United States People

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Disease and Death in Early America

The small groups of people who migrated to the Americas from Asia thousands of years ago brought few germs with them. Although accidents and malnourishment were always possible, few infectious diseases were present in the Americas. When explorers and settlers arrived from densely populated Europe, they introduced diseases such as smallpox, measles, influenza, tuberculosis, whooping cough, scarlet fever, malaria, and gonorrhea. Africans brought smallpox as well, along with yellow fever, dengue fever, and malaria. Most Europeans and Africans had stronger immunities to the common diseases of their homelands, and Africans had discovered how to inoculate themselves against smallpox. Native Americans had no immunity to these imported diseases, and they died in large numbers. One estimate indicates disease was responsible for reducing native populations by 25 to 50 percent (in comparison, warfare reduced native populations by about 10 percent during the 18th and 19th centuries). Some Native American nations became extinct. Starvation and dislocation lasting into the 20th century also contributed to high death rates among Native Americans.

The earliest European settlers in the 17th century experienced high death rates. In Virginia, only about a third of the 104 people who came from England in May 1607 survived eight months after arriving. By 1624, about 7,000 settlers had come ashore, but only about 1,200 remained alive. The emphasis on searching for gold and quick profits meant that these first colonists paid little attention to producing food, building houses, or establishing permanent settlements. Starvation, exposure to the elements, and war with the native peoples caused large numbers of deaths. Half of the first settlers in New England did not survive the first winter, in 1620. However, the death rate decreased sharply in the north as colonists arrived in family groups and quickly created farms and towns to provide economic support. As a consequence of the low death rate, the population in the north grew rapidly without the need for many additional immigrants.

At first more European men than women lived in the south, and the southern population grew more slowly than the northern population. Deaths matched or surpassed births. The hotter climate in the south bred diseases such as malaria and dysentery, and European laborers frequently died of these and other semitropical diseases. Africans, who were imported to labor in the fields, were susceptible to lung diseases, but had some protection against malaria and yellow fever, and against smallpox if they had been inoculated in their homelands. African slaves shared their knowledge of smallpox inoculation during the 18th century, and the English discovered a vaccine against smallpox in the early 19th century. Even so, most diseases remained untreatable because the causes of illness were not understood.

Another source of disease emerged when large cities grew up around northern ports in the 17th and 18th centuries. These early cities were dirty places that grew haphazardly, without provision for clean water or sewage disposal. They served as ports of entry not only for travelers and immigrants but also for the diseases these voyagers brought with them. Epidemics of smallpox, yellow fever, measles, mumps, scarlet fever, and influenza frequently swept through the cities, while the isolated countryside was often spared these devastating illnesses. Among the worst of these was a series of yellow fever epidemics that hit Philadelphia in the 1790s. Ten percent of the population died in 1793, and smaller epidemics occurred in New York, Harrisburg, and other cities.

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Improved Sanitation

These outbreaks prompted the first concerted efforts at health reform in the late 18th and early 19th centuries. Major northern cities began constructing central water systems and collecting garbage. Central water systems meant that people in the largest cities had cleaner water for drinking and water for washing more frequently. Central water systems also made obsolete the rain barrels where disease-carrying mosquitoes bred. Cities invested in nuisance abatement, which included measures such as draining swamps and flooded areas, cleaning outhouses untended by landlords, tearing down abandoned housing, killing rats and mice, rounding up stray dogs, supervising cemeteries and burial practices, enforcing sanitation measures and market inspections, removing trash, and cleaning streets. Cities also enforced the quarantine of arriving passengers until all seemed healthy. Merchants often protested when their ships were quarantined. However, merchants were convinced of the effectiveness of such measures after quarantines helped diminish death rates during cholera epidemics in the 1840s.

By the middle of the 19th century, these civic reforms made the northern cities healthier than the countryside. Rural areas, however, could not afford the public health measures that improved conditions in the largest and most prosperous cities. Cholera was a major killer on wagon trains heading West. Yellow fever, malaria, hookworm, and other maladies still prevailed in the South, which experienced major yellow fever epidemics in the 1850s and in 1873. These epidemics led to the creation of the National Board of Health and a federal quarantine system.

In the mid-19th century, the development of the germ theory, which stated that microorganisms cause infectious diseases, helped people understand how diseases were transmitted. Antiseptic procedures began to be used, saving many lives in surgery and childbirth. Concerned individuals and private groups carried on much of the early fight against germs and disease. Mothers sought to improve health by attacking the germs that might harm their families. They taught their children to brush their teeth, use a handkerchief when blowing their nose, cover their mouths when coughing, wash with soap, and never spit. This concern for health and sanitation even helped fuel the woman’s suffrage movement, as many women demanded the right to vote in order to push for clean water, clean streets, and the pasteurization of milk. In the second half of the 19th century, the health and longevity of African Americans and their children improved substantially after the end of slavery enabled them to form permanent families. Enslaved children had been undernourished, poorly clothed, and denied education. When plantation owners no longer made the decisions about child care, children were healthier and better educated. And after 1867 the Granger movement, which brought farmers together to solve common problems, helped raise standards of sanitation on farms.

By the turn of the 20th century, the United States was a major center for medical research, and vaccines, antiseptic methods, and preventive measures substantially improved medical care. One estimate is that by 1910 a patient had a 50-50 chance of being cured by a doctor’s advice. As the 20th century began, deaths from communicable diseases were generally declining, although deaths from tuberculosis and influenza remained significant. At the same time, degenerative diseases of old age, such as heart disease, started to become more common causes of death.

Improvements in medicine, sanitation, and health, however, were countered by rapid industrialization of the United States in the late 19th century, which created air and water pollution, overcrowded cities, and substantial pockets of abject poverty in urban and rural areas. The Progressive movement of the late 19th and early 20th centuries addressed the health problems of the urban poor. Its many reforms included meat inspections, the Pure Food and Drug Act, and pasteurization of milk. State and federal governments began to enforce public health measures. The well-being of residents was no longer only a personal or a municipal matter, as state and federal agencies began to bring health reforms to larger numbers of Americans.

The New Deal, the government’s program in the 1930s to counteract the effects of the Great Depression, continued the Progressive agenda of improving health and sanitation. It was particularly effective in improving conditions in the South, which lagged behind the health advances made in the North. This regional disparity was largely because the rural, agricultural South lacked the financial resources of the industrial North. The Civil Works Administration, a New Deal agency that provided work relief in 1933 and 1934, targeted malaria as a severe problem in the South. One aspect of the agency’s activities was building improved housing with screened windows to keep out disease-carrying mosquitoes.

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Better Health Care

Access to modern medicine also began to equalize with the New Deal. After 1935 the Social Security Administration began to provide medical aid to children, pregnant women, and the disabled. During this time, private, commercial health insurance began to be developed. In 1929 a group of schoolteachers in Dallas, Texas, contracted with a local hospital to provide health coverage for a fixed fee. Shortly thereafter, the American Hospital Association created Blue Cross and Blue Shield to offer health insurance policies for groups. Health maintenance organizations (HMOs) were developed in the 1940s but did not become widespread until the 1980s.

Higher levels of medical care reached millions as people joined the armed forces during World War II. Community health also improved in many rural areas near military bases, as the government modernized water systems and sewage plants, exterminated mosquitoes and other disease-carrying insects, campaigned against sexually transmitted infections, and provided direct medical attention to civilian workers at the bases.

The federal Department of Health, Education, and Welfare (now the Department of Health and Human Services) was created in 1953. It underwrote the construction of hospitals and clinics and provided funds for medical research. Medicare and Medicaid were added to the Social Security laws in the mid-1960s to offer medical care to the elderly and to the needy. In the 1970s the federal government funded toxic waste cleanups and promoted clean air and water.

Modern antibiotics—including sulfa drugs and penicillin first used during World War II—became available to the American public in the postwar years. These drugs provided the first effective weapons against bacterial infections, and their use transformed medicine in the 1950s. Medical researchers in the 1950s also developed new vaccines, including one against polio. The annual death rate in 1940 (age-adjusted to discount any effect of the postwar baby boom), before the availability of the new antibiotics, was 10.76 percent; by 1960 it was down to 7.6.

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Current Trends

Since those days of miracle drugs, however, the rates for cancer have risen, despite considerable improvements in treatment. Cancer and heart disease were the leading causes of death in the United States at the beginning of the 21st century, in part due to the aging of the American population and the successes in curing other diseases. Another reason these diseases became more common is the unhealthy lifestyle of many Americans, who eat high-fat foods and high-calorie snacks and do not exercise enough. In addition, pollution is a suspected cause of cancer.

Additionally, new diseases emerged and old diseases resurfaced in the last quarter of the 20th century. The most serious of the new diseases was acquired immunodeficiency syndrome (AIDS). In 1995 it ranked as the eighth leading cause of death in the United States, but it has since declined significantly. Some diseases—such as tuberculosis, thought to be nearly wiped out because of antibiotics—developed resistance to drugs most commonly used to treat it. Cases of tuberculosis increased during the 1980s, and decreased only after 1991, when the government started taking aggressive steps to halt the increase.

A significant cause of death in the United States in the 20th century was unrelated to disease. During the span of the 20th century, homicide rose from insignificant levels to become a major cause of death. It was, in 1998, the number-three cause of death among children from the ages of 1 to 4, the number-four cause of death among children from 5 to 14, and the number-two cause among young adults from 15 to 24. Only after age 45 does homicide disappear as a major cause of death. While homicide rates in the United States remain higher than in other industrialized nations, in the 1990s the homicide rate began to fall dramatically. In 1991 there were 9.8 homicide victims for every 100,000 people in the United States; by 1999 the rate had decreased to 5.7 victims per 100,000.

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Age of U.S. Population

America’s population is growing because more people are being born than are dying and because immigrants, most in their late teens or early 20s, are still coming to the United States. This combination means that the American population is younger than in other developed nations. In 2001, 21 percent of the population in the United States was under the age of 15 This compares with 18 percent in Europe and 15 percent in Japan. Because the U.S. population is young, education costs are higher in the United States. Another effect of the increased number of young people is the larger market for goods and services. Furthermore, these young people will eventually be contributing to Social Security to help support the elderly. A younger population also indicates a smaller proportion of older people. In 2001, 13 percent of the U.S. population was over age 65, compared with 18 percent in Japan, and 15 percent in Europe.

The average age of the American population is, however, older than it once was, and projections indicate the percentage of the population over 65 will continue to increase through the first quarter of the 21st century. In the first census of the United States, taken in 1790, about half of the white male population was under the age of 16. This extremely youthful society was a result of the high birthrate and the relatively low life expectancy that prevailed in the 18th century. No figures exist on the elderly at that time, but the percentage was undoubtedly quite small. By 1890 the proportion of the population under age 15 had fallen to 35.5 percent, in large part because of the declining birthrate. Only 3.9 percent of the population was over age 65. The median age of the population—that is, the age at which half the people are older and half are younger—had risen to 22. By 2001, the proportion of the population under age 15 had fallen to 21.1 percent, while 12.6 percent of the population was over age 65. The median age in 1990 was 32.8, and according to estimates it had increased to 35.9 by 2001.

The rapid increase in the median age between 1990 and 2000 was the result of the aging of the baby-boom generation—people who were reaching their 30s, 40s, and 50s. The percentage of those under age 5 increased by 4.5 percent during these years, while the percentage of the population between 50 and 54 increased by some 55 percent. The numbers of those between 65 and 69 years of age actually decreased between 1990 and 2000, a reflection of the decline in birthrate during the 1930s depression.

Age differences also vary by ethnicity and race. The median age in 2000 for the non-Hispanic white population was 37.7, for non-Hispanic blacks 30.2, for Native Americans 28.0, for Asian and Pacific Islanders 27.5, and for Hispanics was 24.6. These differences stem in large measure from differences in birthrates.

Economists look carefully at the proportions of the population under age 15 and over 65. They assume people in these age groups do not hold paying jobs and therefore depend for support on those of working age (between 16 and 64). The proportion of dependents (meaning nonworking people) to working-age people suggests the productive capacity of the economy and the social expenses of providing for the nonworking population. In 1790 the proportion of workers to dependents was roughly 50-50. Supporting so many dependents absorbed substantial proportions of social resources and thus slowed economic growth. By 1890 the proportion in America had shifted in favor of those of working age, and about 40 dependents existed for every 60 workers. In the late 1990s there were 35 dependents for every 65 workers.

At the beginning of the 21st century, the proportion of elderly people in the population was increasing, meaning that there were fewer workers per dependent over 65. With the oldest members of the baby-boom generation expected to reach retirement age in 2011, the ratio of workers to dependents will drop even further. This aging of the population poses complex questions, such as how to provide funding for the Social Security system, whether to make medical insurance more widely available, determining who should pay for long-term care of the elderly, and questioning the meaning of retirement. It is unclear how old age will be experienced in the future. The division of social resources between the youngest and the oldest Americans, for example, between schools and retirement communities, has become a matter of considerable debate.

Within the United States, the age structure of the population varies from one region to another and is influenced by people moving into and out of particular regions as well as by the residential choices immigrants make. People tend to move between the ages of 15 and 25 as they attend schools and universities away from home, find apprenticeships and training programs, and seek job opportunities. After age 35 many people have established careers, started families, and made friends and connections, and are less likely to move.

The states that attract newcomers, such as Alaska, Colorado, Georgia, and Texas, tend to have the highest proportion of young people and the smallest proportion of older people. Job opportunity is the most frequent reason for moving, although recreational and environmental considerations are also important. Those who move also consider the available housing stock and the cost of living. Of all the states, Utah had the largest portion of young people at the beginning of the 21st century, largely because of high birthrates among its predominantly Mormon population. The states that experience more people leaving than arriving tend to have fewer young people and more older ones. Such states include Rhode Island, Pennsylvania, West Virginia, and North Dakota. Similarly, many northeastern cities have large elderly populations, while suburbs in the Southeast and Southwest have large populations of younger people. Florida is an exception to these trends, because it attracts many retirees as well as younger Cubans, Haitians, and other immigrants.