Advances in Anthropology
2013. Vol.3, No.2, 78-90
Published Online May 2013 in SciRes (
Copyright © 2013 SciRes.
Secular Trends in Tuberculosis during the Second
Epidemiological Transition: A Swiss Perspective
Kara L. Holloway1, Renata Henneberg1, Miguel de Barros Lopes2, Kaspar Staub3,
Karl Link3, Frank Rühli3, Maciej Henneberg1
1Biological Anthropology and Comparative A na t omy Research Unit, University of Adelaide,
Adelaide, Australia
2Pharmacy and Medical Sciences , University of South Australia, Adelaide, Australia
3Centre for Evolutionary Medicine, Institute of Anatomy, University of Zürich, Zürich, Switzerland
Received January 17th, 2013; revised Fe bruary 23rd, 2013; accep ted March 1st, 2013
Copyright © 2013 Kara L. Holloway et al. This is an open access article distributed under the Creative Com-
mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, pro-
vided the original work is properly cited.
The second epidemiologic transition is defined as “the age of receding pandemics”, wherein mortality de-
clines, life expectancy increases, and population growth occurs. The major causes of death also shifted
from predominantly acute infectious diseases to degenerative and “man-made” diseases (Omran, 1983).
The aim of this study was to determine the timing of the transition in Zürich (Switzerland) and to investi-
gate patterns of tuberculosis mortality during this period. This is one of the first studies to specifically in-
vestigate the timing of the second transition in Zürich, Switzerland. The data sources for this study were
Swiss records of mortality from the Staatsarchiv (Canton Archives), Stadtarchiv (City Archives) and a
published volume of State Statistics (Historische Statistik der Schweiz). The changes in mortality through
time were addressed for all causes of death in the city of Zürich for the years 1893 to 1933 that is, the
time including the second epidemiological transition. After 1933 the structure of the mortality data collec-
tion changed as the responsibility was transferred away from the canton archives. Mortality from tuber-
culosis was then examined in greater detail and compared with changes in living standards as well as
population density occurring at the time.
Keywords: Tuberculosis; Second Epidemiological Transition; Switzerland
An Overview of Tuberculosis
Tuberculosis is an ancient disease and has been one of the
biggest causes of death among societies throughout history
(Kaufmann & Britton, 2008). Tuberculosis occurs in individu-
als infected with a bacterium called Mycobacterium tuberculo-
sis and who cannot control the organism effectively due to a
lowered immunity (North & Jung, 2004). Tuberculosis is usu-
ally transmitted by inhalation of aerosols generated primarily
by coughing (Cole, Eisenach, McMurray, & Jacobs Jr., 2005).
However, ingestion of contaminated meat and dairy products is
a route of infection for the related bacterium, Mycobacterium
bovis, which predominantly infects cattle but can cause infection
in humans (Waddington, 2004; Wilbur, Farnbach, Knudson, &
Buikstra, 2008).
Mycobacterium tuberculosis does not always cause disease;
in fact only approximately 10% of infected individuals suffer
pathological signs and symptoms (Wilbur et al., 2008). A pa-
tient can even be asymptomatic and thus appear to be “cured”
for long periods of time, yet may show signs and symptoms
later in life. Since M. tuberculosis spreads mostly through the
respiratory tract, the common pathological signs and symptoms
include coughing, difficulty breathing, bloody sputum, weak-
ness, lethargy, loss of appetite and weight, night sweats, pallor
and chest pain (Dormandy, 1999; Wilbur et al., 2009). Tuber-
culosis can affect any part of the body and with time, the bacte-
ria can disseminate from soft tissues of the lungs to the other
parts of the body, including the bones (Wilbur et al., 2008).
In Europe, tuberculosis was likely responsible for 20% to
25% of all deaths during the 1500s (Stead, 2001). There are
difficulties with this estimate, however, because relevant his-
torical records can be absent, or incomplete and ambiguous on
cause of death in the pre-modern era. For example, in many
countries, physicians were hesitant to diagnose tuberculosis
because of the social implications for the patient and instead
recorded the cause of death as some other unspecified pulmo-
nary disease (Johnston, 1995). The term “tuberculosis” also did
not become widely used until the 1830s (Wilbur et al., 2008). A
number of other names were given to pulmonary conditions
presenting tuberculosis-like signs and symptoms including
“consumption”, “phthisis” and “the white plague”, while dis-
eases of other organs caused by M. tuberculosis were referred
to as tabe s m ese nte rica and “scrofula” or “King’s evil” (Herzog,
1998; Miller & Thompson, 1992; S. Newsom, 2006; Smith,
1988). In addition, disease diagnosis prior to the 19th century
did not have a high degree of certainty, and new systems of
disease classification were introduced in the early 20th century
(Dormandy, 1999; Rucker & Kearny, 1913). Improving accu-
racy in diagnostics and shifts in disease classification can cause
problems in interpretation of the mortality and morbidity of
tuberculosis through time as disease categories associated with
tuberculosis can also include several other conditions. For ex-
ample, “phthisis” may also include other pulmonary diseases
with symptoms similar to pulmonary tuberculosis. However,
the disease now known as tuberculosis has been reported in
some ancient literature such as a Babylonian text written by the
monarch Hammurabi between 1948 and 1905 BCE (Herzog,
1998; Kaufmann & Britton, 2008; S. Newsom, 2006; Steinberg,
1996). We investigated patterns in tuberculosis during the 19th
and 20th centuries, many years after it was first described in
these ancient writings. Thus, while some diagnoses are likely to
be incorrect, the majority will not be. We considered the terms
“tuberculo sis”, “consumption”, “pht hisis”, “scrofu la” and “King’s
Evil” as evidence of tuberculosis since these were the most
commonly used terms during the time period under investiga-
tion (Burke, 2011).
Switzerland—Public Health, Demography
and Economy
General Overview of Switzerland
Switzerland is a central European country comprised of 26
regions called “cantons”. These cantons differ in size, popula-
tion, language, geographical features, and extent of urbaniza-
tion. The borders of Switzerland are irregular because they re-
present negotiations and agreements in the past (Steinberg,
1996). For example, the Canton of Basel was split into two
half-cantons (Basel-Stadt and Basel-Land) after a disagreement
between urban and rural areas in 1830 (Bouvier, Craig, Goss-
man, & Schorske, 1994; Steinberg, 1996). The Swiss govern-
ment has been stable since 1848 (Butler, Pender, & Charnley,
2000; Steinberg, 1996), but each canton has its own constitu-
tion, executive, legislative and judiciary, laws and practices,
flag, and coat of arms as well as a separate Parliament (Stein-
berg, 1996). Multiple religions are accepted in Switzerland and
in the past the population was approximately equally divided
between Protestant and Catholic. The country has been neutral
since 1815, but still maintains an army (Remak, 1993). The
country’s economy, while highly specific (banks, watches, che-
ese, and chocolates), has been very successful. This success has
been partly due to dependence on foreign workers, which re-
duces labor costs. These workers came from a variety of coun-
tries including France, Poland, Germany and Italy (Bouvier et
al., 1994).
A Short Hist ory of Switzerland
At the end of the 1700s, Switzerland had no central govern-
ment, no common treasury, troops, currency, judiciary or mark
of sovereignty despite the long history of Confederation dating
back to the 13th century (Bouvier et al., 1994; Remak, 1993).
At the time, each canton was governed separately, though there
was a larger Parliament for the country, which consisted of rep-
resentatives from each canton. However, in 1798 major changes
occurred when Napoleon invaded Switzerland from France
(Remak, 1993). Following the invasion, Napoleon converted
Switzerland into the Helvetic Republic, which united and cen-
tralized the cantons. Napoleon also granted freedom of speech,
movement and religion to the country, and introduced a com-
mon currency, law code, and postage system (Remak, 1993).
However, due to dissatisfaction with some of these changes
among the populace, especially the loss of traditional rights of
the individual cantons, Napoleon altered the Helvetic Republic
with “The Act of Remediation” in 1803, which did not return
the cantons to Swiss control but did reintroduce some tradi-
tional rights. Napoleon lost control of Switzerland in 1814 and
in 1815 a Federal Treaty was signed. This reverted the country
to pre-Napoleonic policies and provided regulations for politi-
cal relationships between the cantons (Bouvier et al., 1994;
Remak, 1993; Steinberg, 1996). France was also required to
pay compensation for damages incurred during Napoleon’s
military campaigns, which supported Switzerland’s economic
development. The Treaty also introduced the concept of neu-
trality. While the Swiss citizenry was supportive of this, they
did not support the Treaty’s centralization of the country (Re-
mak, 1993).
In 1831, the 1815 Treaty was effectively rejected (Steinberg,
1996). Religious schisms also arose, driven in part by issues of
economic inequality: more urban, prosperous cantons were
gradually converting to Protestantism while the poorer and rural
cantons remained Catholic (Remak, 1993). This religious divi-
sion had progressed slowly throughout the 1830’s as Liberalism
became increasingly popular in Switzerland and other neigh-
boring European countries. This led to religion-based alliances
between the Catholic cantons, and widespread unrest, with
some unsuccessful attempts made by protestant Radical groups
to overthrow the government in 1844 and 1845. In 1847, a Civil
War erupted when seven Catholic cantons tried to establish a
separate alliance, though it ended in less than a month with few
casualties (Butler et al., 2000; Remak, 1993; Steinberg, 1996).
After the war, unification between the cantons became favored,
precluding the revolutionary uprisings, which plagued much of
Europe, and a new constitution was drafted in 1848, which
remains in use today. This new Constitution resolved the long-
standing conflict between national centralization and traditional
canton-based freedoms (Steinberg, 1996), by forbidding alli-
ances between the cantons. It created a “bottom-up” system that
allowed citizens to vote on all decisions by the government.
Thus power rests with the people rather than a central authori-
tative group (Bouvier et al., 1994).
Industrialization and the Economy of Switzerland
Switzerland was one of the earliest industrialized countries in
Europe, on a par with the United Kingdom, the United States,
and France (Butler et al., 2000; Steinberg, 1996). By 1780, the
entire region of eastern Switzerland was largely industrialized;
producing exports such as milk products, silk textiles, cotton
and mechanical parts (e.g. watches) (Steinberg, 1996). From
1880 to 1950 only the UK had a higher gross national product
per head. However, several features distinguished industrializa-
tion in Switzerland from that experienced by other early indus-
trializers: a slow rate of urbanization, high levels of economic
specialization (e.g. high quality mechanical parts and textiles,
see below), slow spread of railways, a strong dependence upon
foreign labor, limited geochemical natural resources, such as
coal, a high rate of international investme nt, a geographical con-
centration of economic activities in micro-units, and a very high
level of industrialization (Butler et al., 2000; Steinberg, 1996).
In fact, by 1850, Switzerland ranked fourth in the level of in-
dustrialization behind the United Kingdom, Belgium and the
United States (Siegenthaler, 1972). Railway systems developed
quickly in the mid 19th century in other early industrializers,
Copyright © 2013 SciRes. 79
but lagged in Switzerland, even in comparison to other aspects
of economic growth. This was due to difficulty with the moun-
tainous terrain, the absence of coal (industry and development
was fueled largely with hydropower) the small size of Swiss
cities, and lack of a strong, central government. Mountainous
terrain was also an overall obstacle to economic development in
Swi tz e rl an d: 2 5. 5% of the land is unprod uctive (e.g. High Alps) ,
30.3% is “forested”, and only 38.3% is available for agriculture
(Steinberg, 1996). Only 5.8% is considered surface area suit-
able for habitation and infrastructure. In a small country, this
amounts to a very small area.
In complement to industrialization, Switzerland also main-
tained a vigorous agricultural economy. This economy was fo-
cused on specialized milk products, such as cheese and choco-
late, which, together with tourism, watch making, and textile
production, provided consistent income for rural areas through-
out the 19th century. While the country maintained a high rate
of importation for cereals, exports, particularly of luxury items,
formed a critical component of the economy; only Belgium had
a higher export rate. Switzerland’s overwhelming economic
focus on export and luxury items, like watches and embroidery,
was due to the nation’s dearth of raw materials, and high trans-
port costs (Butler et al., 2000; Siegenthaler, 1972; Steinberg,
1996). Little economic centralization occurred; Swiss industria-
lists and canton governments were not supportive of large scale
production and industrialization or the construction of factories
(Steinberg, 1996). Instead, machines were installed in worker’s
home, allowing a continuation of cottage industry and piece
production (Bouvier et al., 1994; Butler et al., 2000). This prac-
tice resulted in a much lower urban population density than was
found in 19th and 20th century Britain or Germany (Steinberg,
1996). While exportation was expensive, Swiss goods remained
competitive because of low labor costs: wages were 15% lower
and hours 15% longer when compared with Germany (Stein-
berg, 1996). This advantage did not overcome all of Switzer-
land’s disadvantages, however, translating into a heavy empha-
sis on economic specialization and high levels of skilled labor,
high product quality, and involvement in international trade,
ope n ma r k et s , a nd o p ti m ization of trade conditions (Butler et a l .,
Switzerland employed child labor throughout the 19th cen-
tury, but also maintained a system of compulsory education.
Children participated in industrial activities within the home,
and thus were also able to attend school. Education of children
between the ages of 6 and 16, both boys and girls, became
compulsory in the 16th century (Bouvier et al., 1994; Steinberg,
1996). Economic assistance was provided to parents who could
not afford schooling for their children (Steinberg, 1996). Much
of Switzerland’s economic success has been attributed to this
emphasis on high quali ty, accessible educati on even in the face
of rapid economic growth (Butler et al., 2000).
Living Conditions in Switzerland
Switzerland maintained a uniformly high standard of living
in rural and urban areas during industrialization in comparison
to other early industrializers. This was largely due to the use of
white coal (hydropower) brought into the city from rural areas
(rather than black) which produced less pollution, and also to
low urban population density (Schoch, Staub, & Pfister, 2011;
Steinberg, 1996). For instance, in 1900, only 6% of Swiss citi-
zens lived in towns with a population of over 10,000. By 1910
this had only increased to 25%. In comparison, Great Britain
had reached 25% by the 1840s. Zürich had a population of
28,000 during the late 1800s, though in-migration and incorpo-
ration of surrounding regions into Zürich due to economic dif-
ficulties in 1893 pushed this number up to 100,000 (Steinberg,
Economic hardships also affected Switzerland in the 19th
century. Despite intensive agriculture, there were periodic food
shortages in the 1810s, particularly in urban areas and this was
associated with the internal conflict and fall of Napoleon’s
Empire in 1814 (Bouvier et al., 1994; Steinberg, 1996). Later,
in 1845, Switzerland also experienced an epidemic of potato
blight, which precipitated widespread poverty, increased levels
of child labor, and famines during the 1850s (Butler et al.,
2000). However, dietary and economic conditions improved
during the 1880’s, with increased consumption of animal pro-
tein as well as cheap grain (Schoch et al., 2011). With this in-
flux of grain from cheap imports, local farmers decided to focus
on milk products instead. Around this time (1870 to 1912), the
public healthcare system was established and public sanitation
(such as the introduction of sewerage systems, waste removal
and public health education), immunization as well as hous-
ing/working conditions were further improved (Schoch et al.,
2011). The public health system may have addressed factors
such as water pollution, poor quality foods in the marketplace,
disposal of animal waste from slaughterhouses, cemeteries,
problems with leaky sewers and septic tanks, street cleaning,
housing with inadequate ventilation or sunlight and harmful
chemicals or working conditions in industry (Bourdelais, 2006).
Major investments in the urban water supply and sewerage
systems were completed during the last third of the 19th cen-
tury in Switzerland (Condrau & Tanner, 2000). These methods
were more effective in urban areas than in rural areas; likely
because the former have a higher population density and these
measures could be more effectively implemented in cities than
in smaller, country towns. However, economic difficulties as-
sociated with a rise in the price of wheat and flour products due
to poor harvests during 1880-1888 caused many farmers to
become unemployed and forced many people to migrate from
rur a l areas to cities in search of a new occupation ( G r ab e r , 1926;
Schoch et al., 2011). However, while bread prices were rising
substantially in other countries (especially in Europe) the Swiss
Government established an association called the “Wheat Ad-
ministration” on the 9th of January 1915 (Graber, 1926). The
task of this association was to moderate the prices of wheat
products in Switzerland, to control imports of these products
into the country, maintain reserve stocks of cereals and to en-
courage the cultivation of home-grown wheat. Since this ad-
ministration was in control of purchasing wheat, when prices
increased during the 1880’s, it became difficult to afford Swiss-
grown wheat. The Wheat Administration was very successful
during WWI and consequently, bread prices in Switzerland
were tolerable for the consumer, unlike in other countries
around the world.
The conflicts and economic disturbances that ravaged much
of Europe through the 19th and 20th centuries had a moderate
effect upon Switzerland’s economy and living standards. Swit-
zerland did not participate in WWI but did experience minor
economic declines in part because the country maintained a
standing army during the period. Numerous refugees from Rus-
sia, France and Germany were also admitted during the 1910s,
resulting in additional economic declines because these indi-
Copyright © 2013 SciRes.
viduals required housing and subsistence, thus reducing the
amount of land and food available (Steinberg, 1996). Even
during WWI, the standard of living in Switzerland did not de-
cline, largely because of governmental attempts to control and
prevent malnutrition; government subsidies ensured that milk
products were highly accessible and a school lunch policy was
instituted (Schoch et al., 2011). In addition, the Government
also provided sufficient wheat for bread products through direct
cost to the country during WWI (Graber, 1926). During the
1930s, Swiss manufacturing (watches and textiles) was severely
affected by the Great Depression and in some areas, entire in-
dustries collapsed. Changes in currency exchange rates also
severely affected Swiss profits and in north-eastern Switzerland,
many towns relying upon single industries, became economi-
cally vulnerable (Steinberg, 1996).
The City of Zürich—An Overview of Sanitation and
Zürich is a very wealthy city located in northeastern Swit-
zerland, within the canton of Zürich. Economic growth associ-
ated with industrialization began in approximately 1827, and
became focused on cotton textiles around 1857. Industrializa-
tion affected the city in several ways including an increase in
population density, decrease in the level of sanitation and be-
ginning of social stratification. However, these changes oc-
curred to a lesser extent in Switzerland compared to other coun-
tries (Steinberg, 1996). The sanitation and hygiene situation in
Zürich in the early 1800s was similar to the rest of Europe; in
1837, a British tourist published an article in a Swiss magazine
des cri bi ng t he a mount of filth in the streets of Zürich. He stated:
“when it rained the streets turned into lagoons covered in half a
foot of mud” (Lemann, 2008). Due to a lack of sewage systems
in Zürich, human and animal waste and refuse drained into
small alleyways between houses and then into the River Lim-
mat, and water-borne diseases such as cholera (at the time the
records did not state the type of cholera) frequently raged
through the city. To correct this, major sewage refor ms were ins-
tigated between 1866 and 1870, resulting in the regular removal
of household refuse, introduction of simple sewerage systems
for waste and rainwater, and a system of waste management
based on composting and deposition in rural areas. This strat-
egy seems to have been effective; in 1883, Zürich hosted a
national exhibition that presented the city as one of the cleanest
and healthiest in Europe. Furthermore, in the 1890s, Swiss au-
thorities proposed the adoption of a mode of waste disposal
currently popular in Britain—incineration—and in 1899, the
citizens of Zürich allocated 1 million Swiss francs to construc-
tion of an incinerator in Zürich. This was to help control the
city’s waste in the future, since the current management would
be unable to cope with an increasing population. This facility,
finished in 1904, was the first in Switzerland and the fourth in
mainland Europe. Products of this facility did not impact the
health of individuals living in Zürich because it was built some
distance from the city. Other effective, though smaller scale
public health reforms included the use of sealed containers with
sliding lids for storing unwanted household refuse. These were
designed for the purpose in the early 1900s, quickly made
mandatory for all households in Zürich, and eventually mass-
produced throughout the country until plastic rubbish bags
made them obsolete in the 1970s (Lemann, 2008).
Switzerland’s Role in the Treatment of Tuberculosis
Switzerland played a substantial role in the 19th century de-
clines in mortality from tuberculosis. The country’s great num-
ber of sanatoria distributed through its alpine regions—and its
neutrality, which facilitated migration to these centers—long
encouraged individuals infected with tuberculosis to establish
short or long term residence there. The main reason for the
migrations were the reputation of Switzerland’s sanatoria in
aiding those with tuberculosis; many with the disease believed
if they could travel to these establishments that they would be
cured. These establishments were dedicated to the care of pa-
tient with active tuberculosis, and were built throughout the
1800s and 1900s to offer a “cure” for tuberculosis (Rucker &
Kearny, 1913). Contemporary medical thinking about active
disease held that the “open-air” climate found in the high
mountainous areas of Switzerland was an effective cure for the
disease (Warren, 2006). The sanatoria also encouraged rest, in-
cluding sitting in the sun, and “satisfactory” exercise (Dorman-
dy, 1999; Rucker & Kearny, 1913), and provided clean, hygi-
enic environments for patients, as well as a substantial nutri-
tional regime: up to seven meals a day, consisting largely of
dairy products and cod-liver oil (Roberts & Buikstra, 2003;
Warren, 2006). All of these treatment methods related to the
bolstering of disease resistance among patients through aiding
the immune system with proper nutrition and this allowed many
to recover from active tuberculosis. Rucker & Kearny (1913)
describe the success rates of sanatorium treatment of at least
four weeks for tuberculosis patients from 1905 to 1911. For
those with early stage tuberculosis, more than 95% improved,
3.2% were unimproved and only 0.1% died in the sanatoria. Of
cases with more advanced tuberculosis, 85% were improved,
12% were unimproved and only 1.0% died in the sanatoria.
Very advanced disease resulted in 62% improved, 34% unim-
proved and only 3% deaths in the sanatoria. During this period,
in the 19th and early 20th centuries, estimates of the frequency
of tuberculosis in Switzerland are rough, as only mortality from
the disease was recorded. However, in 1928, a law (Anfrage
des Stadtrates betr. Erlass von Vorschriften über die Who-
nungsinspektion) was passed that required the reporting of all
cases of active disease. Importantly, this law also required
treatment of all recorded individuals, not just those who could
afford a stay in a sanatorium (Gesetzgebung: Zürich, 1928).
However, tuberculosis has re-emerged in many other coun-
tries around the globe in the past few decades, following the
development of drug resistance and the HIV/AIDS epidemic
(Corbett et al., 2003; World Health Organization, 2012). Cur-
rently, the WHO estimates that one-third of the world’s popula-
tion is infected and two million die from tuberculosis each year.
Thus, it is important to study this ancient disease in order to
help us combat the current problem of re-emerging and drug
resistant tuberculosis.
Materials and Methods
Data Sources
Historical Records and State Statistics
Data employed in this study include vital records on mortal-
ity from both the Stadtarchiv (“city-archive” (Stadt Zürich,
2012)) and Staatsarchiv (“canton-archive” (Canton of Zürich,
2012)) in the city of Zürich. The Stadtarchiv held records for
causes of death in Zürich city from 1893 (likely because this
Copyright © 2013 SciRes. 81
was when the original city and the surrounding regions were
combined) to 1933, which included mortality attributed to tu-
berculosis. There were many records in this archive, and we
Statistik der Infektionskrankheiten (Statistics of Infectious
Tuberkulose (Tuberculosis): two volumes; 1912-1932 and
1932 to 1935;
Tuberkulose Sterbefaelle (Tuberculosis mortality): five vol-
umes; 1903-1905, 1905-1915, 1915-1920, 1920-1934 and
The Staatsarchiv held information detailing the introduction
of Anfrage des Stadtrates betr. Erlass von Vorschriften über die
Wohnungsinspektion (the Law regarding the compulsory re-
cording and treatment of tuberculosis). Data were also collected
from a volume of primary historical statistics for Switzerland
(State Statistics) titled “Historische Statistik der Schweiz”
(Ritzmann-Blickenstorfer, 1996). Both the Staatsarchiv and Sta-
te Statistics yielded information on mortality attributed to tu-
berculosis for thirteen cantons (i.e. Zürich, Berne, Lucerne, Uri,
Schwyz, Obwalden, Nidwalden, Glarus, Zug, Fribourg, Solo-
thurn, Basel-Stadt and Basel-Land) for 1876 to 1935. From the
book of State Statistics, the relevant table was “D43. Todesfälle
infolge Lungentuberkulose nach Kantonen 1876-1935” (Mor-
tality due to pulmonary tuberculosis by Canton).
The State Statistics also provided data on population sizes for
Zürich city (through censuses) and a number of cantons (i.e.
Zürich, Berne, Lucerne, Uri, Schwyz, Obwalden, Nidwalden,
Glarus, Zug, Fribourg, Solothurn, Basel-Stadt and Basel-Land)
for the years 1888, 1900, 1910 and 1930. This was used to cal-
culate the population density for those years with available data:
1888, 1900, 1910 and 1930 (Gwillim Law, 2009). Each canton
was assigned an arbitrary category of population density: low
(<40 people per km2), medium (40 - 80), high (81 - 100) or
very high (>101). These reflect relative predominance of rural
and urban styles of living. Cantons with low population density
were Uri (19.0 people per km2) and Obwalden (34.0). Medium
density included Nidwalden (49.7), Glarus (49.3), Schwyz
(62.2) and Fribourg (79.4). High density cantons were Berne
(101.7), Lucerne (107.0) and Zug (115.6). Finally, very high
de nsi ty ca nt on s in cl u de d So lo thurn (141. 5), Basel-Land (144 . 4) ,
Zürich (273.2) and Basel-Stadt (3221.6). Since population den-
sity increased through time in all cantons, this designation was
attributed based on the population density estimated for each at
the beginning of observations in 1888. Due to political and
economic stability, population densities in studied areas would
remain comparatively steady in comparison to each other thus
without changing the nature of low-density and high-density
The state statistics also provided average newborn life ex-
pectancies for 1878 to 1991. The available data represent an
average for the whole of Switzerland (Zürich canton and city
specific data were not available) and were used to give an indi-
cation of living conditions for 1840 to 1933.
Data Analysis
Causes of death were grouped into four categories according
to type of disease. These include infectious, “organ” (i.e. diseases
of organ systems such as the renal and reproductive systems),
degenerative, and “other” (e.g. accidents, poisoning). While we
are aware that some of the diseases placed in the group “organ”
may be the result of infectious processes, we could not be sure
and consequently, we simply chose to remove them from our
general overview in order to reduce biases. Diagnoses were
used as reported and no attempt was made to re-interpret them.
Although some terms changed around 1900 (e.g. “phthisis” to
“tuberkulose” (Rucker & Kearny, 1913)), an attempt was made
to keep the causes of death consistent over the time period by
determining which diseases had changed in nomenclature and
their corresponding new names. The percentage contributions
of each of these four disease groups were calculated by dividing
the total deaths from all diseases in that group by the total
deaths from all groups.
Data from literature investigating or describing the second
epidemiological transition in other countries were consulted to
provide a comparison for the Swiss data. Tuberculosis mortal ity
data were available for England and Wales (1860-1960), Japan
(1925-1964), Chile (1915-1965), Sri Lanka (1939-1967), The
Netherlands (1875-1992), Australia (1907-1990) and cities in
the United States (Philadelphia (1870-1930), New York (1866-
1965)). The countries used for comparisons were chosen due to
the availability of data and because they represent a diverse set
of conditions and degrees of urbanization. These comparisons
are thus useful to determine the effects of different living con-
ditions and social factors on tuberculosis mortality through time.
Graphs of percentage mortality from infectious, organ, degen-
erative, and other diseases were produced from the data pre-
sented in publications describing tuberculosis mortality in the
other countries stated above (Carter et al., 2011; Condran &
Cheney, 1982; Lewis, Taylor, & Powles, 1998; Omran, 1983,
2005; Wolleswinkel-van den Bosch, Looman, Van Poppel, &
Mackenbach, 1997). In some cases this was difficult, especially
where the causes of death were grouped or not clearly described.
In some cases, graphs from publications were not clear and
these were reproduced in a different format to allow an estima-
tion of the timing of the second epidemiological transition.
Following established methods, the percentage of tuberculo-
sis mortality was calculated by dividing tuberculosis mortality
by total all-cause mortality. This was plotted for both Canton
Zürich and the city of Zürich in order to observe trends and
patterns over time, but also for comparison of the two. Tuber-
culosis mortality, expressed as a rate per 100,000 living indi-
viduals, was plotted against the calculated population densities
for several Swiss cantons (Zürich, Lucerne, Uri, Schwyz and
Berne) in order to determine an y correlation between the two.
Part One: The Timing of the Second Epidemiological
Transition in Zürich City
The total number of recorded deaths for the causes in each
disease group (i.e. infectious, organ, degenerative, and other)
was expressed as a percentage of the total mortality for 1893 to
1933. This was plotted along with newborn life expectancy and
is shown in Figure 1. The second epidemiological transition,
defined by Omran (1983) as the time when degenerative dis-
eases become more important than epidemic infectious diseases
in terms of mortality, is clearly shown in Figure 1. This transi-
tion takes place in 1911, according to the intersection point of
linear trend lines for degenerative and infectious diseases. The
rate of increase of degenerative diseases was equal to the rate of
decrease of infectious diseases; 0.0079 ± 0.0007 and 0.0078 ±
0.0007 per year, respectively. This transition is reflected in the
Copyright © 2013 SciRes.
Copyright © 2013 SciRes. 83
increase in life expectancy; as individuals began living longer,
they beca me more likely to develop degenerative diseases. The
newborn life expectancy of males increased from 60.5 years in
1895 to 66.5 years in 1935. For females, the values increased
from 62.2 years to 69.6 years over the same time period.
of total mortality, was calculated for the canton of Zürich for
1840 to 1933 (Stadt Zürich, 2012) and Zürich city for a shorter
period, 1893 to 1933 (Ritzman n - Bl i ckenstorfer, 1996). The data
are plotted in Figure 2, along with annotati ons of important his-
torical dates for Switzerland, healthcare and tuberculosis treat-
In the city of Zürich, the percentage of total mortality from
tuberculosis decreased between 1893 and 1933. In the canton of
Zürich there was a peak in tuberculosis mortality around 1890.
This could be a result of economic difficulties involving the
wheat market (as mentioned above) as well as migration,
Part Two: Trends in Tuberculosis Mortality during
the Second Epidemiological Transition in Zürich City
and Zürich Canton
Mortality from tuberculosis, expressed here as a percentage
Figure 1.
Percentage mortality in the city of Zürich for infectious, organ, degenerative and other
diseases, between 1893 and 1933. Newborn life expectancies for males and females are
also plotted.
Figure 2.
Percentage of total mortality from tuberculosis in Canton Zürich (1840-1933) compared with
Zürich city (18 93 -1933). Historical ev en ts are also shown.
resulting in lower nutritional value of the Swiss diet through ra-
tioning (Graber, 1926). The data for the city differed from the
e: Patterns of Tuberculosis in Other Swiss
Cantons duri ng t he Se cond Epidemiological
the tu-
ely 1888 and
cantonal values in that the initial percentage was higher, likely
due to the higher population density of the city (average 1485
people per km2 between 1893 and 1933). Towards 1933, the
percentage of total mortality from tuberculosis in the city began
to approach the value for the entire canton. Finally, the decrease
in tuberculosis mortality is more dramatic in the city than in the
entire canton. This could reflect changes in living conditions as
well as improved access to medical treatment and medical ad-
vances in the city, which would be greater in a higher popula-
tion density area. In more crowded areas, before effective pub-
lic health measures, there was a higher level of infectious dis-
eases due to poor sanitation (waste products were left to de-
compose in the streets) as well as higher transmission rates due
to population density. With the introduction of public health
education and sanitation, these issues can be quickly and effi-
ciently resolved. There is another interesting observation from
Figure 2; the percentage of mortality from tuberculosis was
decreasing even before medical advances related to tuberculosis
care. This is potentially due to the improvements in living con-
ditions and public health care in Switzerland rather than spe-
cific tuberculosis treatments. Additionally, tuberculosis mortal-
ity was also in decline in the city of Zürich before the second
epidemiological transition occurred there, around 1911 (see
Figure 1).
Part Thre
Transition and the Effect of Population Density
Population density (people/km2) was plotted against
berculosis mortality rate per 100,000 living individuals (Figure
to determine whether correlations existed between these two
variables in different cantons during the several years for which
data were available: 1888, 1900, 1910, and 1930.
A positive relationship existed between population density
and tuberculosis mortality in the earlier years, nam
00 (Figure 3). The mortality rate decreased through time,
Figure 3.
Tuberculosis mortality rate per 100,000 living people compared wit
density (logarithmic scale) in various Swiss cantons (1888-
despite an increase in population density. The decrease in tu-
berculosis mortality is more dramatic in cantons with a higher
When compared with countries that industri-
alized in the 19th and eares, and the cities within
ly. For instance, in the earliest
industrializers, the
1930). Cantons include: Zürich, Berne, Lucerne, Uri, Schwyz, Obwal-
den, Nidwalden, Glarus, Zug, Fribourg, Solothurn, Basel-Stadt and
population density than those with a lower population density.
In those with lower density, the tuberculosis mortality rate in
1888 was 146 (per 100,000 living) but decreased to 90 by 1930.
In cantons of very high population density, the tuberculosis mor-
tality rate was 239 (per 100,000 living) in 1888 and decreased
to 91 by 1930. Note that in 1930 the correlation between tuber-
culosis mortality and population density disappeared and both
high and low density areas had the same tuberculosis mortality
rates (approximately 90 per 100,000).
Part One: The Timing of the Second Epidemiological
Transition in Zürich City
data from other
ly 20th centuri
them, evidence here suggests that Switzerland and Zürich un-
derwent the second transition ear
transition occurred during the 1920s in Great
Britain (Omran, 2005), and before 1930 in major urban areas in
the US, namely Philadelphia and New York (Condran & Che-
ney, 1982; Omran, 1983). In the Netherlands, for example,
which experienced intensive industrialization in the 1860s and
1870s, cause of death and all-cause mortality data, covering the
period from 1875 to 1992, suggest that the transition occurred
there only in the 1930s (Wolleswinkel-van den Bosch et al.,
1997). Other, later industrializing countries, including Nauru,
Japan, Mexico, and Chile exhibited patterns of an epidemiol-
ogical transition later, in 1955, 1951, 1957, and 1974, respec-
tively (Carter et al., 2011; Omran, 1983, 2005). Evidence from
Australia, for example, which industrialized mainly throughout
the 20th century, seems to suggest that the transition occurred
there in the 1920s; infectious disease mortality declined in the
1940s, stabilizing by 1950, and degenerative diseases, specifi-
cally cardiovascular disease and cancer, increased from 1920
on, only plateauing in 1940. Overall, the epidemiological tran-
sition in all of these other countries occurred later than in Swit-
The decrease in infectious disease mortality observed so
early is attributable to several possible causes. Refrigeration,
which would have reduced morbidity and mortality from gas-
trointestinal disease, is one possible cause. Refrigeration was
under development in the early 1800s and was in widespread
use in 1884 in the United States (Krasner-Khait, 2011); it likely
became widespread in Switzerland at approximately the same
time. The mortality rate from gastrointestinal diseases, many of
which may be caused by an infectious agent (though not al-
ways), in Zürich city decreased substantially from 17% of all
deaths in 1898 to 2% in 1914. This pattern suggests that the
decline may be linked with improvements in food technologies,
such as refrigeration. The decline would have substantially
lowered mortality among children, the age group most affected
by this type of disease, thus allowing more individuals within
the population to reach adulthood. This theory is supported by
the increase in life expectancy among newborns through time
as shown in Figure 1.
Improvements in general sanitation also likely played a role
in precipitating Switzerland’s early transition. For instance,
sewage control, which was introduced between 1866 and 1870
Copyright © 2013 SciRes.
in Zürich, and the increased accessibility of potable running
water in Zürich and other cities in the same time period, would
erland also, unlike these other
The 19th century witnessed several major shifts in mortality
enactment of the
arship on the second epidemiol-
fest symptoms for many years. As such, the picture of
ve facilitated the epidemiological transition in Switzerland by
further reducing mortality from water borne and many gastro-
intestinal diseases. Similar structural changes were occurring in
both England and Germany, but at a slightly later date. For
instance, in England, a Public Health Act in 1875 required ap-
propriate waterworks to be present and functional, while in
Germany, all larger cities (i.e. more than 25,000 people) had
efficient sewerage systems by the year 1900 (Vögele, 1998).
These changes, lagging slightly behind those in Switzerland,
are reflected in the decline of infectious diseases through time
in these nations. For tuberculosis, these improvements in living
conditions helped to increase the general immunity of the
population and consequently decreased the number of people
who developed active disease.
Importantly, Switzerland was a stable country during the
time periods investigated, and unlike many other early and late
industrializing countries, did not take part in any international
wars in the mid-19th and early 20th centuries (and into the
present day). Data from Switz
untries, show little evidence of poorer living conditions in
highly populated cities compared with rural areas. In contrast,
Great Britain, for example, experienced extensive damage to
their urban, economic, and public health infrastructures during
WWI and WWII. In WWII in particular, living conditions in
urban areas dramatically deteriorated due to damage to build-
ings and homes, leading to overcrowding as well as rationing of
food. This did not occur in Switzerland; living conditions re-
mained stable throughout the wars. In Switzerland, many of the
penalties associated with urban factories were avoided because
individuals could work at home and were not subject to the
poor conditions of living and working in large cities. This kept
many native Swiss in their hometowns and encouraged some
immigrants to move to these areas; thus helping to prevent cit-
ies becoming overcrowded. These factors, combined, seem to
have contributed to a buffering of the epidemiological costs
associated with industrialization and urbanization in Switzer-
land, and a comparatively earlier transition to a reduced regime
of infectious disease and greater longevity among its citizens.
Part Two: Trends in Tuberculosis Mortality during
the Second Epidemiological Transition in Zürich City
as Well as the Entire Canton of Zürich
from tuberculosis in Zürich. Between 1840 and 1870, the pe
centage of total mortality from tuberculosis in the Canton of
Zürich decreased substantially. This coincided with changes in
health policies, including sanitary reforms and
ew Poor Law” (the “Old Poor Law” was introduced in the
16th century), which required the segregation of wealthy and
poor individuals and encouraged those with the ability to work
to find employment and support themselves (Wilson, 2005).
The Newer Poor Law aimed at providing housing, clothing,
food and education (for children) to the poor in return for sev-
eral hours of labor per day in a workhouse (The National Ar-
chives, 2012). Separating these poorer individuals from those of
higher socioeconomic status helped to reduce tuberculosis
among the latter because they had less contact and opportunity
for transmission of the disease with poor people with lower
immunity due to a lower nutritional status. However, after the
Prussian-French War (1870-1871), the percentage mortality due
to tuberculosis increased, which may be attributed to the influx
of a large number of both French troops and refugees, who
were likely poorly nourished and stressed, into the canton near
the end of the war. This trend persisted until approximately
1910, when the percentage decreased again in both the city and
Canton of Zürich. This decline coincided with a number of
important developments in tuberculosis prevention and control
in Switzerland, including the discovery of X-rays in 1895 (these
were later used as a method of diagnosing active pulmonary
infection) (Herzog, 1998), and the initiation of testing cattle to
control bovine tuberculosis around 1907 in many European
countries (S. W. B. Newsom, 2006). These innovations were
later followed by the first use of the Bacille Calmette Guerin
(BCG) vaccine in 1921, which was the first—and only—vac-
cine to provide protection from tuberculosis, particularly in
children (Herzog, 1998). Lastly, the 1928 Swiss law which re-
quired reporting and treatment of cases of tuberculosis (Ge-
setzgebung: Zürich, 1928), and the invention of surgical treat-
ment for pulmonary tuberculosis in the 1930s (Herzog, 1998)
likely contributed to the steady early 20th century decline in the
disease in Switzerland and Zürich specifically. Interestingly,
the years associated with the beginning of industrialization and
economic hardship in Zürich (19th century), and thus poten-
tially reduced overall health were not associated with increased
mortality from tuberculosis.
The fact that tuberculosis mortality decreased before medical
interventions in Zürich suggests that medical treatment and
advances on their own may not be major causes of declines in
mortality from tuberculosis in a given population. This finding
is congruent with other schol
ical transition, such as Omran (2005), which suggests that
ecobiological changes, such as aspects of the environment, and
the biology of hosts and pathogens, and socioeconomic, politi-
cal and cultural changes, such as standards of living, hygiene
and nutrition, exerted far more influence in precipitating the
second transition than did medical intervention, such as surgery,
drugs and vaccination. Likewise, our results suggest that in
Switzerland, the second transition occurred before the imple-
mentation of major medical advances, such as chemical ther-
apy/antibiotics and in the case of tuberculosis, before use of
BCG vaccine. It seems that this early occurrence of the epide-
miological transition is a result specific for Switzerland’s com-
bination of sanitation, local health care arrangements and living
conditions. These latter ones included lack of overcrowded ex-
tensive urban agglomerations, working at home or in small
establishments, relatively good food sup ply, and stable social re-
lationships. This observation has important implications in the
current global situation because there are a number of low-
income countries struggling with the problem of multi-drug
resistant bacteria (World Health Organization, 2012). Our find-
ings suggest that clinical endeavors and public health initiatives
in these contexts should emphasize improving overall health,
general nutrition, and living standards, as much—if not more
so—developing and providing new drugs and treatment regi-
Tuberculosis, however, does defy easy categorization into
the shifting patterns of mortality characteristic to the second
transition. This is because it is an infectious condition, but also
a chronic disease which, like degenerative diseases, often does
not mani
decline in infectious disease mortality in Zürich and of tuber-
Copyright © 2013 SciRes. 85
culosis specifically in the early 20th century is not straightfor-
ward; instead the data suggest a combination of infectious and
non-infectious causes producing mortality through a chronic
and long-lasting process. Tuberculosis does have an infectious
origin, but active disease is a result of an individual’s inability
to control the disease. Mortality from the disease gives us in-
formation about a combination of the levels of transmission,
nutritional status and level of public health, but it is very diffi-
cult to split these factors during corresponding interpretations.
However, this information is useful for providing a general
overview of the population’s ability to resist other infectious
agents and as this increases, the second epidemiological transi-
tion is observed.
Part Three: Patterns of Tuberculosis in Other Swiss
Cantons duri ng t he Se cond Epidemiological
Transition and the Effect of Population Density
The results presented here suggest that tuberculosis mortality
proving living conditions in high-density areas to
the second epidemiological transition. For in-
stance, historical records, which are relied upon here, can be
ugh uneven distribution of ages or
s are likely to be more complete as compared with an
rates declined more rapidly in high population density canton
than in low-density cantons (from 1910 onwards), which ma
be due to progressive improvements in sanitation and chan
strategies for handling tuberculosis patients which may be
fective in more crowded areas (as mentioned previously).
However, high density areas also showed higher initial rates of
tuberculosis mortality (during the years 1888 and 1900 specifi-
cally) likely due to poorer living conditions and increased hu-
man contact in these urban areas in comparison to low density
rural areas.
These results further suggest that in 19th and 20th century
Switzerland, living conditions exerted a substantial impact on
mortality rates from tuberculosis, while medical interventions
exerted less of an effect. Sanitation methods may have become
effective in im
ake them comparable with lower density areas. The effect of
good sanitation may result in a reduction of transmission of
diseases because the population’s immune systems are bom-
barded by infectious agents to a lesser extent than in the case of
poor sanitation. With a lower level of infectious agents in the
environment, accompanied by an increase in nutrition, the im-
mune system of an individual will have a higher chance of con-
trolling diseases. Additionally, outbreaks of specific diseases
(e.g. cholera) will be less likely when there are fewer opportu-
nities for the pathogens to be transmitted from one person to
another. In the case of lower density areas, there are already
fewer opportunities for the spread of pathogens. This has im-
plications for developing nations, where a similar situation is
currently present (poor living conditions, overcrowding and
poor nutrition). Regions such as sub-Saharan Africa, South-
East Asia and some countries in South America currently are
considered high burden areas in terms of tuberculosis (World
Health Organization, 2012). Consequently, improving the stan-
dard of living through sanitation (improving waste management
and especially public health education) and reviewing and
modifying how tuberculosis patients are handled could possibly
be used to obtain the same effect as observed for Switzerland.
Currently, many individuals are given antibiotic therapy for
tuberculosis, but often do not finish the course of treatment
(Tiemersma, van der Werf, Borgdorff, Williams, & Nagelkerke,
2011). This can be for a number of reasons including inability
to obtain or afford the drugs, non-compliance (due to side ef-
fects) and lack of time to visit the clinic. However, there are
obvious differences between modern developing nations and
19th and 20th century Switzerland including economical and
geographical considerations. Thus it is impossible to predict the
outcomes of improved sanitation, vaccination, and immuno-
therapy, but it should still be considered important to use all
methods available to improve human health and combat a dis-
ease that has been a major cause of death for many years. In
particular, sanitation and public health education have been
very effective in reducing the mortality due to tuberculosis in
Switzerland. Part of the gradual decline in tuberculosis mortal-
ity may be due to the country’s attitude towards the disease.
Many highly reputable sanatoria were built in Switzerland and
people migrated from around the world to spend time in these
establishments. Consequently, the Swiss population would have
known about the disease and hygienic measures that aid in its
treatment (Rucker & Kearny, 1913). Vaccination and drug
therapy were introduced many years after the initial decline in
tuberculosis, indicating that these are not necessary for the de-
cline in tuberculosis mortality, though they do assist where
Limitations of the Study
There are several possible interpretive issues and limitations
involved in analyses examining mortality and morbidity from
tuberculosis in
incomplete and biased thro
cioeconomic status (Doege, 1965; Rieder, Zwahlen, & Zim-
mermann, 1998). There may also be issues with the disease
nomenclature, wherein certain diseases may be identified by
several different cognates (e.g., phthisis) (Puranen, 1999).
These issues may also lead to an inability to determine the ac-
tual cause of a disease in specific terms (i.e. the single disease
which caused death) as well as whether an infectious agent was
involved. In some cases, the nomenclature does not give us the
opportunity to determine the cause of a disease as infectious or
other. For this reason, we created the “organ” group to help
remove this bias that would prevent us from giving an informa-
tive overview of the epidemiological transition in Switzerland.
However, since the records employed here cover a time period
after the modern nomenclature (“tuberculosis”) had come into
widespread use (1901 in Switzerland (Rucker & Kearny, 1913)),
this issue likely did not substantially affect the results presented
here. Difficulties with determining population size, and thus
density, also present a possible limitation (see Antunes &
Waldman, 1999), as both the population size and the geogra-
phical size of urban areas in Switzerland increased with ur-
banization throughout the mid to late 19th and 20th centuries.
While the city of Zürich expanded substantially in 1893, the
records employed begin at this time and thus it is unlikely to
have affected the results presented here. Only data from the
entire Canton of Zürich predate 1893 but no major increases in
population size occurred across the whole canton before this
Another limitation is that much of the data employed here are
derived from Zürich city only, and thus do not necessarily rep-
resent larger patterns within other cantons or Switzerland as a
whole. This is however, also an advantage in that the death
tire canton since the entire canton includes rural areas which
may be overlooked during a census. Additionally, comparison
of the results presented here with other literature regarding the
Copyright © 2013 SciRes.
second epidemiological transition showed that the trends ob-
served in Switzerland are similar to what occurred in other
countries, meaning our results can be extended to a wider area
of Europe.
Comparison with the Literature
It is possible to compare evidence from Switzerland on tuber-
culosis mortality with that of numerous other nations for the
period after 1870 because of the increased availability and
completeness of data for this this period. Comparisons made
or France, for instance, are between Switzerland and England
useful because similar events (e.g. sanitation, improvements in
public health) were occurring around the same time period at
the same rate in these countries and therefore, any differences
between them can be interpreted as being the result of differ-
ences in the country, such as culture and extent of urbanization
and development. A comparison of Switzerland and Japan is
also useful because the latter underwent urbanization later (at
the end of the 19th century and early 20th century) and at a
more rapid rate; thus the differences between the two countries
can be used to give an indication of the impact of urbanization
on tuberculosis mortality. In Switzerland, in 1901, tuberculosis
mortality was 273 per 100,000 population for the entire country.
Two countries, namely Hungary and France exhibited tubercu-
losis mortality rates above 300 per 100,000 in 1900 (Figure 4)
(Johnston, 1995). Italy, Netherlands, Spain, United States, Den-
mark, England and Japan exhibited values closer to those of
Switzerland, ranging between 160 and 199 per 100,000 (Gub-
éran, 1980; Johnston, 1995). Based on these comparisons, Swit-
zerland has a higher tuberculosis mortality rate than many other
countries in Europe (as well as the US). The reason for this
could be a higher accuracy of historical records in Switzerland
compared with other countries due to compulsory reporting of
cases of tuberculosis. Another possibility is that Swiss cities did
not grow in size until late in the 19th century. This is certainly
true for Zürich; in 1893, the city expanded substantially and
this would have had a major impact on the levels of overcrowd-
ing as immigrants had a larger area to migrate into. For cities
such as London and Paris, their areas were defined earlier in the
19th century and thus public health and sanitation efforts were
introduced into a well-known area.
Of these countries, mortality data for tuberculosis are also.
Figure 4.
Tuberculosis mortality rates per 100,000 living population for Switzer-
land and several other countries in the year 1900.
available for several major cities (London, Paris and Tokyo). In
1900, tuberculosis mortality in Zürich city was 422 per 100,000
In Tokyo, it was 480 per 100,000 in 1900 (Johnston, 1995), and
in London the tuberculosis mortality rate was estimated at 180
per 100,000 in 1891-1900 (Nathanson, 2007). Paris tuberculo-
sis death rates were 173 per 100,000 (Preston & Walle, 1978).
This comparison is useful because it shows that Zürich and
Tokyo had similar, very high rates of tuberculosis mortality.
London and Paris also had similar rates of mortality, but much
lower than those of Zürich and Tokyo. Both Zürich and Toky o
had poor sanitation and hygiene around 1900, but Switzerland
improved this situation at a faster rate than in Japan. This is
because they both adopted different measures to help control
tuberculosis. Switzerland initiated public health systems as well
as sanitation and Japan used much cheaper methods of facilities
(for the care of patients with tuberculosis) and public educatio
, 1995). The reason that both London and Paris have
introduced Public
f Public
lower rates of tuberculosis mortality than either Zürich or To-
kyo may be due to the fact the former had
Health Acts long before the latter did. England and Wales first
introduced Public Health Acts in the 1840’s (Szreter, 1988) and
France in the 1850’s (Preston & Walle, 1978). Thus, by 1900,
both of these cities had improved living conditions when com-
pared to Zürich and Tokyo, which did not introduce Public
Health Acts until later, although Zürich introduced sewerage
reforms earlier than Germany and England and Wales.
Over the 19th and 20th centuries, several major shifts were
observed in tuberculosis mortality among developing nations
undergoing the second transition. In most countries, tuberculo-
sis mortality decreased through time in parallel with improve-
ments in living conditions and sanitation. This is true for the
US, where tuberculosis mortality declined in two stages: first
during the first few years of the 20th century, and second be-
tween 1944 and 1950 (Doege, 1965). These two periods were
associated with two different events; the introduction of sanita-
tion and then later, specific drug therapy. Switzerland shows a
decline equivalent to that in the US in the early 1900s, likely
due to the same reasons of improving living conditions and
public health campaigns. Data for the 1940’s in Switzerland
Gubéran (1980) reveal another similar trend to the US. During
WWII, tuberculosis mortality rates remained stable, but later
when the war had ended and streptomycin was introduced, the
rate declined substantially. Declines in tuberculosis mortality
have also been documented for Great Britain starting from the
1830’s due to the introduction of a large number o
ealth Acts (Szreter, 1988). In contrast, data suggest that Japan
experienced high mortality from tuberculosis starting around
1895 and 1900, and extending to after WWII (Johnston, 1995).
Antibiotics and other medical interventions (e.g. surgery, other
chemical agents) were introduced after the war and this was
responsible for almost all of the decline in tuberculosis mortal-
ity in Japan. Rather than shifts in the disease nomenclature and
diagnostic accuracy for tuberculosis, declines in tuberculosis
mortality have also been described in low-income countries
undergoing industrialization and the second transition later
during the 20th century, such as Brazil, which witnessed major
declines in mortality rates in São Paulo between 1945 and 1985
(Antunes & Waldman, 1999). However, in Brazil and other
low-income nations, the transition was facilitated by medical
interventions, such as antibiotics, as well as by improvements
in living conditions and public health (Omran, 2005).
Changes in the age distribution of tuberculosis mortality
Copyright © 2013 SciRes. 87
have also been discussed for high-income nations undergoing
industrialization and the second transition in the 19th and 20th
centuries. For instance, Preston and Walle (1978) showed that
in urban areas of France, such as Marseilles, Paris, and Lyon,
tuberculosis mortality was highest in young adults (20 to 29
years) but changed to older age groups (30 to 39 years) through
the 19th century (1816-1882). Doege (1965) showed that for
the US this trend was also observed from 1900 to 1960 and not
simply attributable due to an increase in life expectancy, but
rather due to a change in the manifestation of tuberculosis
across age groups. Tuberculosis was becoming a disease of the
elderly and remained latent in younger individuals before reac-
tivation later in life. Additionally, the average age of fatal tu-
berculosis increased in the US from 34.4 years in 1900 to 58.1
years in 1960 (Doege, 1965). While age information is not
available for Zürich, life expectancy did increase in Switzerland
over the time period 1893 to 1933 (Figure 1) while tuberculo-
sis mortality decreased. Additionally, one study by Gubéran
uggestions and describe them in relation to their
is was also true for the US (Doege 1965)
are a
out, but rather a combination of improved
ogical transition, characterized by an increase in the drug resis-
980) for Switzerland as a whole showed that older age groups
were more commonly affected by tuberculosis through time for
the studied period: 1875 to 1935. This may indicate that living
conditions and health of children and young adults improved
such that older individuals were far more affected by the dis-
ease due to lowered immunity in later life (Omran, 2005). This
theory supports the other data presented here, suggesting that
tuberculosis mortality decreases with improvement in living
Some studies have also found sex-based differences in tu-
berculosis mortality for some high-income industrializing coun-
tries undergoing the second transition. Data on sex in relation to
tuberculosis mortality in Switzerland are largely unavailable,
but Gubéran (1980) has demonstrated that for the country as a
whole, females aged 15 to 29 years had a higher mortality rate
than did their male peers between 1900 and 1960. Similar
patterns have been found in the US and Japan (Doege, 1965;
Johnston, 1995).
Several reasons for the decrease in tuberculosis mortality
through time during the 19th and 20th centuries in many coun-
tries have been suggested. For instance, Miller and Thompson
(1992) describe some criteria that assisted in the control and
prevention of tuberculosis in Newcastle, Britain around the year
1907. These included compulsory notification of tuberculosis,
sanatoria, building of hospitals and dispensaries, prevention of
infection of the lungs and abdominal tract, education, and es-
tablishment of a national health authority. Other authors agree
with these s
n work on different countries. Preston and Walle (1978)
reported that urban areas in France had poorer living conditions
than the rest of the country as a whole. They additionally sug-
gested that water supply, public health, and hygiene all must be
controlled for a decrease in tuberculosis mortality to occur. This
did occur in France during the late 19th and early 20th centuries.
They highlighted that medicine, including vaccination, surgery
and drug therapy, was not important in the decline of tubercu-
losis in France. Th
ring the initial decline in the early 1900s. However, antibiot-
ics were responsible for the secondary decline between 1944
and 1950. In São Paulo (Antunes & Waldman, 1999), the situa-
tion was slightly different, with tuberculosis mortality rates re-
mainning high until after WWII. Reasons for the decline there
included, besides the most important medication, preventative
and therapeutic measures (such as public education, antibiotics,
surgical interventions and a general increase in immunity
through improvements in nutrition and living conditions), in-
creased provision of health services (e.g. more clinics), and
social changes (e.g. how the population interacted with one
another, avoiding contact with others when they were conta-
gious). However, recently the tuberculosis mortality rate has
begun to increase again at an exponential rate, most likely
alongside the growing HIV/AIDS problem in Brazil.
The situation in Japan (Johnston, 1995) is similar to what
occurred in Brazil (Antunes & Waldman, 1999). Antibiotics to
combat tuberculosis were not available until after 1950 but after
that date were an important factor in the decline. Before this,
the Japanese used facilities (such as sanatoria and specialist
hospitals) and health education in order to combat the disease.
While these measures are less expensive than social and eco-
nomical changes, they are also less effective (Johnston, 1995).
In Japan, transmission of the disease was mostly due to female
industry workers returning to their homes in rural locations
from urban areas and from migrating soldiers. Both of these
groups were exposed to poor living conditions and thus were
more likely to develop active tuberculosis. Finally, Szreter
(1988) presents a series of arguments demonstrating that both
improved nutrition and various public health measures were
responsible for the historical decline in Great Britain. Szreter
(1988) also mentions the numerous Public Health Acts in Eng-
land and Wales that would have impacted living conditions.
They also highlighted how nutrition is important, but so
mber of other factors including overcrowding, lack of sun-
light, ventilation and occupational hazards (e.g. dust and smoke),
all of which were common problems in the initial stages of
In Switzerland, many of these factors did play some role in
the decline of tuberculosis through time. Living conditions
improved substantially during the second half of the 1800’s,
following the first sewerage reform in 1866. Public Health ser-
vices were excellent (e.g. many hospitals, well-educated medi-
cal personnel) in Switzerland and contributed to the overall
high quality of life in Swiss cities, which experienced few
health disadvantages as observed in other countries. Industri-
alization did not affect Switzerland as negatively as other coun-
tries, due to some unique characteristics of the economy, such
as the small number of factories and production centered within
the home, and the slow growth of urban centers.
From these descriptions, it is clear that prior to chemical
therapy and antibiotics, a series of factors were important in the
decline of tuberculosis mortality through time. No single factor
could be pointed
ing conditions as well as public health changes was ulti-
mately responsible for the decline in Switzerland. This is also
true for other countries, but Switzerland is unique in that it was
neutral during the years when conflict was common and has
had a stable government since 1848. This allowed the second
epidemiological transition to occur quickly and earlier than in
other countries. This knowledge could be implemented in the
high burden countries at present and consequently reduce mor-
tality from tuberculosis in these areas, just as it occurred in
Switzerland and other countries, many years ago. Many of
these countries are currently undergoing the third epidemiol-
Copyright © 2013 SciRes.
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