all deaths during the 1500s (Stead, 2001). There are

difficulties with this estimate, however, because relevant his-

torical records can be absent, or incomplete and ambiguous on

cause of death in the pre-modern era. For example, in many

countries, physicians were hesitant to diagnose tuberculosis

because of the social implications for the patient and instead

recorded the cause of death as some other unspecified pulmo-

nary disease (Johnston, 1995). The term “tuberculosis” also did

not become widely used until the 1830s (Wilbur et al., 2008). A

number of other names were given to pulmonary conditions

presenting tuberculosis-like signs and symptoms including

“consumption”, “phthisis” and “the white plague”, while dis-

eases of other organs caused by M. tuberculosis were referred

to as tabe s m ese nte rica and “scrofula” or “King’s evil” (Herzog,

1998; Miller & Thompson, 1992; S. Newsom, 2006; Smith,

1988). In addition, disease diagnosis prior to the 19th century

did not have a high degree of certainty, and new systems of

disease classification were introduced in the early 20th century

(Dormandy, 1999; Rucker & Kearny, 1913). Improving accu-

racy in diagnostics and shifts in disease classification can cause

K. L. HO LLOWAY ET AL.

problems in interpretation of the mortality and morbidity of

tuberculosis through time as disease categories associated with

tuberculosis can also include several other conditions. For ex-

ample, “phthisis” may also include other pulmonary diseases

with symptoms similar to pulmonary tuberculosis. However,

the disease now known as tuberculosis has been reported in

some ancient literature such as a Babylonian text written by the

monarch Hammurabi between 1948 and 1905 BCE (Herzog,

1998; Kaufmann & Britton, 2008; S. Newsom, 2006; Steinberg,

1996). We investigated patterns in tuberculosis during the 19th

and 20th centuries, many years after it was first described in

these ancient writings. Thus, while some diagnoses are likely to

be incorrect, the majority will not be. We considered the terms

“tuberculo sis”, “consumption”, “pht hisis”, “scrofu la” and “King’s

Evil” as evidence of tuberculosis since these were the most

commonly used terms during the time period under investiga-

tion (Burke, 2011).

Switzerland—Public Health, Demography

and Economy

General Overview of Switzerland

Switzerland is a central European country comprised of 26

regions called “cantons”. These cantons differ in size, popula-

tion, language, geographical features, and extent of urbaniza-

tion. The borders of Switzerland are irregular because they re-

present negotiations and agreements in the past (Steinberg,

1996). For example, the Canton of Basel was split into two

half-cantons (Basel-Stadt and Basel-Land) after a disagreement

between urban and rural areas in 1830 (Bouvier, Craig, Goss-

man, & Schorske, 1994; Steinberg, 1996). The Swiss govern-

ment has been stable since 1848 (Butler, Pender, & Charnley,

2000; Steinberg, 1996), but each canton has its own constitu-

tion, executive, legislative and judiciary, laws and practices,

flag, and coat of arms as well as a separate Parliament (Stein-

berg, 1996). Multiple religions are accepted in Switzerland and

in the past the population was approximately equally divided

between Protestant and Catholic. The country has been neutral

since 1815, but still maintains an army (Remak, 1993). The

country’s economy, while highly specific (banks, watches, che-

ese, and chocolates), has been very successful. This success has

been partly due to dependence on foreign workers, which re-

duces labor costs. These workers came from a variety of coun-

tries including France, Poland, Germany and Italy (Bouvier et

al., 1994).

A Short Hist ory of Switzerland

At the end of the 1700s, Switzerland had no central govern-

ment, no common treasury, troops, currency, judiciary or mark

of sovereignty despite the long history of Confederation dating

back to the 13th century (Bouvier et al., 1994; Remak, 1993).

At the time, each canton was governed separately, though there

was a larger Parliament for the country, which consisted of rep-

resentatives from each canton. However, in 1798 major changes

occurred when Napoleon invaded Switzerland from France

(Remak, 1993). Following the invasion, Napoleon converted

Switzerland into the Helvetic Republic, which united and cen-

tralized the cantons. Napoleon also granted freedom of speech,

movement and religion to the country, and introduced a com-

mon currency, law code, and postage system (Remak, 1993).

However, due to dissatisfaction with some of these changes

among the populace, especially the loss of traditional rights of

the individual cantons, Napoleon altered the Helvetic Republic

with “The Act of Remediation” in 1803, which did not return

the cantons to Swiss control but did reintroduce some tradi-

tional rights. Napoleon lost control of Switzerland in 1814 and

in 1815 a Federal Treaty was signed. This reverted the country

to pre-Napoleonic policies and provided regulations for politi-

cal relationships between the cantons (Bouvier et al., 1994;

Remak, 1993; Steinberg, 1996). France was also required to

pay compensation for damages incurred during Napoleon’s

military campaigns, which supported Switzerland’s economic

development. The Treaty also introduced the concept of neu-

trality. While the Swiss citizenry was supportive of this, they

did not support the Treaty’s centralization of the country (Re-

mak, 1993).

In 1831, the 1815 Treaty was effectively rejected (Steinberg,

1996). Religious schisms also arose, driven in part by issues of

economic inequality: more urban, prosperous cantons were

gradually converting to Protestantism while the poorer and rural

cantons remained Catholic (Remak, 1993). This religious divi-

sion had progressed slowly throughout the 1830’s as Liberalism

became increasingly popular in Switzerland and other neigh-

boring European countries. This led to religion-based alliances

between the Catholic cantons, and widespread unrest, with

some unsuccessful attempts made by protestant Radical groups

to overthrow the government in 1844 and 1845. In 1847, a Civil

War erupted when seven Catholic cantons tried to establish a

separate alliance, though it ended in less than a month with few

casualties (Butler et al., 2000; Remak, 1993; Steinberg, 1996).

After the war, unification between the cantons became favored,

precluding the revolutionary uprisings, which plagued much of

Europe, and a new constitution was drafted in 1848, which

remains in use today. This new Constitution resolved the long-

standing conflict between national centralization and traditional

canton-based freedoms (Steinberg, 1996), by forbidding alli-

ances between the cantons. It created a “bottom-up” system that

allowed citizens to vote on all decisions by the government.

Thus power rests with the people rather than a central authori-

tative group (Bouvier et al., 1994).

Industrialization and the Economy of Switzerland

Switzerland was one of the earliest industrialized countries in

Europe, on a par with the United Kingdom, the United States,

and France (Butler et al., 2000; Steinberg, 1996). By 1780, the

entire region of eastern Switzerland was largely industrialized;

producing exports such as milk products, silk textiles, cotton

and mechanical parts (e.g. watches) (Steinberg, 1996). From

1880 to 1950 only the UK had a higher gross national product

per head. However, several features distinguished industrializa-

tion in Switzerland from that experienced by other early indus-

trializers: a slow rate of urbanization, high levels of economic

specialization (e.g. high quality mechanical parts and textiles,

see below), slow spread of railways, a strong dependence upon

foreign labor, limited geochemical natural resources, such as

coal, a high rate of international investme nt, a geographical con-

centration of economic activities in micro-units, and a very high

level of industrialization (Butler et al., 2000; Steinberg, 1996).

In fact, by 1850, Switzerland ranked fourth in the level of in-

dustrialization behind the United Kingdom, Belgium and the

United States (Siegenthaler, 1972). Railway systems developed

quickly in the mid 19th century in other early industrializers,

K. L. HO LLOWAY ET AL.

but lagged in Switzerland, even in comparison to other aspects

of economic growth. This was due to difficulty with the moun-

tainous terrain, the absence of coal (industry and development

was fueled largely with hydropower) the small size of Swiss

cities, and lack of a strong, central government. Mountainous

terrain was also an overall obstacle to economic development in

Swi tz e rl an d: 2 5. 5% of the land is unprod uctive (e.g. High Alps) ,

30.3% is “forested”, and only 38.3% is available for agriculture

(Steinberg, 1996). Only 5.8% is considered surface area suit-

able for habitation and infrastructure. In a small country, this

amounts to a very small area.

In complement to industrialization, Switzerland also main-

tained a vigorous agricultural economy. This economy was fo-

cused on specialized milk products, such as cheese and choco-

late, which, together with tourism, watch making, and textile

production, provided consistent income for rural areas through-

out the 19th century. While the country maintained a high rate

of importation for cereals, exports, particularly of luxury items,

formed a critical component of the economy; only Belgium had

a higher export rate. Switzerland’s overwhelming economic

focus on export and luxury items, like watches and embroidery,

was due to the nation’s dearth of raw materials, and high trans-

port costs (Butler et al., 2000; Siegenthaler, 1972; Steinberg,

1996). Little economic centralization occurred; Swiss industria-

lists and canton governments were not supportive of large scale

production and industrialization or the construction of factories

(Steinberg, 1996). Instead, machines were installed in worker’s

home, allowing a continuation of cottage industry and piece

production (Bouvier et al., 1994; Butler et al., 2000). This prac-

tice resulted in a much lower urban population density than was

found in 19th and 20th century Britain or Germany (Steinberg,

1996). While exportation was expensive, Swiss goods remained

competitive because of low labor costs: wages were 15% lower

and hours 15% longer when compared with Germany (Stein-

berg, 1996). This advantage did not overcome all of Switzer-

land’s disadvantages, however, translating into a heavy empha-

sis on economic specialization and high levels of skilled labor,

high product quality, and involvement in international trade,

ope n ma r k et s , a nd o p ti m ization of trade conditions (Butler et a l .,

2000).

Switzerland employed child labor throughout the 19th cen-

tury, but also maintained a system of compulsory education.

Children participated in industrial activities within the home,

and thus were also able to attend school. Education of children

between the ages of 6 and 16, both boys and girls, became

compulsory in the 16th century (Bouvier et al., 1994; Steinberg,

1996). Economic assistance was provided to parents who could

not afford schooling for their children (Steinberg, 1996). Much

of Switzerland’s economic success has been attributed to this

emphasis on high quali ty, accessible educati on even in the face

of rapid economic growth (Butler et al., 2000).

Living Conditions in Switzerland

Switzerland maintained a uniformly high standard of living

in rural and urban areas during industrialization in comparison

to other early industrializers. This was largely due to the use of

white coal (hydropower) brought into the city from rural areas

(rather than black) which produced less pollution, and also to

low urban population density (Schoch, Staub, & Pfister, 2011;

Steinberg, 1996). For instance, in 1900, only 6% of Swiss citi-

zens lived in towns with a population of over 10,000. By 1910

this had only increased to 25%. In comparison, Great Britain

had reached 25% by the 1840s. Zürich had a population of

28,000 during the late 1800s, though in-migration and incorpo-

ration of surrounding regions into Zürich due to economic dif-

ficulties in 1893 pushed this number up to 100,000 (Steinberg,

1996).

Economic hardships also affected Switzerland in the 19th

century. Despite intensive agriculture, there were periodic food

shortages in the 1810s, particularly in urban areas and this was

associated with the internal conflict and fall of Napoleon’s

Empire in 1814 (Bouvier et al., 1994; Steinberg, 1996). Later,

in 1845, Switzerland also experienced an epidemic of potato

blight, which precipitated widespread poverty, increased levels

of child labor, and famines during the 1850s (Butler et al.,

2000). However, dietary and economic conditions improved

during the 1880’s, with increased consumption of animal pro-

tein as well as cheap grain (Schoch et al., 2011). With this in-

flux of grain from cheap imports, local farmers decided to focus

on milk products instead. Around this time (1870 to 1912), the

public healthcare system was established and public sanitation

(such as the introduction of sewerage systems, waste removal

and public health education), immunization as well as hous-

ing/working conditions were further improved (Schoch et al.,

2011). The public health system may have addressed factors

such as water pollution, poor quality foods in the marketplace,

disposal of animal waste from slaughterhouses, cemeteries,

problems with leaky sewers and septic tanks, street cleaning,

housing with inadequate ventilation or sunlight and harmful

chemicals or working conditions in industry (Bourdelais, 2006).

Major investments in the urban water supply and sewerage

systems were completed during the last third of the 19th cen-

tury in Switzerland (Condrau & Tanner, 2000). These methods

were more effective in urban areas than in rural areas; likely

because the former have a higher population density and these

measures could be more effectively implemented in cities than

in smaller, country towns. However, economic difficulties as-

sociated with a rise in the price of wheat and flour products due

to poor harvests during 1880-1888 caused many farmers to

become unemployed and forced many people to migrate from

rur a l areas to cities in search of a new occupation ( G r ab e r , 1926;

Schoch et al., 2011). However, while bread prices were rising

substantially in other countries (especially in Europe) the Swiss

Government established an association called the “Wheat Ad-

ministration” on the 9th of January 1915 (Graber, 1926). The

task of this association was to moderate the prices of wheat

products in Switzerland, to control imports of these products

into the country, maintain reserve stocks of cereals and to en-

courage the cultivation of home-grown wheat. Since this ad-

ministration was in control of purchasing wheat, when prices

increased during the 1880’s, it became difficult to afford Swiss-

grown wheat. The Wheat Administration was very successful

during WWI and consequently, bread prices in Switzerland

were tolerable for the consumer, unlike in other countries

around the world.

The conflicts and economic disturbances that ravaged much

of Europe through the 19th and 20th centuries had a moderate

effect upon Switzerland’s economy and living standards. Swit-

zerland did not participate in WWI but did experience minor

economic declines in part because the country maintained a

standing army during the period. Numerous refugees from Rus-

sia, France and Germany were also admitted during the 1910s,

resulting in additional economic declines because these indi-

K. L. HO LLOWAY ET AL.

viduals required housing and subsistence, thus reducing the

amount of land and food available (Steinberg, 1996). Even

during WWI, the standard of living in Switzerland did not de-

cline, largely because of governmental attempts to control and

prevent malnutrition; government subsidies ensured that milk

products were highly accessible and a school lunch policy was

instituted (Schoch et al., 2011). In addition, the Government

also provided sufficient wheat for bread products through direct

cost to the country during WWI (Graber, 1926). During the

1930s, Swiss manufacturing (watches and textiles) was severely

affected by the Great Depression and in some areas, entire in-

dustries collapsed. Changes in currency exchange rates also

severely affected Swiss profits and in north-eastern Switzerland,

many towns relying upon single industries, became economi-

cally vulnerable (Steinberg, 1996).

The City of Zürich—An Overview of Sanitation and

Hygiene

Zürich is a very wealthy city located in northeastern Swit-

zerland, within the canton of Zürich. Economic growth associ-

ated with industrialization began in approximately 1827, and

became focused on cotton textiles around 1857. Industrializa-

tion affected the city in several ways including an increase in

population density, decrease in the level of sanitation and be-

ginning of social stratification. However, these changes oc-

curred to a lesser extent in Switzerland compared to other coun-

tries (Steinberg, 1996). The sanitation and hygiene situation in

Zürich in the early 1800s was similar to the rest of Europe; in

1837, a British tourist published an article in a Swiss magazine

des cri bi ng t he a mount of filth in the streets of Zürich. He stated:

“when it rained the streets turned into lagoons covered in half a

foot of mud” (Lemann, 2008). Due to a lack of sewage systems

in Zürich, human and animal waste and refuse drained into

small alleyways between houses and then into the River Lim-

mat, and water-borne diseases such as cholera (at the time the

records did not state the type of cholera) frequently raged

through the city. To correct this, major sewage refor ms were ins-

tigated between 1866 and 1870, resulting in the regular removal

of household refuse, introduction of simple sewerage systems

for waste and rainwater, and a system of waste management

based on composting and deposition in rural areas. This strat-

egy seems to have been effective; in 1883, Zürich hosted a

national exhibition that presented the city as one of the cleanest

and healthiest in Europe. Furthermore, in the 1890s, Swiss au-

thorities proposed the adoption of a mode of waste disposal

currently popular in Britain—incineration—and in 1899, the

citizens of Zürich allocated 1 million Swiss francs to construc-

tion of an incinerator in Zürich. This was to help control the

city’s waste in the future, since the current management would

be unable to cope with an increasing population. This facility,

finished in 1904, was the first in Switzerland and the fourth in

mainland Europe. Products of this facility did not impact the

health of individuals living in Zürich because it was built some

distance from the city. Other effective, though smaller scale

public health reforms included the use of sealed containers with

sliding lids for storing unwanted household refuse. These were

designed for the purpose in the early 1900s, quickly made

mandatory for all households in Zürich, and eventually mass-

produced throughout the country until plastic rubbish bags

made them obsolete in the 1970s (Lemann, 2008).

Switzerland’s Role in the Treatment of Tuberculosis

Switzerland played a substantial role in the 19th century de-

clines in mortality from tuberculosis. The country’s great num-

ber of sanatoria distributed through its alpine regions—and its

neutrality, which facilitated migration to these centers—long

encouraged individuals infected with tuberculosis to establish

short or long term residence there. The main reason for the

migrations were the reputation of Switzerland’s sanatoria in

aiding those with tuberculosis; many with the disease believed

if they could travel to these establishments that they would be

cured. These establishments were dedicated to the care of pa-

tient with active tuberculosis, and were built throughout the

1800s and 1900s to offer a “cure” for tuberculosis (Rucker &

Kearny, 1913). Contemporary medical thinking about active

disease held that the “open-air” climate found in the high

mountainous areas of Switzerland was an effective cure for the

disease (Warren, 2006). The sanatoria also encouraged rest, in-

cluding sitting in the sun, and “satisfactory” exercise (Dorman-

dy, 1999; Rucker & Kearny, 1913), and provided clean, hygi-

enic environments for patients, as well as a substantial nutri-

tional regime: up to seven meals a day, consisting largely of

dairy products and cod-liver oil (Roberts & Buikstra, 2003;

Warren, 2006). All of these treatment methods related to the

bolstering of disease resistance among patients through aiding

the immune system with proper nutrition and this allowed many

to recover from active tuberculosis. Rucker & Kearny (1913)

describe the success rates of sanatorium treatment of at least

four weeks for tuberculosis patients from 1905 to 1911. For

those with early stage tuberculosis, more than 95% improved,

3.2% were unimproved and only 0.1% died in the sanatoria. Of

cases with more advanced tuberculosis, 85% were improved,

12% were unimproved and only 1.0% died in the sanatoria.

Very advanced disease resulted in 62% improved, 34% unim-

proved and only 3% deaths in the sanatoria. During this period,

in the 19th and early 20th centuries, estimates of the frequency

of tuberculosis in Switzerland are rough, as only mortality from

the disease was recorded. However, in 1928, a law (Anfrage

des Stadtrates betr. Erlass von Vorschriften über die Who-

nungsinspektion) was passed that required the reporting of all

cases of active disease. Importantly, this law also required

treatment of all recorded individuals, not just those who could

afford a stay in a sanatorium (Gesetzgebung: Zürich, 1928).

However, tuberculosis has re-emerged in many other coun-

tries around the globe in the past few decades, following the

development of drug resistance and the HIV/AIDS epidemic

(Corbett et al., 2003; World Health Organization, 2012). Cur-

rently, the WHO estimates that one-third of the world’s popula-

tion is infected and two million die from tuberculosis each year.

Thus, it is important to study this ancient disease in order to

help us combat the current problem of re-emerging and drug

resistant tuberculosis.

Materials and Methods

Data Sources

Historical Records and State Statistics

Data employed in this study include vital records on mortal-

ity from both the Stadtarchiv (“city-archive” (Stadt Zürich,

2012)) and Staatsarchiv (“canton-archive” (Canton of Zürich,

2012)) in the city of Zürich. The Stadtarchiv held records for

causes of death in Zürich city from 1893 (likely because this

K. L. HO LLOWAY ET AL.

was when the original city and the surrounding regions were

combined) to 1933, which included mortality attributed to tu-

berculosis. There were many records in this archive, and we

examined:

 Statistik der Infektionskrankheiten (Statistics of Infectious

Diseases);

 Tuberkulose (Tuberculosis): two volumes; 1912-1932 and

1932 to 1935;

 Tuberkulose Sterbefaelle (Tuberculosis mortality): five vol-

umes; 1903-1905, 1905-1915, 1915-1920, 1920-1934 and

1929-1936.

The Staatsarchiv held information detailing the introduction

of Anfrage des Stadtrates betr. Erlass von Vorschriften über die

Wohnungsinspektion (the Law regarding the compulsory re-

cording and treatment of tuberculosis). Data were also collected

from a volume of primary historical statistics for Switzerland

(State Statistics) titled “Historische Statistik der Schweiz”

(Ritzmann-Blickenstorfer, 1996). Both the Staatsarchiv and Sta-

te Statistics yielded information on mortality attributed to tu-

berculosis for thirteen cantons (i.e. Zürich, Berne, Lucerne, Uri,

Schwyz, Obwalden, Nidwalden, Glarus, Zug, Fribourg, Solo-

thurn, Basel-Stadt and Basel-Land) for 1876 to 1935. From the

book of State Statistics, the relevant table was “D43. Todesfälle

infolge Lungentuberkulose nach Kantonen 1876-1935” (Mor-

tality due to pulmonary tuberculosis by Canton).

The State Statistics also provided data on population sizes for

Zürich city (through censuses) and a number of cantons (i.e.

Zürich, Berne, Lucerne, Uri, Schwyz, Obwalden, Nidwalden,

Glarus, Zug, Fribourg, Solothurn, Basel-Stadt and Basel-Land)

for the years 1888, 1900, 1910 and 1930. This was used to cal-

culate the population density for those years with available data:

1888, 1900, 1910 and 1930 (Gwillim Law, 2009). Each canton

was assigned an arbitrary category of population density: low

(<40 people per km2), medium (40 - 80), high (81 - 100) or

very high (>101). These reflect relative predominance of rural

and urban styles of living. Cantons with low population density

were Uri (19.0 people per km2) and Obwalden (34.0). Medium

density included Nidwalden (49.7), Glarus (49.3), Schwyz

(62.2) and Fribourg (79.4). High density cantons were Berne

(101.7), Lucerne (107.0) and Zug (115.6). Finally, very high

de nsi ty ca nt on s in cl u de d So lo thurn (141. 5), Basel-Land (144 . 4) ,

Zürich (273.2) and Basel-Stadt (3221.6). Since population den-

sity increased through time in all cantons, this designation was

attributed based on the population density estimated for each at

the beginning of observations in 1888. Due to political and

economic stability, population densities in studied areas would

remain comparatively steady in comparison to each other thus

without changing the nature of low-density and high-density

areas.

The state statistics also provided average newborn life ex-

pectancies for 1878 to 1991. The available data represent an

average for the whole of Switzerland (Zürich canton and city

specific data were not available) and were used to give an indi-

cation of living conditions for 1840 to 1933.

Data Analysis

Causes of death were grouped into four categories according

to type of disease. These include infectious, “organ” (i.e. diseases

of organ systems such as the renal and reproductive systems),

degenerative, and “other” (e.g. accidents, poisoning). While we

are aware that some of the diseases placed in the group “organ”

may be the result of infectious processes, we could not be sure

and consequently, we simply chose to remove them from our

general overview in order to reduce biases. Diagnoses were

used as reported and no attempt was made to re-interpret them.

Although some terms changed around 1900 (e.g. “phthisis” to

“tuberkulose” (Rucker & Kearny, 1913)), an attempt was made

to keep the causes of death consistent over the time period by

determining which diseases had changed in nomenclature and

their corresponding new names. The percentage contributions

of each of these four disease groups were calculated by dividing

the total deaths from all diseases in that group by the total

deaths from all groups.

Data from literature investigating or describing the second

epidemiological transition in other countries were consulted to

provide a comparison for the Swiss data. Tuberculosis mortal ity

data were available for England and Wales (1860-1960), Japan

(1925-1964), Chile (1915-1965), Sri Lanka (1939-1967), The

Netherlands (1875-1992), Australia (1907-1990) and cities in

the United States (Philadelphia (1870-1930), New York (1866-

1965)). The countries used for comparisons were chosen due to

the availability of data and because they represent a diverse set

of conditions and degrees of urbanization. These comparisons

are thus useful to determine the effects of different living con-

ditions and social factors on tuberculosis mortality through time.

Graphs of percentage mortality from infectious, organ, degen-

erative, and other diseases were produced from the data pre-

sented in publications describing tuberculosis mortality in the

other countries stated above (Carter et al., 2011; Condran &

Cheney, 1982; Lewis, Taylor, & Powles, 1998; Omran, 1983,

2005; Wolleswinkel-van den Bosch, Looman, Van Poppel, &

Mackenbach, 1997). In some cases this was difficult, especially

where the causes of death were grouped or not clearly described.

In some cases, graphs from publications were not clear and

these were reproduced in a different format to allow an estima-

tion of the timing of the second epidemiological transition.

Following established methods, the percentage of tuberculo-

sis mortality was calculated by dividing tuberculosis mortality

by total all-cause mortality. This was plotted for both Canton

Zürich and the city of Zürich in order to observe trends and

patterns over time, but also for comparison of the two. Tuber-

culosis mortality, expressed as a rate per 100,000 living indi-

viduals, was plotted against the calculated population densities

for several Swiss cantons (Zürich, Lucerne, Uri, Schwyz and

Berne) in order to determine an y correlation between the two.

Results

Part One: The Timing of the Second Epidemiological

Transition in Zürich City

The total number of recorded deaths for the causes in each

disease group (i.e. infectious, organ, degenerative, and other)

was expressed as a percentage of the total mortality for 1893 to

1933. This was plotted along with newborn life expectancy and

is shown in Figure 1. The second epidemiological transition,

defined by Omran (1983) as the time when degenerative dis-

eases become more important than epidemic infectious diseases

in terms of mortality, is clearly shown in Figure 1. This transi-

tion takes place in 1911, according to the intersection point of

linear trend lines for degenerative and infectious diseases. The

rate of increase of degenerative diseases was equal to the rate of

decrease of infectious diseases; 0.0079 ± 0.0007 and 0.0078 ±

0.0007 per year, respectively. This transition is reflected in the

K. L. HO LLOWAY ET AL.

increase in life expectancy; as individuals began living longer,

they beca me more likely to develop degenerative diseases. The

newborn life expectancy of males increased from 60.5 years in

1895 to 66.5 years in 1935. For females, the values increased

from 62.2 years to 69.6 years over the same time period.

of total mortality, was calculated for the canton of Zürich for

1840 to 1933 (Stadt Zürich, 2012) and Zürich city for a shorter

period, 1893 to 1933 (Ritzman n - Bl i ckenstorfer, 1996). The data

are plotted in Figure 2, along with annotati ons of important his-

torical dates for Switzerland, healthcare and tuberculosis treat-

ment.

In the city of Zürich, the percentage of total mortality from

tuberculosis decreased between 1893 and 1933. In the canton of

Zürich there was a peak in tuberculosis mortality around 1890.

This could be a result of economic difficulties involving the

wheat market (as mentioned above) as well as migration,

Part Two: Trends in Tuberculosis Mortality during

the Second Epidemiological Transition in Zürich City

and Zürich Canton

Mortality from tuberculosis, expressed here as a percentage

Figure 1.

Percentage mortality in the city of Zürich for infectious, organ, degenerative and other

diseases, between 1893 and 1933. Newborn life expectancies for males and females are

also plotted.

Figure 2.

Percentage of total mortality from tuberculosis in Canton Zürich (1840-1933) compared with

Zürich city (18 93 -1933). Historical ev en ts are also shown.

K. L. HO LLOWAY ET AL.

resulting in lower nutritional value of the Swiss diet through ra-

tioning (Graber, 1926). The data for the city differed from the

e: Patterns of Tuberculosis in Other Swiss

Cantons duri ng t he Se cond Epidemiological

the tu-

ely 1888 and

cantonal values in that the initial percentage was higher, likely

due to the higher population density of the city (average 1485

people per km2 between 1893 and 1933). Towards 1933, the

percentage of total mortality from tuberculosis in the city began

to approach the value for the entire canton. Finally, the decrease

in tuberculosis mortality is more dramatic in the city than in the

entire canton. This could reflect changes in living conditions as

well as improved access to medical treatment and medical ad-

vances in the city, which would be greater in a higher popula-

tion density area. In more crowded areas, before effective pub-

lic health measures, there was a higher level of infectious dis-

eases due to poor sanitation (waste products were left to de-

compose in the streets) as well as higher transmission rates due

to population density. With the introduction of public health

education and sanitation, these issues can be quickly and effi-

ciently resolved. There is another interesting observation from

Figure 2; the percentage of mortality from tuberculosis was

decreasing even before medical advances related to tuberculosis

care. This is potentially due to the improvements in living con-

ditions and public health care in Switzerland rather than spe-

cific tuberculosis treatments. Additionally, tuberculosis mortal-

ity was also in decline in the city of Zürich before the second

epidemiological transition occurred there, around 1911 (see

Figure 1).

Part Thre

Transition and the Effect of Population Density

Population density (people/km2) was plotted against

berculosis mortality rate per 100,000 living individuals (Figure

to determine whether correlations existed between these two

variables in different cantons during the several years for which

data were available: 1888, 1900, 1910, and 1930.

A positive relationship existed between population density

and tuberculosis mortality in the earlier years, nam

00 (Figure 3). The mortality rate decreased through time,

Figure 3.

Tuberculosis mortality rate per 100,000 living people compared wit

density (logarithmic scale) in various Swiss cantons (1888-

despite an increase in population density. The decrease in tu-

berculosis mortality is more dramatic in cantons with a higher

When compared with countries that industri-

alized in the 19th and eares, and the cities within

ly. For instance, in the earliest

industrializers, the

population

1930). Cantons include: Zürich, Berne, Lucerne, Uri, Schwyz, Obwal-

den, Nidwalden, Glarus, Zug, Fribourg, Solothurn, Basel-Stadt and

Basel-Land.

population density than those with a lower population density.

In those with lower density, the tuberculosis mortality rate in

1888 was 146 (per 100,000 living) but decreased to 90 by 1930.

In cantons of very high population density, the tuberculosis mor-

tality rate was 239 (per 100,000 living) in 1888 and decreased

to 91 by 1930. Note that in 1930 the correlation between tuber-

culosis mortality and population density disappeared and both

high and low density areas had the same tuberculosis mortality

rates (approximately 90 per 100,000).

Discussion

Part One: The Timing of the Second Epidemiological

Transition in Zürich City

data from other

ly 20th centuri

them, evidence here suggests that Switzerland and Zürich un-

derwent the second transition ear

transition occurred during the 1920s in Great

Britain (Omran, 2005), and before 1930 in major urban areas in

the US, namely Philadelphia and New York (Condran & Che-

ney, 1982; Omran, 1983). In the Netherlands, for example,

which experienced intensive industrialization in the 1860s and

1870s, cause of death and all-cause mortality data, covering the

period from 1875 to 1992, suggest that the transition occurred

there only in the 1930s (Wolleswinkel-van den Bosch et al.,

1997). Other, later industrializing countries, including Nauru,

Japan, Mexico, and Chile exhibited patterns of an epidemiol-

ogical transition later, in 1955, 1951, 1957, and 1974, respec-

tively (Carter et al., 2011; Omran, 1983, 2005). Evidence from

Australia, for example, which industrialized mainly throughout

the 20th century, seems to suggest that the transition occurred

there in the 1920s; infectious disease mortality declined in the

1940s, stabilizing by 1950, and degenerative diseases, specifi-

cally cardiovascular disease and cancer, increased from 1920

on, only plateauing in 1940. Overall, the epidemiological tran-

sition in all of these other countries occurred later than in Swit-

zerland.

The decrease in infectious disease mortality observed so

early is attributable to several possible causes. Refrigeration,

which would have reduced morbidity and mortality from gas-

trointestinal disease, is one possible cause. Refrigeration was

under development in the early 1800s and was in widespread

use in 1884 in the United States (Krasner-Khait, 2011); it likely

became widespread in Switzerland at approximately the same

time. The mortality rate from gastrointestinal diseases, many of

which may be caused by an infectious agent (though not al-

ways), in Zürich city decreased substantially from 17% of all

deaths in 1898 to 2% in 1914. This pattern suggests that the

decline may be linked with improvements in food technologies,

such as refrigeration. The decline would have substantially

lowered mortality among children, the age group most affected

by this type of disease, thus allowing more individuals within

the population to reach adulthood. This theory is supported by

the increase in life expectancy among newborns through time

as shown in Figure 1.

Improvements in general sanitation also likely played a role

in precipitating Switzerland’s early transition. For instance,

sewage control, which was introduced between 1866 and 1870

K. L. HO LLOWAY ET AL.

in Zürich, and the increased accessibility of potable running

water in Zürich and other cities in the same time period, would

erland also, unlike these other

The 19th century witnessed several major shifts in mortality

enactment of the

“N

arship on the second epidemiol-

fest symptoms for many years. As such, the picture of

ve facilitated the epidemiological transition in Switzerland by

further reducing mortality from water borne and many gastro-

intestinal diseases. Similar structural changes were occurring in

both England and Germany, but at a slightly later date. For

instance, in England, a Public Health Act in 1875 required ap-

propriate waterworks to be present and functional, while in

Germany, all larger cities (i.e. more than 25,000 people) had

efficient sewerage systems by the year 1900 (Vögele, 1998).

These changes, lagging slightly behind those in Switzerland,

are reflected in the decline of infectious diseases through time

in these nations. For tuberculosis, these improvements in living

conditions helped to increase the general immunity of the

population and consequently decreased the number of people

who developed active disease.

Importantly, Switzerland was a stable country during the

time periods investigated, and unlike many other early and late

industrializing countries, did not take part in any international

wars in the mid-19th and early 20th centuries (and into the

present day). Data from Switz

untries, show little evidence of poorer living conditions in

highly populated cities compared with rural areas. In contrast,

Great Britain, for example, experienced extensive damage to

their urban, economic, and public health infrastructures during

WWI and WWII. In WWII in particular, living conditions in

urban areas dramatically deteriorated due to damage to build-

ings and homes, leading to overcrowding as well as rationing of

food. This did not occur in Switzerland; living conditions re-

mained stable throughout the wars. In Switzerland, many of the

penalties associated with urban factories were avoided because

individuals could work at home and were not subject to the

poor conditions of living and working in large cities. This kept

many native Swiss in their hometowns and encouraged some

immigrants to move to these areas; thus helping to prevent cit-

ies becoming overcrowded. These factors, combined, seem to

have contributed to a buffering of the epidemiological costs

associated with industrialization and urbanization in Switzer-

land, and a comparatively earlier transition to a reduced regime

of infectious disease and greater longevity among its citizens.

Part Two: Trends in Tuberculosis Mortality during

the Second Epidemiological Transition in Zürich City

as Well as the Entire Canton of Zürich

from tuberculosis in Zürich. Between 1840 and 1870, the pe

centage of total mortality from tuberculosis in the Canton of

Zürich decreased substantially. This coincided with changes in

health policies, including sanitary reforms and

ew Poor Law” (the “Old Poor Law” was introduced in the

16th century), which required the segregation of wealthy and

poor individuals and encouraged those with the ability to work

to find employment and support themselves (Wilson, 2005).

The Newer Poor Law aimed at providing housing, clothing,

food and education (for children) to the poor in return for sev-

eral hours of labor per day in a workhouse (The National Ar-

chives, 2012). Separating these poorer individuals from those of

higher socioeconomic status helped to reduce tuberculosis

among the latter because they had less contact and opportunity

for transmission of the disease with poor people with lower

immunity due to a lower nutritional status. However, after the

Prussian-French War (1870-1871), the percentage mortality due

to tuberculosis increased, which may be attributed to the influx

of a large number of both French troops and refugees, who

were likely poorly nourished and stressed, into the canton near

the end of the war. This trend persisted until approximately

1910, when the percentage decreased again in both the city and

Canton of Zürich. This decline coincided with a number of

important developments in tuberculosis prevention and control

in Switzerland, including the discovery of X-rays in 1895 (these

were later used as a method of diagnosing active pulmonary

infection) (Herzog, 1998), and the initiation of testing cattle to

control bovine tuberculosis around 1907 in many European

countries (S. W. B. Newsom, 2006). These innovations were

later followed by the first use of the Bacille Calmette Guerin

(BCG) vaccine in 1921, which was the first—and only—vac-

cine to provide protection from tuberculosis, particularly in

children (Herzog, 1998). Lastly, the 1928 Swiss law which re-

quired reporting and treatment of cases of tuberculosis (Ge-

setzgebung: Zürich, 1928), and the invention of surgical treat-

ment for pulmonary tuberculosis in the 1930s (Herzog, 1998)

likely contributed to the steady early 20th century decline in the

disease in Switzerland and Zürich specifically. Interestingly,

the years associated with the beginning of industrialization and

economic hardship in Zürich (19th century), and thus poten-

tially reduced overall health were not associated with increased

mortality from tuberculosis.

The fact that tuberculosis mortality decreased before medical

interventions in Zürich suggests that medical treatment and

advances on their own may not be major causes of declines in

mortality from tuberculosis in a given population. This finding

is congruent with other schol

ical transition, such as Omran (2005), which suggests that

ecobiological changes, such as aspects of the environment, and

the biology of hosts and pathogens, and socioeconomic, politi-

cal and cultural changes, such as standards of living, hygiene

and nutrition, exerted far more influence in precipitating the

second transition than did medical intervention, such as surgery,

drugs and vaccination. Likewise, our results suggest that in

Switzerland, the second transition occurred before the imple-

mentation of major medical advances, such as chemical ther-

apy/antibiotics and in the case of tuberculosis, before use of

BCG vaccine. It seems that this early occurrence of the epide-

miological transition is a result specific for Switzerland’s com-

bination of sanitation, local health care arrangements and living

conditions. These latter ones included lack of overcrowded ex-

tensive urban agglomerations, working at home or in small

establishments, relatively good food sup ply, and stable social re-

lationships. This observation has important implications in the

current global situation because there are a number of low-

income countries struggling with the problem of multi-drug

resistant bacteria (World Health Organization, 2012). Our find-

ings suggest that clinical endeavors and public health initiatives

in these contexts should emphasize improving overall health,

general nutrition, and living standards, as much—if not more

so—developing and providing new drugs and treatment regi-

mens.

Tuberculosis, however, does defy easy categorization into

the shifting patterns of mortality characteristic to the second

transition. This is because it is an infectious condition, but also

a chronic disease which, like degenerative diseases, often does

not mani

decline in infectious disease mortality in Zürich and of tuber-

K. L. HO LLOWAY ET AL.

culosis specifically in the early 20th century is not straightfor-

ward; instead the data suggest a combination of infectious and

non-infectious causes producing mortality through a chronic

and long-lasting process. Tuberculosis does have an infectious

origin, but active disease is a result of an individual’s inability

to control the disease. Mortality from the disease gives us in-

formation about a combination of the levels of transmission,

nutritional status and level of public health, but it is very diffi-

cult to split these factors during corresponding interpretations.

However, this information is useful for providing a general

overview of the population’s ability to resist other infectious

agents and as this increases, the second epidemiological transi-

tion is observed.

Part Three: Patterns of Tuberculosis in Other Swiss

Cantons duri ng t he Se cond Epidemiological

Transition and the Effect of Population Density

The results presented here suggest that tuberculosis mortality

ging

proving living conditions in high-density areas to

the second epidemiological transition. For in-

stance, historical records, which are relied upon here, can be

ugh uneven distribution of ages or

s are likely to be more complete as compared with an

rates declined more rapidly in high population density canton

than in low-density cantons (from 1910 onwards), which ma

be due to progressive improvements in sanitation and chan

strategies for handling tuberculosis patients which may be

fective in more crowded areas (as mentioned previously).

However, high density areas also showed higher initial rates of

tuberculosis mortality (during the years 1888 and 1900 specifi-

cally) likely due to poorer living conditions and increased hu-

man contact in these urban areas in comparison to low density

rural areas.

These results further suggest that in 19th and 20th century

Switzerland, living conditions exerted a substantial impact on

mortality rates from tuberculosis, while medical interventions

exerted less of an effect. Sanitation methods may have become

effective in im

ake them comparable with lower density areas. The effect of

good sanitation may result in a reduction of transmission of

diseases because the population’s immune systems are bom-

barded by infectious agents to a lesser extent than in the case of

poor sanitation. With a lower level of infectious agents in the

environment, accompanied by an increase in nutrition, the im-

mune system of an individual will have a higher chance of con-

trolling diseases. Additionally, outbreaks of specific diseases

(e.g. cholera) will be less likely when there are fewer opportu-

nities for the pathogens to be transmitted from one person to

another. In the case of lower density areas, there are already

fewer opportunities for the spread of pathogens. This has im-

plications for developing nations, where a similar situation is

currently present (poor living conditions, overcrowding and

poor nutrition). Regions such as sub-Saharan Africa, South-

East Asia and some countries in South America currently are

considered high burden areas in terms of tuberculosis (World

Health Organization, 2012). Consequently, improving the stan-

dard of living through sanitation (improving waste management

and especially public health education) and reviewing and

modifying how tuberculosis patients are handled could possibly

be used to obtain the same effect as observed for Switzerland.

Currently, many individuals are given antibiotic therapy for

tuberculosis, but often do not finish the course of treatment

(Tiemersma, van der Werf, Borgdorff, Williams, & Nagelkerke,

2011). This can be for a number of reasons including inability

to obtain or afford the drugs, non-compliance (due to side ef-

fects) and lack of time to visit the clinic. However, there are

obvious differences between modern developing nations and

19th and 20th century Switzerland including economical and

geographical considerations. Thus it is impossible to predict the

outcomes of improved sanitation, vaccination, and immuno-

therapy, but it should still be considered important to use all

methods available to improve human health and combat a dis-

ease that has been a major cause of death for many years. In

particular, sanitation and public health education have been

very effective in reducing the mortality due to tuberculosis in

Switzerland. Part of the gradual decline in tuberculosis mortal-

ity may be due to the country’s attitude towards the disease.

Many highly reputable sanatoria were built in Switzerland and

people migrated from around the world to spend time in these

establishments. Consequently, the Swiss population would have

known about the disease and hygienic measures that aid in its

treatment (Rucker & Kearny, 1913). Vaccination and drug

therapy were introduced many years after the initial decline in

tuberculosis, indicating that these are not necessary for the de-

cline in tuberculosis mortality, though they do assist where

implemented.

Limitations of the Study

There are several possible interpretive issues and limitations

involved in analyses examining mortality and morbidity from

tuberculosis in

incomplete and biased thro

cioeconomic status (Doege, 1965; Rieder, Zwahlen, & Zim-

mermann, 1998). There may also be issues with the disease

nomenclature, wherein certain diseases may be identified by

several different cognates (e.g., phthisis) (Puranen, 1999).

These issues may also lead to an inability to determine the ac-

tual cause of a disease in specific terms (i.e. the single disease

which caused death) as well as whether an infectious agent was

involved. In some cases, the nomenclature does not give us the

opportunity to determine the cause of a disease as infectious or

other. For this reason, we created the “organ” group to help

remove this bias that would prevent us from giving an informa-

tive overview of the epidemiological transition in Switzerland.

However, since the records employed here cover a time period

after the modern nomenclature (“tuberculosis”) had come into

widespread use (1901 in Switzerland (Rucker & Kearny, 1913)),

this issue likely did not substantially affect the results presented

here. Difficulties with determining population size, and thus

density, also present a possible limitation (see Antunes &

Waldman, 1999), as both the population size and the geogra-

phical size of urban areas in Switzerland increased with ur-

banization throughout the mid to late 19th and 20th centuries.

While the city of Zürich expanded substantially in 1893, the

records employed begin at this time and thus it is unlikely to

have affected the results presented here. Only data from the

entire Canton of Zürich predate 1893 but no major increases in

population size occurred across the whole canton before this

time.

Another limitation is that much of the data employed here are

derived from Zürich city only, and thus do not necessarily rep-

resent larger patterns within other cantons or Switzerland as a

whole. This is however, also an advantage in that the death

record

tire canton since the entire canton includes rural areas which

may be overlooked during a census. Additionally, comparison

of the results presented here with other literature regarding the

K. L. HO LLOWAY ET AL.

second epidemiological transition showed that the trends ob-

served in Switzerland are similar to what occurred in other

countries, meaning our results can be extended to a wider area

of Europe.

Comparison with the Literature

It is possible to compare evidence from Switzerland on tuber-

culosis mortality with that of numerous other nations for the

period after 1870 because of the increased availability and

completeness of data for this this period. Comparisons made

or France, for instance, are between Switzerland and England

useful because similar events (e.g. sanitation, improvements in

public health) were occurring around the same time period at

the same rate in these countries and therefore, any differences

between them can be interpreted as being the result of differ-

ences in the country, such as culture and extent of urbanization

and development. A comparison of Switzerland and Japan is

also useful because the latter underwent urbanization later (at

the end of the 19th century and early 20th century) and at a

more rapid rate; thus the differences between the two countries

can be used to give an indication of the impact of urbanization

on tuberculosis mortality. In Switzerland, in 1901, tuberculosis

mortality was 273 per 100,000 population for the entire country.

Two countries, namely Hungary and France exhibited tubercu-

losis mortality rates above 300 per 100,000 in 1900 (Figure 4)

(Johnston, 1995). Italy, Netherlands, Spain, United States, Den-

mark, England and Japan exhibited values closer to those of

Switzerland, ranging between 160 and 199 per 100,000 (Gub-

éran, 1980; Johnston, 1995). Based on these comparisons, Swit-

zerland has a higher tuberculosis mortality rate than many other

countries in Europe (as well as the US). The reason for this

could be a higher accuracy of historical records in Switzerland

compared with other countries due to compulsory reporting of

cases of tuberculosis. Another possibility is that Swiss cities did

not grow in size until late in the 19th century. This is certainly

true for Zürich; in 1893, the city expanded substantially and

this would have had a major impact on the levels of overcrowd-

ing as immigrants had a larger area to migrate into. For cities

such as London and Paris, their areas were defined earlier in the

19th century and thus public health and sanitation efforts were

introduced into a well-known area.

Of these countries, mortality data for tuberculosis are also.

Figure 4.

Tuberculosis mortality rates per 100,000 living population for Switzer-

land and several other countries in the year 1900.

available for several major cities (London, Paris and Tokyo). In

1900, tuberculosis mortality in Zürich city was 422 per 100,000

In Tokyo, it was 480 per 100,000 in 1900 (Johnston, 1995), and

in London the tuberculosis mortality rate was estimated at 180

per 100,000 in 1891-1900 (Nathanson, 2007). Paris tuberculo-

sis death rates were 173 per 100,000 (Preston & Walle, 1978).

This comparison is useful because it shows that Zürich and

Tokyo had similar, very high rates of tuberculosis mortality.

London and Paris also had similar rates of mortality, but much

lower than those of Zürich and Tokyo. Both Zürich and Toky o

had poor sanitation and hygiene around 1900, but Switzerland

improved this situation at a faster rate than in Japan. This is

because they both adopted different measures to help control

tuberculosis. Switzerland initiated public health systems as well

as sanitation and Japan used much cheaper methods of facilities

(for the care of patients with tuberculosis) and public educatio

, 1995). The reason that both London and Paris have

introduced Public

f Public

(Johnston

lower rates of tuberculosis mortality than either Zürich or To-

kyo may be due to the fact the former had

Health Acts long before the latter did. England and Wales first

introduced Public Health Acts in the 1840’s (Szreter, 1988) and

France in the 1850’s (Preston & Walle, 1978). Thus, by 1900,

both of these cities had improved living conditions when com-

pared to Zürich and Tokyo, which did not introduce Public

Health Acts until later, although Zürich introduced sewerage

reforms earlier than Germany and England and Wales.

Over the 19th and 20th centuries, several major shifts were

observed in tuberculosis mortality among developing nations

undergoing the second transition. In most countries, tuberculo-

sis mortality decreased through time in parallel with improve-

ments in living conditions and sanitation. This is true for the

US, where tuberculosis mortality declined in two stages: first

during the first few years of the 20th century, and second be-

tween 1944 and 1950 (Doege, 1965). These two periods were

associated with two different events; the introduction of sanita-

tion and then later, specific drug therapy. Switzerland shows a

decline equivalent to that in the US in the early 1900s, likely

due to the same reasons of improving living conditions and

public health campaigns. Data for the 1940’s in Switzerland

Gubéran (1980) reveal another similar trend to the US. During

WWII, tuberculosis mortality rates remained stable, but later

when the war had ended and streptomycin was introduced, the

rate declined substantially. Declines in tuberculosis mortality

have also been documented for Great Britain starting from the

1830’s due to the introduction of a large number o

ealth Acts (Szreter, 1988). In contrast, data suggest that Japan

experienced high mortality from tuberculosis starting around

1895 and 1900, and extending to after WWII (Johnston, 1995).

Antibiotics and other medical interventions (e.g. surgery, other

chemical agents) were introduced after the war and this was

responsible for almost all of the decline in tuberculosis mortal-

ity in Japan. Rather than shifts in the disease nomenclature and

diagnostic accuracy for tuberculosis, declines in tuberculosis

mortality have also been described in low-income countries

undergoing industrialization and the second transition later

during the 20th century, such as Brazil, which witnessed major

declines in mortality rates in São Paulo between 1945 and 1985

(Antunes & Waldman, 1999). However, in Brazil and other

low-income nations, the transition was facilitated by medical

interventions, such as antibiotics, as well as by improvements

in living conditions and public health (Omran, 2005).

Changes in the age distribution of tuberculosis mortality

K. L. HO LLOWAY ET AL.

have also been discussed for high-income nations undergoing

industrialization and the second transition in the 19th and 20th

centuries. For instance, Preston and Walle (1978) showed that

in urban areas of France, such as Marseilles, Paris, and Lyon,

tuberculosis mortality was highest in young adults (20 to 29

years) but changed to older age groups (30 to 39 years) through

the 19th century (1816-1882). Doege (1965) showed that for

the US this trend was also observed from 1900 to 1960 and not

simply attributable due to an increase in life expectancy, but

rather due to a change in the manifestation of tuberculosis

across age groups. Tuberculosis was becoming a disease of the

elderly and remained latent in younger individuals before reac-

tivation later in life. Additionally, the average age of fatal tu-

berculosis increased in the US from 34.4 years in 1900 to 58.1

years in 1960 (Doege, 1965). While age information is not

available for Zürich, life expectancy did increase in Switzerland

over the time period 1893 to 1933 (Figure 1) while tuberculo-

sis mortality decreased. Additionally, one study by Gubéran

uggestions and describe them in relation to their

is was also true for the US (Doege 1965)

are a

out, but rather a combination of improved

liv

ogical transition, characterized by an increase in the drug resis-

980) for Switzerland as a whole showed that older age groups

were more commonly affected by tuberculosis through time for

the studied period: 1875 to 1935. This may indicate that living

conditions and health of children and young adults improved

such that older individuals were far more affected by the dis-

ease due to lowered immunity in later life (Omran, 2005). This

theory supports the other data presented here, suggesting that

tuberculosis mortality decreases with improvement in living

conditions.

Some studies have also found sex-based differences in tu-

berculosis mortality for some high-income industrializing coun-

tries undergoing the second transition. Data on sex in relation to

tuberculosis mortality in Switzerland are largely unavailable,

but Gubéran (1980) has demonstrated that for the country as a

whole, females aged 15 to 29 years had a higher mortality rate

than did their male peers between 1900 and 1960. Similar

patterns have been found in the US and Japan (Doege, 1965;

Johnston, 1995).

Several reasons for the decrease in tuberculosis mortality

through time during the 19th and 20th centuries in many coun-

tries have been suggested. For instance, Miller and Thompson

(1992) describe some criteria that assisted in the control and

prevention of tuberculosis in Newcastle, Britain around the year

1907. These included compulsory notification of tuberculosis,

sanatoria, building of hospitals and dispensaries, prevention of

infection of the lungs and abdominal tract, education, and es-

tablishment of a national health authority. Other authors agree

with these s

n work on different countries. Preston and Walle (1978)

reported that urban areas in France had poorer living conditions

than the rest of the country as a whole. They additionally sug-

gested that water supply, public health, and hygiene all must be

controlled for a decrease in tuberculosis mortality to occur. This

did occur in France during the late 19th and early 20th centuries.

They highlighted that medicine, including vaccination, surgery

and drug therapy, was not important in the decline of tubercu-

losis in France. Th

ring the initial decline in the early 1900s. However, antibiot-

ics were responsible for the secondary decline between 1944

and 1950. In São Paulo (Antunes & Waldman, 1999), the situa-

tion was slightly different, with tuberculosis mortality rates re-

mainning high until after WWII. Reasons for the decline there

included, besides the most important medication, preventative

and therapeutic measures (such as public education, antibiotics,

surgical interventions and a general increase in immunity

through improvements in nutrition and living conditions), in-

creased provision of health services (e.g. more clinics), and

social changes (e.g. how the population interacted with one

another, avoiding contact with others when they were conta-

gious). However, recently the tuberculosis mortality rate has

begun to increase again at an exponential rate, most likely

alongside the growing HIV/AIDS problem in Brazil.

The situation in Japan (Johnston, 1995) is similar to what

occurred in Brazil (Antunes & Waldman, 1999). Antibiotics to

combat tuberculosis were not available until after 1950 but after

that date were an important factor in the decline. Before this,

the Japanese used facilities (such as sanatoria and specialist

hospitals) and health education in order to combat the disease.

While these measures are less expensive than social and eco-

nomical changes, they are also less effective (Johnston, 1995).

In Japan, transmission of the disease was mostly due to female

industry workers returning to their homes in rural locations

from urban areas and from migrating soldiers. Both of these

groups were exposed to poor living conditions and thus were

more likely to develop active tuberculosis. Finally, Szreter

(1988) presents a series of arguments demonstrating that both

improved nutrition and various public health measures were

responsible for the historical decline in Great Britain. Szreter

(1988) also mentions the numerous Public Health Acts in Eng-

land and Wales that would have impacted living conditions.

They also highlighted how nutrition is important, but so

mber of other factors including overcrowding, lack of sun-

light, ventilation and occupational hazards (e.g. dust and smoke),

all of which were common problems in the initial stages of

industrialization.

In Switzerland, many of these factors did play some role in

the decline of tuberculosis through time. Living conditions

improved substantially during the second half of the 1800’s,

following the first sewerage reform in 1866. Public Health ser-

vices were excellent (e.g. many hospitals, well-educated medi-

cal personnel) in Switzerland and contributed to the overall

high quality of life in Swiss cities, which experienced few

health disadvantages as observed in other countries. Industri-

alization did not affect Switzerland as negatively as other coun-

tries, due to some unique characteristics of the economy, such

as the small number of factories and production centered within

the home, and the slow growth of urban centers.

Conclusion

From these descriptions, it is clear that prior to chemical

therapy and antibiotics, a series of factors were important in the

decline of tuberculosis mortality through time. No single factor

could be pointed

ing conditions as well as public health changes was ulti-

mately responsible for the decline in Switzerland. This is also

true for other countries, but Switzerland is unique in that it was

neutral during the years when conflict was common and has

had a stable government since 1848. This allowed the second

epidemiological transition to occur quickly and earlier than in

other countries. This knowledge could be implemented in the

high burden countries at present and consequently reduce mor-

tality from tuberculosis in these areas, just as it occurred in

Switzerland and other countries, many years ago. Many of

these countries are currently undergoing the third epidemiol-

K. L. HO LLOWAY ET AL.

tance of the tuberculosis bacterium. This limits the usefulness

of medicine as a method of therapy. Instead, consideration of

the ideas and practiceswiss and later, in

other

timore: The Johns Hopkins University Press.

Bouvier, N., Craig, G, C. E. (1994). Gen-

eva, Zurich, Basel:ity. Princeton,

ndon: Macmillan Press Ltd.

u. Asia Pacific Journal of Public Health, 23, 10-23.

Cole, S. T., Eisenach, K. D., McMurray, D. N., & Jacobs Jr., W. R.

(Eds.) (2005). Tuberculosis and the tubercle bacillus. Washington

DC: ASM Press.

C cholera

e, 163, 1009-1021.

45-

D, T. (1999). The white death: A history of tuberculosis. Lon-

G. Switzerland cantons. URL (last checked February

Jo95). The modern epidemic: A history of tuberculosis in

Kr of refrigera-

Lalian mortality

he United States, France, Great

British Journal

uarterly, 83, 731-757.

Rnc.

R1913). Tuberculosis in Switzerland:

75-107.

Snerability to tuberculosis in Am-

S). Cambridge: Cam-

T12). 1834 Poor Law. URL (last checked 7

employed by the S

areas in Europe, may present another viable option for

treatment, prevention, and ultimately reducing the global bur-

den of tuberculosis.

Acknowledgements

Information derived from historical records was accessed at

the StadtArchiv & Staatsarchiv (Zürich) and the staff at these

organizations should be acknowledged for their assistance with

locating the records of interest.

This research is supported by the Australian Postgraduate

Award, Dorothy and Walter Duncan Trust Award, School of

Medical Sciences Postgraduate Travel Award, Research Abroad

Scholarship, Faculty of Health Sciences Postgraduate Travelling

Fellowship, The University of Adelaide and the Mäxi Founda-

tion Zürich.

REFERENCES

Antunes, J. L. F., & Waldman, E. A. (1999). Tuberculosis in the twen-

tieth century: Time-series mortality in São Paulo, Brazil, 1900-97

(pp. 463-476). Ri o de Janeiro: Cadernos de Saúde Pública.

Bourdelais, P. (2006). Epidemics laid low: A history of what happened

in rich countries. Bal

. A., Gossman, L., & Schorske

History, culture and national ident

NJ: Princeton University Press.

Burke, S. D. A. (2011). Tuberculosis: Past and present. Reviews in An-

thropology, 40, 27-52.

Butler, M., Pender, M., & Charnley, J. (Eds.) (2000). The making of

modern Switzerland, 1848-19 98. Lo

Canton of Zürich (2012). Staatsarchiv. URL (last checked 7 September

2012).

http://www.staatsarchiv.zh.ch/internet/justiz_inneres/sta/de/home.ht

Carter, K., Soakai, T. S ., Taylor, R. , Gadabu , I., Rao, C., Tho ma, K., &

Lopez, A. D. (2011). Mortality trends and the epidemiological transi-

tion in Naur

Condran, G. A., & Cheney, R. A. (1982). Mortality trends in Philadel-

phia: Age- and cause-specific death rates 1870-1930. Demography,

19, 97-123.

ondrau, F., & Tanner, J. (2000). Working-class experiences,

and public health reform in nineteenth-century Switzerland. In S.

Sheard, & H. Power (Eds.), Body and city: Histories of urban publ

health (pp. 109-122) . Farnham: Ashgate Publishing Ltd.

orbett, E. L., Watt, C. J., Walker, N., Maher, D., Williams, B. G.,

Raviglione, M. C., & Dye, C. (2003). The growing burden of tuber-

culosis: Global trends and interactions with the HIV epidemic. Ar-

chives of Internal Medicin

Doege, T. C. (1965). Tuberculosis mortality in the United States, 1900

to 1960. Journal of the American Medical Association, 192, 10

1048.

ormandy

don: The Hambledon Press.

Gesetzgebung: Zürich (1928). Request of the City Council: Adoption of

rules on housing insp ec ti on . Zürich

aber, P. (1926). Concerning the wheat monopoly in Switzerland (Vol.

3). Geneva: French University Pre ss.

Gubéran, E. (1980). Mortality trends in Switzerland 2. Infectious Dis-

eases 1876-1977. Swiss Medicine Weekly, 110, 574-588.

willim Law (2009)

2011). http://www.statoids.com/uch.html

erzog, H. (1998). Histor y of tuberculosis. Respiration, 65, 5-15.

hnston, W. (19

Japan. Cambridge, MA: Harvard University Press.

aufmann, S. H. E., & Britton, W. J. (Eds.) (2008). Handbook of tu-

berculosis: Immunology and c e l l b i o logy. Weinheim: Wiley-VCH.

asner-Khait, B. (2011). History magazine—The impact

tion. URL (last checked 21 January 2011).

http://www.history-magazine.com/refrig.html

emann, M. F. (2008). Waste management. Bern: Peter Lang.

ewis, M., Taylor, R., & Powles, J. (1998). The Austr

decline: All-cause mortality 1788-1990. Australian and New Zealand

Journal of Public Heal t h , 22, 27-36.

iller, F. JM., & Thompson, M. D. (1992). Decline and fall of the tuber-

cle bacillus: The Newcastle story 1882-1988. Archives of Disease in

Childhood, 67, 251-255.

Nathanson, C. A. (2007). Disease prevention as social change: The

state, society, and public health in t

Britain, and Canada. New Yor k: R ussell Sage Foundat io n.

ewsom, S. W. B. (2006). The history oNf infection control: Tuberculo-

sis: Part two—Finding the cause and trying to eliminate it. British

Journal of Infection Control, 7, 8-11.

Newsom, S. (2006). The history of infection control: Tuberculosis, part

one: Defining a disease and its social consequences.

of Infection Control, 7, 14-17.

North, R. J., & Jung, Y. J. (2004). Immunity to tuberculosis. Annual

Review of Immunology, 22, 599-623.

Omran, A. R. (1983). The epidemiologic transition theory. A prelimi-

nary update. Journal of Tropical Pediatrics, 29, 305-316.

Omran, A. R. (2005). The epidemiologic transition: A theory of the

epidemiology of population change. Milbank Q

reston, S. H., & Walle, E. van de (1978). French mortality in the nine-

teenth century. Population Studie s , 32, 275-297.

Puranen, B. (1999). Tuberculosis and the decline of mortality in Swe-

den. In R. Schofield, D. Reher, & A. Bideau (Eds.), The decline of

mortality in Europe (pp. 97-117). New York: Oxford University

Press.

emak, J. (1993). A v er y c i vi l war : The Swiss Sonderbu nd War of 18 4 7 .

Boulder, CO: Westview Press, I

Rieder, H. L., Zwahlen, M., & Zimmermann, H. (1998). Mortality from

respiratory tuberculosis in Switzerland. Sozial- und Präventi vmedi zin/

Social and Preventive Medicine, 43, 162-166.

Ritzmann-Blickenstorfer, H. (1996). Historische statistik der Schweiz

[Historical Statistics of Switzerland]. Zürich: Chronos Verlag.

oberts, C. A., & Buikstra, J. (2003). ThRe Bioarchaeology of tubercu-

losis: A global view on a reemerging disease. Gainesville, FL: Uni-

versity Press of Florida .

ucker, W. C., & Kearny, R. A. (

Results of the campaign against the disease. Public Health Reports

(1896-1970), 28, 2815-2829.

Schoch, T., Staub, K., & Pfister, C. (2011). Social inequality and the

biological standard of living: An anthropometric analysis of Swiss

conscription data, 1875-1950. Economics and Human Biology, in

Print.

Siegenthaler, J. K. (1972). A scale analysis of nineteenth-century in-

dustrialization. Explorations in Economic History, 10,

Smith, F. B. (1988). The retreat of tuberculosis 1850-1950. New York:

Croom Helm Ltd.

tadt, Z. (2012). Stadtarchiv—Stadt Zürich. URL (last checked 7 Sep-

tember 2012)

http://www.stadt-zuerich.ch/content/prd/de/index/stadtarchiv.html

tead, W. W. (2001). Variation in vul

erica today: Random, or legacies of different ancestral epidemics?

International Journa l of Tu b erculosis and Lung Dise a se, 5, 807-814.

teinberg, J. (1996). Why Switzerland? (2nd ed.

bridge University Press.

zreter, S. (1988). The importance of social intervention in Britain’

mortality decline c. 1850-1914: A re-interpretation of the role of

public health. The Society for the Social History o f Med ic in e, 1, 1-38.

he National Archives. (20

September 2012).

http://www.nationalarchives.gov.uk/education/lesson08.htm

K. L. HO LLOWAY ET AL.

TM. J., Borgdorff, M. W., Williams, B.

V1998). Urban mortality change in England and Germany,

Wvine

04. Canadian Bulletin of Medical History, 23, 457-

Ar-

W Buikstra, J. E.

Wmmentary: Medicine, population, and tuber-

Wenbach, J. P. (1997). Cause-specific mortality trends in The

W/en

iemersma, E. W., van der Werf,

G., & Nagelkerke, N. J. D. (2011). Natural history of tuberculosis:

Duration and fatality of untreated pulmonary tuberculosis in HIV

negative patients: A systematic revi ew . PloS ONE, 6(4), e17601.

ögele, J. (

1870-1913. Liverpool: Liverpool Unive rsity Press.

addington, K. (2004). To stamp out “So Terrible a Malady”: Bo

tuberculosis and tuberculin testing in Britain, 1890-1939. Medical

History, 48, 29-48.

Warren, P. (2006). The evolution of the sanatorium: The first half-

century, 1854-19

476.

Wilbur, A. K., Bouw man, A. S., Stone, A. C., Roberts, C. A., Pfister , L.

A., Buikstra, J. E., & Brown, T. A. (2009). Deficiencies and chal-

lenges in the study of ancient tuberculosis DNA. Journal of

chaeological Science, 36, 1990-1997.

ilbur, A. K., Farnbach, A. W., Knudson, K. J., &

(2008). Diet, tuberculosis, and the paleopathological record. Current

Anthropology, 49, 963-991.

ilson, L. G. (2005). Co

culosis. International Journal of Epidemiology, 34, 521-524.

olleswinkel-van den Bosch, J. H., Looman, C. W., Van Poppel, F. W.,

& Mack

Netherlands, 1875-1992: A formal analysis of the epidemiologic

transition. International Jou rnal of Epidemiology, 2 6, 772-781.

orld Health Organization (2012). WHO tubercul os is .

http://www.who.int/topics/tuberculosis

上一篇:Mapping Three-Dimensional Dens 下一篇:Patients with Dementia and Epi

我要分享到：

职称论文发表交流平台！

Secular Trends in Tuberculosis during the Second Epidemiological Transition: A Swiss Perspective

最新文章NEWS

推荐期刊Tui Jian

热点文章HOT