Abstract
BackgroundThis study examines the claim that social inequality in health in European populations was absent prior to 1750. This claim is primarily based on comparisons of life expectancy at birth in England between general and ducal (elite aristocrat) social classes from the 1550s to the 1870s. MethodsWe examined historic childhood mortality trends among the English ducal class and the general population, based on previously published data. We compared mid-childhood to adolescent mortality (age 5–14) and early-childhood mortality (age 0–4) between the ducal class and the general population from the 17th to 19th centuries. ResultsPrior to 1750, ducal early-childhood mortality was higher than the general population. However, mid-childhood to adolescent mortality was lower among the ducal class than the general population in all observed periods for boys, and almost all periods for girls. Among the ducal class, but not the general population, there was a sharp decline in early-childhood mortality around the 1750s which may partly explain the divergent trends in overall life expectancy at birth. ConclusionHealth inequality between the ducal class and general population was present in England from the 16th to mid-18th centuries, with disadvantages in mortality for ducal children in infancy and early childhood, but survival advantages in mid-childhood and adolescence. These opposing effects are obscured in life expectancy at birth data. Relatively high early-childhood mortality among ducal families before 1750 likely resulted from short birth intervals and harmful infant feeding practices during this time.
Highlights
Reducing unfair differences in health between more and less socially advantaged groups – known variously as “health inequalities” in the UK, “health disparities” in the USA, and “health inequities” by the World Health Organisation – is a major priority for public policymakers in the 21st century
We have not found evidence against the claim that improved medical technology was the main driver of diverging life expectancy between rich and poor, as childhood mortality did not begin to decrease among the general population until at least the mid-19th century (Woods et al, 1989)
One such factor that might have contributed to high ducal childhood mortality prior to 1750 is the harmful effect of aristocratic child rearing practices in early modern England on vulnerability to disease – in particular, short birth spacing and early childhood feeding practices such as wet nursing or dry feeding
Summary
Reducing unfair differences in health between more and less socially advantaged groups – known variously as “health inequalities” in the UK, “health disparities” in the USA, and “health inequities” by the World Health Organisation – is a major priority for public policymakers in the 21st century. Several scholars have pinpointed the mid-18th century as a watershed moment for health inequality in Europe, arguing that substantial differences in health outcomes relating to social inequality first emerged at that time This claim has been based on historical demographic data on trends in life expectancy at birth, comparing general and ducal (elite aristocrat) classes, from which causal inferences have been drawn (Davey Smith, 2003; Deaton, 2013; Lindstrom & Davey Smith, 2019; Livi-Bacci & Croft-Murray Trans, 1991). While McKeown acknowledged the contribution of medical innovations such as antibiotics and vaccination in reducing mortality, he demonstrated that long-term decreases in population mortality began well before their development These proposals were controversial at the time they were made and continue to stir disagreement among historical demographers and epidemiologists (Colgrove, 2002; Grundy, 2005; Szreter, 2000). Other researchers in epidemiology and demography have expressed scepticism about the existence of health inequalities prior to the 18th century, based on similar comparisons of class-based mortality data in England and sub-national areas of Sweden and Quebec (Edvinsson & Brostrom, 2017; Gagnon et al, 2011; Harris, 2008)
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