The present water closet system, with all its boasted advantages, is the worst that can generally be adopted, briefly because it is a most extravagant method of converting a molehill into a mountain. It merely removes the bulk of our excreta from our houses to choke our rivers with foul deposits and rot at our neighbors’ door. It introduces into our houses a most deadly enemy. —chemist quoted in the Scientific American (July 24, 1869:57)
Abstract
Mortality rates in the United States fell more rapidly during the late nineteenth and early twentieth centuries than in any other period in American history. This decline coincided with an epidemiological transition and the disappearance of a mortality “penalty” associated with living in urban areas. There is little empirical evidence and much unresolved debate about what caused these improvements, however. In this article, we report the causal influence of clean water technologies— filtration and chlorination—on mortality in major cities during the early twentieth century. Plausibly exogenous variation in the timing and location of technology adoption was used to identify these effects, and the validity of this identifying assumption is examined in detail. We found that clean water was responsible for nearly half the total mortality reduction in major cities, three quarters of the infant mortality reduction, and nearly two thirds of the child mortality reduction. Rough calculations suggest that the social rate of return to these technologies was greater than 23 to 1, with a cost per person-year saved by clean water of about $500 in 2003 dollars. Implications for developing countries are briefly considered.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Baker, M.N. 1948. The Quest for Pure Water: The History of Water Purification From the Earliest Records to the Twentieth Century. New York: American Water Works Association.
Blake, N.M. 1956. Water for the Cities: A History of the Urban Water Supply Problem in the United States. Syracuse, NY: Syracuse University Press.
Cain, L.P. and E.J. Rotella. 2001. “Death and Spending: Urban Mortality and Municipal Expenditure on Sanitation.” Annales de Demographie Historique 1:139–54.
Condran, G.A. and E. Crimmins-Gardner. 1978. “Public Health Measures and Mortality in U.S. Cities in the Late Nineteenth Century.” Human Ecology 6(1):27–54.
Costa, D.L. and M.E. Kahn. 2002. “Changes in the Value of Life: 1940-1980.” Working Paper No. 9396. National Bureau of Economic Research, Cambridge, MA.
Cutler, D. and G. Miller. Forthcoming. “Water, Water Everywhere: Municipal Finance and Water Supply in American Cities.” In Corruption and Reform: Lessons From America’s History, edited by E. Glaeser and C. Goldin. Chicago: University of Chicago Press.
Deaton, A. and C. Paxson. 2001. “Mortality, Education, Income, and Inequality Among American Cohorts.” Pp. 129–70 in Themes in the Economics of Aging, edited by D.A. Wise. Chicago: University of Chicago Press.
Dow, W.H., J. Holmes, T. Philipson, and X. Sala-i-Martin. 1999. “Disease Complementarities and the Evaluation of Public Health Interventions.” American Economic Review 89:1357–72.
Duffy, J. 1990. The Sanitarians: A History of American Public Health. Urbana: University of Illinois Press.
Elo, I.T. and S.H. Preston. 1996. “Educational Differentials in Mortality: United States, 1979–1985. ” Social Science and Medicine 42(1):47–57.
Ewbank, D.C. and S.H. Preston. 1990. “Personal Health Behaviour and the Decline in Infant and Child Mortality: The United States, 1900–1930.” Pp. 116–50 in What We Know About Health Transition: The Culture, Social and Behavioural Determinants of Health, Volume 1, edited by J. Caldwell. Canberra: Australian National University Printing Service.
Ferrie, J. and W. Troesken. 2004. “Death in the City: Mortality and Access to Public Water and Sewer in Chicago, 1880.” Mimeo. Department of Economics, Northwestern University, Evanston, IL, and Office of the Dean, University of Pittsburgh, Pittsburgh, PA.
Fogel, R.W. 1994. “Economic Growth, Population Theory, and Physiology: The Bearing of Long-Term Processes on the Making of Economic Policy.” American Economic Review 84: 369–95.
Haines, M.R. 2001. “The Urban Mortality Transition in the United States: 1800–1940.” Annales de Demographie Historique 2001:33–64.
Hamlin, C. 1990. A Science of Impurity: Water Analysis in Nineteenth Century Britain. Los Angeles: University of California Press.
Lleras-Muney, A. 2002. “The Relationship Between Education and Adult Mortality in the United States.” Working Paper No. 8986. National Bureau of Economic Research, Cambridge, MA.
McCarthy, M.P. 1987. Typhoid and the Politics of Public Health in Nineteenth Century Philadelphia. Philadelphia: American Philosophical Society.
McKeown, T. 1976. The Modern Rise of Population. New York: Academic Press.
Meeker, E. 1972. “The Improving Health of the United States, 1850–1915.” Explorations in Economic History 10:353–73.
Melosi, M. 2000. The Sanitary City: Urban Infrastructure in America From Colonial Times to the Present. Baltimore, MD: Johns Hopkins University Press.
Murphy, K.M. and R.H. Topel. 2003. “The Economic Value of Medical Knowledge.” Pp. 110–62 in Exceptional Returns, edited by K.M. Murphy and R.H. Topel. Chicago: University of Chicago Press.
Philipson, T. 2000. “Economic Epidemiology.” Pp. 1761–99 in Handbook of Health Economics, edited by J.P. Newhouse and A.J. Culyer. New York: North-Holland.
Preston, S. and M. Haines. 1991. Fatal Years: Child Mortality in Late Nineteenth-Century America. Princeton, NJ: Princeton University Press.
Preston, S.H. and E. van de Walle. 1978. “Urban French Mortality in the Nineteenth Century.” Population Studies 32:275–97.
Sedgwick, W.T. and J.S. MacNutt. 1910. “On the Mills-Reincke Phenomenon and Hazen’s Theorem Concerning the Decrease in Mortality From Diseases Other Than Typhoid Fever Following the Purification of Public Water Supplies.” Journal of Infectious Diseases 8:489–564.
Smith, F.B. 1988. The Retreat of Tuberculosis 1850–1950. New York: Croom Helm.
Szreter, S. 1988. “The Importance of Social Intervention in Britain’s Mortality Decline c.1850–1914: A Re-interpretation of the Role of Public Health.” Social History of Medicine 1(1):1–37.
Szreter, S. and G. Mooney. 1998. “Urbanization, Mortality, and the Standard of Living Debate: New Estimates of the Expectation of Life at Birth in Nineteenth-century British Cities.” Economic History Review 51(1):84–112.
Troesken, W. 2002. “The Limits of Jim Crow: Race and the Provision of Water and Sewerage Services in American Cities, 1880–1925.” Journal of Economic History 62:734–72.
U.S. Census Bureau. 1916. General Statistics of Cities: 1915. Washington, DC: U.S. Government Printing Office.
—. 1941. Sixteenth Census of the United States, 1940. Washington, DC: U.S. Government Printing Office.
U.S. Census Office. 1888. Tenth Census of the United States, 1880. Washington, DC: U.S. Government Printing Office.
—. 1902. Twelfth Census of the United States, 1900. Washington, DC: U.S. Government Printing Office.
Viscusi, W.K. and J.E. Aldy. 2003. “The Value of a Statistical Life: A Critical Review of Market Estimates Throughout the World.” Working Paper No. 9487. National Bureau of Economic Research, Cambridge, MA.
World Health Organization. 2003. The World Health Report 2003: Shaping the Future. Geneva: World Health Organization.
World Health Organization and United Nations Children’s Fund. 2000. Global Water Supply and Sanitation Assessment 2000 Report. Geneva: World Health Organization.
Wrigley, E.A. and R.S. Schofield. 1989. The Population History of England, 1541–1871: A Reconstruction. Cambridge, England: Cambridge University Press.
Author information
Authors and Affiliations
Corresponding author
Additional information
Research support from the National Institute on Aging, Grant T32 AG00186, through the NBER is gratefully acknowledged. We thank Joe Harrington, as well as participants of the Harvard-MIT labor/development economics seminar and the Harvard Center for Population and Development Studies seminar, for their helpful comments; Kurt Keeley at the American Water Works Association for help in navigating historical data sources; municipal water and sanitation department employees too numerous to name for clarification of historical information; and Mireya Almazan and John Indellicate for their capable research assistance. A longer version of this article, which contains additional results not presented here, is available as NBER Working Paper No. 10511. All of our data are available on request, and all errors are our own.
Rights and permissions
About this article
Cite this article
Cutler, D., Miller, G. The role of public health improvements in health advances: The twentieth-century United States. Demography 42, 1–22 (2005). https://doi.org/10.1353/dem.2005.0002
Issue Date:
DOI: https://doi.org/10.1353/dem.2005.0002