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Public health and the development of infant mortality in Germany, 1875–1930 Jo¨rg Vo¨gele*, Wolfgang Woelk Institut fu¨r Geschichte der Medizin, Universita¨t Du¨sseldorf, Postfach 10 10 07, D-40001 Du¨sseldorf, Germany

Abstract The substantial increase in life expectancy over the past 150 years can largely be attributed to a drastic decline in infant mortality. In the continuing debate about the reasons for this development, recent research has focused attention on the role of public health. Since the 1870s in Germany, municipal and national public health strategies were launched. One major element of this policy was the fight against high infant mortality rates in urban areas. The establishment of municipal milk supplies and the creation of infant welfare centers attacked gastrointestinal disorders, the predominant cause of death among infants. This article investigates these developments in the largest German cities, particularly Du¨sseldorf, which is located in one of the most industrialized regions. D 2002 Elsevier Science Inc. All rights reserved. Keywords: Infant mortality; Life expectancy; Public health

1. Introduction Over the past 150 years, average life expectancy in western Europe has more than doubled, largely as a result of a dramatic decline in infant mortality. Whereas there were periods in Imperial Germany when only one in three infants survived childhood, the current infant mortality rate is only 6.7 per 1000 live births, and infants have a higher life expectancy than older children (Daten des Gesundheitswesens, 1993, p. 184). The reasons for this remarkable decline, however, remain largely unknown and are the subject of continuing debate. Recent

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Corresponding author. Tel.: +49-211-81-13942. E-mail address: [email protected] (J. Vo¨gele).

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studies have cited a number of key variables as determinants of infant mortality trends, including fertility, nutritional practice, housing quality, living conditions, educational attainment, economic well-being, and parental occupation (Imhof, 1994; Woods, Watterson, & Woodward, 1988/1989). In analyzing social and regional differences in German infant mortality rates, infant-feeding practices are considered key, as well as attitudes to life and death (Imhof, 1981; Kintner, 1982; Ottmu¨ller, 1991; Sto¨ckel, 1986). However, regional differences became less significant in Prussia during the 19th century, despite rising social inequality (Spree, 1988, 1995), and the absence of any linear trend in infant mortality by social class undermines the significance of economic factors. Attention in recent years, therefore, has focused increasingly on the influence of public health on infant mortality (Vo¨gele, 1997). For most of the 19th century, large cities were considered a ‘‘negative factor for health’’ (Bleker, 1983; Vo¨gele, 1994), but from the 1870s onward, they developed new public health strategies that attacked urban health problems at several levels and played an active role in the struggle against disease. Both municipal and national public health programs peaked during the Weimar Republic. Moreover, the fight against high infant mortality in urban areas was an important element in both cases, and serves as the focus for this article. For the pre-1914 period, the development of infant mortality will be analyzed in Germany’s 10 most populous cities (Berlin, Breslau, Cologne, Dresden, Du¨sseldorf, Frankfurt/Main, Hamburg, Leipzig, Munich, and Nuremberg), as well as in towns with populations over 15,000. For the period after World War I, the study will concentrate on the city of Du¨sseldorf. It is situated in one of the most densely populated regions of Germany, and it was specifically in the industrial areas of the Rhineland and Westphalia that urban authorities and county administration systematically developed public health programs and infant welfare provisions. Two key elements of infant care policy will be investigated in detail: the establishment of municipal milk supplies and the role of the Society for Infant Welfare in the district of Du¨sseldorf (Verein fu¨r Sa¨uglingsfu¨rsorge im Regierungsbezirk Du¨sseldorf).

2. The development of urban mortality in Germany, 1875–1930 Between 1875 and 1930, Germany was transformed from an agricultural to an industrial nation, a process accompanied by rapid population growth (Ko¨llmann, 1974; Laux, 1989; Matzerath, 1985; Reulecke, 1985). In 1871, 36% of Germany’s population lived in towns with more than 2000 inhabitants; by 1910, the proportion had risen to 60% and, by 1925, to 64% (excluding the Saar region) (Hohorst, Kocka, & Ritter, 1975, p. 44; Petzina, Abelshauser, & Faust, 1978, p. 37). Moreover, urban living conditions changed fundamentally. Prussian urban mortality rates, in general, reached their peak during the 1860s and 1870s, and began to decline during the following decades (Vo¨gele, 1991, 1996). This trend was initially evident among young children over 1 year of age, but infant mortality, which was highest in urban areas, eventually registered the most significant improvement in absolute terms. In Prussia, for example, infant mortality rates (per 100 live births) fell from 21 (in 1875), to 15 (1913), and finally to 8 (1930).

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At the beginning of this period, infant mortality was significantly higher in towns than in the countryside, but there was a continuous decline from the 1870s onward. By contrast, infant mortality rates in Prussia as a whole, specifically in rural areas, only began to fall in the early 20th century (Fig. 1) (Petzina et al., 1978, p. 33; Preussische Statistik, 1878–1914; Rothenbacher, 1982, p. 396; Vero¨ffentlichungen, 1878–1914). By 1900, infant mortality rates in towns of over 15,000 inhabitants were lower than in rural areas and in Prussia overall. This trend accelerated during the following decades to the benefit, in particular, of large cities. By 1905–1906, average life-expectancy in large cities of over 100,000 inhabitants stood at 42.7 years for men and 48.4 years for women, considerably higher than in medium-sized towns with 20,000–100,000 inhabitants (where life expectancy was 42.6 and 47.6 years,

Fig. 1. Infant mortality rates in German towns and in Prussia/German empire, 1875 – 1930.

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respectively) (Ballod, 1913, p. 58). Illegitimate infant mortality also fell in urban areas at a time when a perceptible increase was registered in rural districts (Prinzing, 1899, p. 613). The main causes of infant deaths were gastrointestinal disorders and limited viability at birth, often aggravated by emaciation as a result of gastrointestinal illness (Flu¨gge, 1894, p. 275; Kintner, 1986, p. 50; Prinzing, 1899; Prinzing, 1900, p. 636; Wu¨rzburg, 1887/1888, pp. 48–52). In 1877, these two causes of death accounted respectively for 50 and almost 25% of all infant deaths in the 10 largest German cities. Disorders of the respiratory system, with significantly lower mortality rates, ‘‘other causes,’’ and disorders of the nervous system followed them in ranking terms. Although the 10 largest cities had a lower incidence of infectious childhood diseases (such as scarlet fever, whooping cough, measles and rubella, diphtheria and croup), their higher infant mortality rates were primarily a result of deaths from gastrointestinal diseases, limited viability, and respiratory illness. Similar differences in the cause of death spectrum were evident in Prussia between urban and rural areas, and the decline in infant mortality during the period under consideration was due mainly to a reduction in the incidence of gastrointestinal diseases (Prinzing, 1930/1931, pp. 398–400; Vo¨gele, 1994, pp. 408–409).

3. Public health and infant mortality trends During the last decades of the 19th century, municipal authorities launched a systematic program to develop their sanitary and hygienic infrastructure, including the provision of central water supplies and sewerage systems, disinfection, and a stricter control of foodstuffs. Municipal milk supplies were also organized in the fight against infant mortality, as the high death rate from intestinal illness focused attention on the importance of infant nutrition (Weyl, 1904, p. 1). Although some contemporaries continued to argue that high infant mortality was essentially a matter of fate (Pfaffenholz, 1902, pp. 402–403), the simultaneous decline in Germany’s birthrate prompted growing fears over the country’s economic and military future. Infant welfare policies, however, remained focused solely on nutritional issues and no consideration was given to the need for broader sociopolitical measures (Frevert, 1985). According to Neumann (1902, p. 459), ‘‘it is not humanly possible to change the sad living conditions of the thousands of inhabitants in the cities. Therefore, infant welfare is limited to propagating breast-feeding, or—whenever this is not possible—to the supply of substitute nutrition in the form of high quality milk.’’ The supply of adequate milk, suitably pasteurized and sterilized using contemporary scientific standards, was considered a responsibility of the municipal authorities. The distribution of treated milk was initiated in the late 1880s, and municipal milk depots were established from the 1890s onward following the French example of the Goutte-de-Lait. The number of depots reached a peak in 1913 when 258 retail centers in 85 towns had a total turnover of 4.9 million liters. The milk depots, which were particularly numerous in the Rhineland (Kamp, 1914; Stadtarchiv Du¨sseldorf, III-4912a), also played an active role in the struggle against alcoholism through their propagation of milk as a substitute drink (Heggen, 1988; Ho¨lzer, 1988). But their impact should not be overestimated; the milk distributed in

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1913 represented the amount needed to supply Du¨sseldorf for a period of only 6 weeks (Die deutsche Milchwirtschaft in Wort und Bild, 1914, p. XIX). Private traders originally handled urban milk supplies, but municipal authorities tried increasingly to establish their own distribution systems (Spiegel, 1908, p. 232). Civic involvement was viewed as a means of improving the control of the urban milk trade and of guaranteeing the supply of cheaper, better quality milk to those families in greatest need. The daily supply of milk in large cities was subject to disruption in periods of crisis, as was the case in Du¨sseldorf during World War I. In March 1913, the city’s daily milk supply amounted to 134,000 litres; by December 1916 and February 1919, this had fallen to 36,000 and 11,000 litres, respectively (Statistische Jahresberichte der Stadt Du¨sseldorf). Although the pre-war figure had been regained by the late 1920s, supply shortages encouraged the emergence of a black market; those in greatest need of good quality, fresh milk, such as pregnant women, infants of single parents, or poor families, as well as the old and sick, simply could not afford the inflated prices. The supply of milk was not covered by Imperial foodstuff regulations and, by 1900, only three cities (Berlin, Dresden, and Munich) had imposed special municipal controls on infant milk. Not surprisingly, there were massive complaints relating to low standards (Flu¨gge, 1894, p. 321). A 1910 report by Du¨sseldorf journalist Isaak Thalheimer (1922, pp. 4–6) found traces of feces, straw, and formaldehyde in milk, and provided clear evidence of extensive milk adulteration by corrupt traders. Before 1901, police officers in Du¨sseldorf could only test milk by tasting and smelling it, and a lack of formal training meant that a significant amount of unsatisfactory milk was made available for human consumption. Legal regulations of the trade in milk and other dairy products were only introduced after 1901 when all milk imported into Du¨sseldorf had to be registered and inspected, and all milk traders were forced to register with the police so that any complaints could be dealt with efficiently (Schrakamp, 1908, pp. 110– 113). Although the proportion of contaminated milk found by laboratory tests fell from 23% to 3% between 1895 and 1906, the bacterial investigations to determine its microbial content remained complicated and difficult to apply in everyday tests (Schrakamp, 1908, p. 110). As a result, the amount of infant milk that was specially treated or subject to official control remained low at about 500 litres per day per 100,000 inhabitants. It was over twice the price of uncontrolled milk (50–60 Pfennige) and could only be afforded by well-to-do families (Pfaffenholz, 1902, pp. 400–404). Nevertheless, the food industry protested against the distribution of high quality milk and used costly publicity campaigns, supported by allegedly scientific expertise, to encourage the purchase of milk substitutes. In Bonn in 1902, for example, young families automatically received a brochure signed by a pediatrician recommending a specific dried milk substitute (Cramer, 1902, p. 419). Transportation remained a major problem in relation to urban milk supply. As industrialization progressed, urban milk production continuously declined, and large amounts had to be imported over long distances, often using inadequate facilities. Particularly during the hot summer season, milk quality deteriorated significantly. In Du¨sseldorf, for example, milk was imported from a distance of 80 km, and it was seldom completely sterilized because of the extra cost (Stadtarchiv Du¨sseldorf, III-4901; Das Reichsgesundheitsamt, 1926, p. 96). Despite these difficulties, local authorities remained convinced that the municipal milk supply had a

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positive impact on infant mortality rates, although its actual organization was often a point of conflict between wholesale and retail traders. An extreme example was the Du¨sseldorf milk war (Woelk, 1998a). Before 1914, the city’s milk supply had been in private hands, but the imposition of wartime controls had given rise to conflict, which was rarely expressed in public for the sake of unity. The situation changed abruptly, however, in the immediate postwar period. The supply of certain products, such as milk, remained under government control, but neither official intervention nor private-sector initiatives could prevent periodic shortages in the milk supply. The German government was therefore urged to reinforce the ability of local authorities to guarantee the milk supply, by influencing price levels and controlling distribution. In Du¨sseldorf, this led to the creation of the city’s own milk supply company (Du¨sseldorfer Milchversorgungs G.m.b.H, or DMVG), as a joint public–private enterprise (Stadtarchiv Du¨sseldorf, VII-969). Initially, the city planned to control the importation of all milk, but local protests from wholesale and retail traders led to strikes, violent conflicts, and what the local press termed the Du¨sseldorf milk war. On a number of days in autumn 1921, the city’s milk supply system collapsed completely. As a local newspaper reported, ‘‘The city regulations amounted to municipalizing the milk supply. The measures were not very popular in the eyes of the public because they represented a return to government control of the economy, whereas the war and post-war experience supported the case for a free-market

Fig. 2. Mortality from gastrointestinal disorders in German towns exceeding 15,000 inhabitants (per 100,000 living), 1877 – 1930.

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economy. In any case, the municipality was not equipped for a milk war whether in terms of the importation of milk or its distribution to consumers’’ (Du¨sseldorfer Nachrichten, 1921). The conflict was eventually resolved when producers and traders agreed to deliver emergency supplies of milk to the DMVG for infants, pregnant women, the elderly, and the sick. The city registered traders for this special milk supply, and all other milk was sold on the free market at a price fixed by the municipality.

4. Milk supply and infant mortality The question of whether an improved milk supply actually affected infant mortality rates remains controversial. Beaver (1973) and Dwork (1987) have argued that the substantial fall in infant mortality in England after the turn of the century was mainly a result of an improved supply of pasteurized milk, the promotion and distribution of dried milk for infant consumption, and an increasing use of condensed milk. Other authors (Woods et al., 1988/ 1989, pp. 116–120) have been skeptical of the impact of municipal milk supply on infant mortality trends. As breast-feeding remained widespread (over 90% of infants were breastfed), infant survival would have been dependent primarily on demographic and socio-

Fig. 3. The seasonal distribution of infant mortality in selected German cities, 1898 – 1902.

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economic factors. Moreover, the frequent use of inferior milk may well have been a cause of poor health (Atkins, 1992, p. 227). The situation in Germany, however, was markedly different, due to a relatively low rate of breast-feeding and the predominance of gastrointestinal diseases as a cause of infant death. Despite the enhanced propaganda for breast-feeding and the payment of breast-feeding premiums as part of official infant welfare programs, breast-feeding rates continued to decline (Kintner, 1985, pp. 169–172; Prinzing, 1906, p. 294). In the 1870s and 1880s, approximately 94% of mothers in Cologne breast-fed their children, but by 1902, the proportion had fallen to 40%. The comparative rates in Berlin in 1885 and 1900 were 55.5% and 31.4%, respectively (Neumann, 1902, p. 795). In regions of Germany where breast-feeding was not traditional, these rates were even lower. For example, data from the Munich Pediatric Hospital reveal a continuous rise in the proportion of infants who were never breast-fed from 78.3% (in 1861– 1869) to 82.3% (1870–1878) and 86.4% (1879–1886) (Bu¨ller, 1887, p. 320; Escherich, 1887, p. 233; Seidlmayer, 1937, p. 29). The fall in urban infant mortality, therefore, coincided with a reduction in the extent of breast-feeding. An improvement in milk supply, under these circumstances, would have had a significantly greater impact on mortality rates than was the case in England and Wales; it reduced the incidence of diseases of the digestive tract and initiated a decisive increase in infant survival.

Fig. 4. The seasonal distribution of infant mortality in Du¨sseldorf, 1905 (per 100 births).

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On average, the mortality rate from diseases of the digestive tract in towns with over 15,000 inhabitants fell sharply at the beginning of the 20th century (Fig. 2). However, infant mortality rates continued to reflect the influence of climatic conditions. The coolness of summer 1902 resulted in low mortality levels (see Fig. 1), whereas the extreme heat of summer 1911 was accompanied by a dramatic increase in infant deaths (Kruse, 1912, pp. 175–201; Seidlmayer, 1937, p. 20; Spiegel, 1908, p. 225). Seasonal variations persisted throughout the pre-1914 period, such as the typical summer peak in infant mortality in Berlin, Hamburg, Munich, Dresden, and Leipzig between 1898 and 1902 (Fig. 3; Prinzing, 1930/ 1931, p. 402). Moreover, in the case of Du¨sseldorf, this peak cannot be attributed to a simultaneous increase in the birth rate (Fig. 4); summer mortality rates were particularly high among disadvantaged infants, including illegitimate offspring (Jahresbericht des Statistischen Amts der Stadt Du¨sseldorf, 1905, pp. 4–5). In Berlin (Fig. 5), infants fed with milk substitutes were especially affected, whereas breast-feeding provided a certain protection during hot summer weather (Statistisches Jahrbuch der Stadt Berlin, 1913, p. 183). The disappearance of the summer peak during World War I must have been the result of a change in attitude toward breast-feeding by many mothers, perhaps because of economic difficulties and the deterioration in the urban milk supply. Breast-feeding rates continued to improve during the 1920s and, by 1926–1928, the summer peak in infant mortality had generally

Fig. 5. The seasonal distribution of infant mortality in Berlin (1908) according to nourishment.

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Fig. 6. The seasonal distribution in infant in selected German cities, 1926 – 1928.

disappeared (Hecker, 1923, p. 287; Prinzing, 1930/1931, p. 402; Seidlmayer, 1937, pp. 22 and 31) (Fig. 6).

5. The society for infant welfare in the administrative district of Du¨sseldorf The precise impact of municipal infant care programs can only be analyzed effectively within a local context. Around 1900, the need for a broad range of measures to reduce infant mortality rates was increasingly accepted, including improved milk standards, extensive infant welfare programs (involving breast-feeding campaigns), and better education about the causes of infant death. This process was reinforced by the creation of infant welfare societies in the first decade of the 20th century and the call in 1904 by the Empress Auguste Victoria for an intensification of infant welfare work (Weindling, 1989, pp. 37–55 and 200–209). Du¨sseldorf, however, was the first city to develop a new and comprehensive concept of infant care aimed at bringing together government, local authorities, and private welfare providers (Schnabel, 1995; Sto¨ckel, 1996; Woelk, 1998a). The pediatrician Professor Arthur Schlossmann became the leading figure in this movement. He organized a model dairy farm in Du¨sseldorf, which was designed to produce high quality milk. Extensive production costs and high prices meant that it was beyond the reach of poor mothers. He also emphasized the

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importance of education and advocated the operation of an infant welfare society that would focus on local issues through a broad network of institutions (both public and private). Following the call by the Empress, Schlossmann developed a detailed concept for an infant welfare society supported by the municipal administration and private welfare organization, and financed by the community. The result was the Society for Infant Welfare (Verein fu¨r Sa¨uglingsfu¨rsorge), which was founded in 1907 (Woelk, 1998b). This society embarked on a wide range of activities that took into account the economic structure, religious affiliation, and population density of Du¨sseldorf’s individual districts, and necessitated the compilation of information on infant mortality and existing welfare provision (Bericht u¨ber das erste Gescha¨ftsjahr des Vereins fu¨r Sa¨uglingsfu¨rsorge im Regierungsbezirk Du¨sseldorf, 1908; Woelk, 1999). A home-visiting service was developed and welfare workers provided advice on hygiene and housekeeping issues. However, the home visitors, who were mostly female and middle-class, often interfered in private family affairs and propagated bourgeois ideas on hygiene and morality. Many mothers remained ambivalent about this aspect of infant welfare work. The society, however, concluded that only an extension of the existing welfare network, as well as additional measures, would reduce infant mortality. The dramatic rise in the number of infant deaths during the hot summer 1911, therefore, left Schlossmann (1911, p. 2) in considerable despair: ‘‘Has everything that has been done for infants during recent times been in vain? Should we simply give up and say to ourselves that all our efforts were in vain and all future efforts will also be in vain? It was simply wrong to believe that our battle lines in the fight against infant mortality would be sufficiently fortified in such a short time that we would also be victorious in periods of hot weather.’’ Indeed, seasonal fluctuations in infant mortality were aggravated by national crises. Although breastfeeding increased during World War I, more women were employed in industry and had sole responsibility for their households. As a result, welfare programs, such as infant care courses for working mothers, were increasingly regarded with skepticism. Major employers reported a widespread lack of interest in the work of female counselors and dedicated training courses: ‘‘The women explained that after a hard day’s work as well as evening housework, they had neither the time nor inclination to attend the course’’ (Stadtarchiv Du¨sseldorf, III-4276: Schreiben der Mannesmann, 1916). The clear limitations of existing welfare programs reinforced the idea of a wider welfare concept, which would include the entire period of childhood and youth as well as the whole family. As a result, the society changed its name in 1919 and became Verein fu¨r Sa¨uglingsfu¨rsorge und Wohlfahrtspflege im Regierungsbezirk Du¨sseldorf (Society for Infant Welfare and Welfare Work in the Administrative District of Du¨sseldorf). However, following the establishment of the ‘‘controversial’’ Weimar welfare state (Peukert, 1987, p. 132), the municipal authorities assumed responsibility for a wide range of tasks that had previously been carried out by the society. This had always been a long-term aim of the society, and the adoption and successful implementation of infant welfare concepts by central government was widely welcomed by its members. An objective assessment of the society’s welfare work is hampered by the relative lack of suitable data. However, a number of weaknesses in the infant welfare movement can be identified. Firstly, the target group (working-class women) seldom attended its courses; instead

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the audience often consisted of members of other local welfare societies and their relatives. Secondly, the concentration on illegitimate children meant that the society’s work had a narrow focus. Not until after 1918 was it generally accepted that married women would also benefit from a better insight into proper infant care and feeding. Thirdly, the city’s central welfare office was located in the municipal hospital, a considerable distance from residential working-class districts. A visit to the office was therefore either time-consuming or expensive, given the gradual development of the public transportation system. Fourthly, the welfare office only gave advice and could not offer treatment. Sick children were sent to the municipal hospital’s pediatric department or were dealt with by private physicians. Many mothers, therefore, had little contact with the welfare office and preferred to take their children to general practitioners even if they were seldom qualified in the new discipline of pediatrics. 6. Conclusion Infant mortality in Germany reached a peak during the 1860s and 1870s at a time of extensive industrialization. A gradual decline in mortality rates followed, although the trend was not apparent in Prussia as a whole until the early 20th century. By this time, urban infant mortality was lower than the national average and in rural areas in general. Large cities, in particular, benefited from this trend, which coincided with improvements in health and hygiene, and in municipal milk supplies. However, the impact of these measures on infant mortality rates was muted. In most cases, the causes of disease were still unknown, and local measures seldom met actual hygienic requirements. The number of milk depots was insufficient, and the supply of good quality milk was never adequate for poorer families. Only the increase in breast-feeding between 1914 and 1918 had a decisive influence on mortality rates, and this was essentially a reflection of wartime pressures. However, contemporary attitudes toward infant mortality changed significantly; it was no longer accepted as a matter of fate and the belief that appropriate policies would improve infant survival became widespread. The most important causes of infant mortality were investigated, and systematic strategies were developed to combat high mortality rates. The foundations of a new approach to infant welfare were established, even when they involved welfare societies based on bourgeois values, which had only a limited impact in improving the health of the working class. Although the Society for Infant Welfare tried to adopt a broader approach, it was constrained by the legacy of the past. Its advocacy of comprehensive infant welfare programs, however, did not go unheeded, as government policy during the 1920s, specifically in terms of the municipal welfare system, increasingly reflected a wider concept of social welfare. References Atkins, P. J. (1992). White poison? The social consequences of milk consumption in London, 1850 – 1939. Social History of Medicine, 5, 207 – 228. Ballod, C. (1913). Grundriss der Statistik. Berlin: J. Guttentag. Beaver, M. W. (1973). Population, infant mortality and milk. Population Studies, 27, 243 – 254.

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