, Volume 42, Issue 1, pp 1–22 | Cite as

The role of public health improvements in health advances: The twentieth-century United States

  • David CutlerEmail author
  • Grant Miller


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.


Gross Domestic Product Clean Water Child Mortality Typhoid Fever Decennial Census 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 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.Google Scholar
  2. 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.Google Scholar
  3. 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.Google Scholar
  4. 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.CrossRefGoogle Scholar
  5. 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.Google Scholar
  6. 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.Google Scholar
  7. 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.Google Scholar
  8. 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.CrossRefGoogle Scholar
  9. Duffy, J. 1990. The Sanitarians: A History of American Public Health. Urbana: University of Illinois Press.Google Scholar
  10. Elo, I.T. and S.H. Preston. 1996. “Educational Differentials in Mortality: United States, 1979–1985. ” Social Science and Medicine 42(1):47–57.CrossRefGoogle Scholar
  11. 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.Google Scholar
  12. 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.Google Scholar
  13. 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.Google Scholar
  14. Haines, M.R. 2001. “The Urban Mortality Transition in the United States: 1800–1940.” Annales de Demographie Historique 2001:33–64.Google Scholar
  15. Hamlin, C. 1990. A Science of Impurity: Water Analysis in Nineteenth Century Britain. Los Angeles: University of California Press.Google Scholar
  16. 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.Google Scholar
  17. McCarthy, M.P. 1987. Typhoid and the Politics of Public Health in Nineteenth Century Philadelphia. Philadelphia: American Philosophical Society.Google Scholar
  18. McKeown, T. 1976. The Modern Rise of Population. New York: Academic Press.Google Scholar
  19. Meeker, E. 1972. “The Improving Health of the United States, 1850–1915.” Explorations in Economic History 10:353–73.Google Scholar
  20. Melosi, M. 2000. The Sanitary City: Urban Infrastructure in America From Colonial Times to the Present. Baltimore, MD: Johns Hopkins University Press.Google Scholar
  21. 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.Google Scholar
  22. 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.Google Scholar
  23. Preston, S. and M. Haines. 1991. Fatal Years: Child Mortality in Late Nineteenth-Century America. Princeton, NJ: Princeton University Press.Google Scholar
  24. Preston, S.H. and E. van de Walle. 1978. “Urban French Mortality in the Nineteenth Century.” Population Studies 32:275–97.CrossRefGoogle Scholar
  25. 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.Google Scholar
  26. Smith, F.B. 1988. The Retreat of Tuberculosis 1850–1950. New York: Croom Helm.Google Scholar
  27. 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.CrossRefGoogle Scholar
  28. 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.CrossRefGoogle Scholar
  29. 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.CrossRefGoogle Scholar
  30. U.S. Census Bureau. 1916. General Statistics of Cities: 1915. Washington, DC: U.S. Government Printing Office.Google Scholar
  31. —. 1941. Sixteenth Census of the United States, 1940. Washington, DC: U.S. Government Printing Office.Google Scholar
  32. U.S. Census Office. 1888. Tenth Census of the United States, 1880. Washington, DC: U.S. Government Printing Office.Google Scholar
  33. —. 1902. Twelfth Census of the United States, 1900. Washington, DC: U.S. Government Printing Office.Google Scholar
  34. 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.Google Scholar
  35. World Health Organization. 2003. The World Health Report 2003: Shaping the Future. Geneva: World Health Organization.Google Scholar
  36. World Health Organization and United Nations Children’s Fund. 2000. Global Water Supply and Sanitation Assessment 2000 Report. Geneva: World Health Organization.Google Scholar
  37. Wrigley, E.A. and R.S. Schofield. 1989. The Population History of England, 1541–1871: A Reconstruction. Cambridge, England: Cambridge University Press.Google Scholar

Copyright information

© Population Association of America 2005

Authors and Affiliations

  1. 1.University and National Bureau of Economic ResearchUSA
  2. 2.Health Policy ProgramHarvard UniversityUSA
  3. 3.Department of EconomicsHarvard University, Littauer CenterCambridge

Personalised recommendations