Mortality in Late Tsarist Russia: A Reconnaissance

© 1995 7Tir Society fir the Social History of Medicine

Mortality in Late Tsarist Russia: A Reconnaissance

By K. DAVID PATTERSON*

SUMMARY. This essay explores mortality trends in the European provinces of theRussian Empire, with attention to regional, seasonal, ethnic, and urban-rural varia-tions. Russia experienced higher mortality rates than most European or North Ameri-can countries in the late-nineteenth and early-twentieth centuries and sharp mortalitycrises continued into the 1890s. There was a modest downward trend in both crudeand infant mortality rates by the last decade of the nineteenth century, largely due todeclining tolls from infectious diseases. Progress was slow and very uneven, butmodest improvements in literacy, famine control, public health, and medical servicesall contributed to lower death rates. Many questions await research and further studiesaddressing specific diseases, regions, cities, and ethnic and social groups are essential.

KEYWORDS: Russia, mortality, morbidity, public health, vital statistics, medicalhistory, infectious diseases, demographic transition, epidemics, infant welfare.

Discussions on the nature and causes of the mortality decline in Europe andNorth America over the past two or three centuries have thus far touched onlytangentially on the experience of the Russian Empire.1 Broad rates for Russiahave been published, but there has been little attempt to characterize or analysemortality patterns in any detail. The purpose of this essay is to explore Russia'smortality experience in the context of the wider debate.

Demographic and medical history is still in its infancy for most of theterritories of the former Soviet Union.2 Since the Revolution, most of thescholarly attention devoted to these subjects has focused on the Soviet period.Closed archives, the suppression of data (most spectacularly the 1937 census),ideological blinders, and a long-standing ban on discussion of the demo-graphic consequences of collectivization, forced industrialization, and thepurges have hindered both Soviet and foreign scholars until very recently.There has been a surge of activity on Soviet-era topics in the past few years,as demographic issues have been prominent among the 'blank spots' of historynow being discussed.3 Earlier periods, with less current political relevance,have still attracted little attention.

* 272 Cameron Applied Research Center, University of North Carolina at Charlotte, Charlotte,NC, 28223, USA.

1 Research for this paper was supported by grants from the University of Illinois SummerResearch Laboratory on Russia and Eastern Europe and the Kennan Institute for AdvancedRussian Studies. Barbara Lisenby and her colleagues in the interlibrary loan division of the AtkinsLibrary of UNC-Charlotte deserve special thanks. I am grateful to John Hutchinson of SimonFraser University, Stephen Kunitz of the University of Rochester, and two anonymous refereesfor helpful comments on earlier drafts.

2 David L. Ransel, 'Recent Soviet Studies in Demographic History', Russian Review, 40 (1981),143-57. The Baltic States are a partial exception. David M. Heer presents a general overview in'The Demographic Transition in the Russian Empire and the Soviet Union', Journal of SocialHistory, 1 (1968), 193-240.

3 See, for example, S. G. Wheatcroft, 'Famine and Factors Influencing Mortality in the USSR:the Demographic Crises of 1914-1922 and 1930-1933', Centre for Russian and East European

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180 K. David Patterson

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One reason for this relative neglect is the availability and quality of demo-graphic and medical information. Data are scattered, often unpublished, andfrequently of questionable reliability. Russia did not take a national censusuntil 1897, and the exercise was not repeated until 1926. Vital registrationremained largely in the hands of religious leaders and medically-certifiedmortality returns were rare before the 1890s. Russia lagged decades behindmost western European countries in these matters, though not necessarilybehind much of eastern Europe or some states of the USA.

From 1722 until 1858, the Imperial government conducted ten 'revisions'to list and enumerate heads of households for tax and military purposes. Thesecounts of'souls' neglected children and most women, but provided some indi-cation of the total population. Between revisions, police and officials of theMinistry of the Interior kept lists which they tried to update for births, deaths,and migration, so figures, albeit of dubious value, could be produced for specificplaces between revisions. The need for accurate censuses was understood fordecades prior to 1897 and many major cities and some provinces and districtstook special censuses; 79 were conducted between 1860 and 1889.4

As in most European countries, clergymen reported statistics for births,marriages, and deaths to the government. In 1722 Peter the Great orderedchurch officials to keep vital statistics for the Orthodox majority. Lutheranpastors were given the same task in 1764, Moslem mullahs in 1828, Jewishrabbis in 1835, and Old Believers (Orthodox sectarians) had to provide dataafter 1874. Clergymen actually recorded religious ceremonies associated withbirths and deaths, so stillborn or very young babies, Jewish girls, and suicidestended to be under-recorded. Counts of vagrants were sometimes left to thepolice.

The vast extent of the Empire and the chronic under-administration of theRussian countryside, where the overwhelming majority of the populationlived as peasant farmers in small, often widely-scattered villages, made collect-ing vital statistics difficult. Peasants were intensely suspicious of officials,landlords, and even doctors, so clerical collection of demographic informationwas probably more effective than direct government measures would havebeen. Administration of the provinces, and knowledge of what was going onin them, improved from the 1860s and 1870s, when reforms created provincialand district zemstvos, rural councils, in a majority of the European provinces.Zemstvos had some authority in health and economic matters and manybecame quite active in collecting and analysing statistics.5

Studies, University of Birmingham, nos. 20-21, (1981); Susan Gross Solomon and John F.Hutchinson (eds.) Health and Society in Revolutionary Russia (Bloomington, 1990); and ChristopherWilliams, 'The Revolution from Above in Soviet Medicine, Leningrad 1928-1932', Journal ofUrban History, 20 (1994), 512-40.

4 A. I. Gozulov, Istoriya otecheswennoi statistiki (Moscow, 1957), 26-8; N. Ekk, Opyt obrabotkistatisticheskykh dannykh o smertnosti v Rossii (St Petersburg, 1888), 24—81.

5 For discussion of data problems and collection methods, see Ekk, Opyt, 24-81; Heer, 'The

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Mortality in Late Tsarist Russia: A Reconnaissance 181

Mortality information for Tsarist Russia is, therefore, of mixed quality.Publication was erratic, so it is often difficult to find runs of figures. Infor-mation was not always collected in consistent categories, or in categoriesmodern researchers would select. None the less, mortality was reported con-sistently from 1867 and information tended to improve over time, as zemstvoleaders, doctors, and bureaucrats became more eager and experienced collec-tors and consumers of statistics. Vital registration was more accurate thanpopulation estimates before 1897, with the size and age structure of thepopulation poorly known prior to the census.6 The growing sophistication ofRussia's medical and public health establishment resulted in many valuableinvestigations of specific districts, towns, and problems. By the 1890s, author-ities in St Petersburg and Moscow were attempting universal medical certifica-tion of causes of death, and the tolls from specific diseases were being muchmore accurately tabulated in most places.

This essay will focus on the fifty provinces (gubernii, sing, gubernia) ofEuropean Russia. About two-thirds of these had zemstvo organizations, andmost of the rest were in the west or the Baltic, where administration tendedto be much tighter than in the mountains of Caucasia, the steppes of centralAsia, or the almost empty expanses of Siberia. Figures were often aggregatedfor 'European Russia', so convenience and relatively good data provide a jointrationale for this focus. Russian Poland and the Grand Duchy of Finland wereadministered separately and are not considered here.

In 1897, the empire had some 129 million inhabitants, a little over 94 millionof whom lived in European Russia. Of these, about 85 per cent were Ortho-dox (mostly Belorussians, Russians, and Ukrainians), about 4 per cent Catholic(mostly Poles and Lithuanians), 3 per cent Protestant (mostly Estonian, Ger-man, and Latvian Lutherans), 3 per cent Jewish (mostly in the Pale in thewestern and southwestern provinces), and 3 per cent Moslem (mostly Tatarsand Bashkirs in the Volga provinces). A few 'idolaters' were detected in theUrals and the far north. Only 12.9 per cent lived in places classified as urban.

Numbers of births and deaths and crude rates are shown in Figures 1 and 2for 1867-1913. The raw numbers are high, trend upward, and fluctuate widelyfrom year to year. Rates are also high. Indeed, crude birth rates were extremelyhigh for any large population, suggesting that village priests and other clericsdid a fairly thorough job. Even the death rates were high enough by contem-

Demographic Transition', 204-5; Brokhaus-Efron, Entsiklopedicheskii Slouar, v. 37, 'Rossiya', 75-6; 92. The standard history of the zemstvos, with much material on medical matters, is BorisVesilovskii, Istoriya zemstva za sorok let, 4 vols., (St Petersburg, 1909-1911). In addition to thesources cited, mortality data were collected from the statistical annual: Russia, MinisterstvoVnutrennykh Del, Tsentralnii Statisticheskii Komitet, Dvizhenie naselenie v Evropeiskoi Rossii.

6 Stephen L. Hoch, 'On Good Numbers and Bad: Malthus, Population Trends, and PeasantStandards of Living in Late Imperial Russia', Slavic Review, 53 (1994), 57-8.

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0.5 -

i

1867

1870

i

1873

1876

1879

1882

1885

1888

1891

1894

1897

1900

19 90 03 (J

1909

1912

Year

——Births —r— Deaths

FIG. 1. Births and deaths in European Russia, 1867—1913, in millions.

Source: Novoselskii, 'Obzor', 1916, 36-7.

Rate/1000

' Crude Birth Rates " Crude Death Rates

FIG. 2. Crude birth and death rates per 1000 in European Russia, 1861-1865; 1867-1913.

Source: Rashin, Naselenie, 155-6 (1866 missing).

porary standards to suggest good reporting. Substantial annual fluctuationsindicate a demographic regime driven in part by crises, such as prevailed acentury or more earlier in western Europe. The impact of the 1892 famineand the associated cholera and typhus epidemics is evident; births recovered

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h4ortaJity in Late Tsarist Russia: A Reconnaissance 183

Crude Death Rates11.000, 1871-75, by Gubernia

0 1 5 - 2 0 1 2 0 - 2 5 25 - 30 0 30 - 35 35 - 40 4 0 - 45 = 45 - 50

MAP 1.

sharply in 1893. Both birth and death rates trend downward from the mid- 1890s.

European Russia covered a huge area, so mortality varied over space as well as over time. Maps 1, 2, and 3 show average crude death rates by province for 1871-75; 18%-1900, and 1906-13 respectively. In the first period, rates far lower than the 50-province mean (37.1 per 1000) were found in the Baltic

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1 84 K. David Patterson

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Crude Death Rates11,000, 1886 - 1900, by Gubernia

gubemii of Estland, Livonia (Lifland), Kurland, and Kovno. Belorussian provinces like Vilna, Vitebsk, Grodno, and Minsk also had below average rates, as did part of the southern Ukraine (Bessarabia, Kherson, Tauridia, and Ekaterinoslav). Higher mortality prevailed in the central provinces around Moscow and along the Volga. By 18%-1900, the average had fallen to 34.5, but the same pattern of low mortality rates prevailed in the northwest, west,

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Crude Death Rales11,000, 1906 - 1910, by Gubernia

and southwest. Higher rates continued in central Russia, in remote Perm and Viatka, and in the lower Volga provinces (Saratov, Samara, and Astrakhan). At the end of the period, 1906-13, with the average down to 29.5 per 1000, the Baltics continued to lead, followed by the Belorussian gubernii and Ukrainian provinces like Poltava and Volynia. The situation had improved in many of the central Russian provinces from Smolensk and Novgorod to Penza

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Deaths (Thousands)

100 -

1870 1872 1874 1876

' Saratov

1878Year

—H Simbirsk

1880 1884

FIG. 3. Deaths in two Volga provinces, 1870-1885.

Source: Ekk, Opyt, 30-3.

and Kursk. A belt of relatively high mortality extended in the east from Permto Astrakhan.

Numbers of deaths for selected high and low mortality provinces are shownin Figures 3 and 4. While population data are inadequate to calculate rates forall years, it is evident that the curves for the two Baltic provinces show muchless fluctuation than those for Saratov and Simbirsk, even though the periodends before the disasters of 1892, which were most severe in that region.Coefficients of variation (standard deviation/mean times 100) were 7.48 forLifland (Livonia) and 7.66 for Kurland, compared to 12.58 for Simbirsk and13.28 for Saratov. Not only were crude mortality rates substantially lower inLifland and Kurland (essentially modern Latvia and southern Estonia), but theVolga provinces experienced much more 'crisis' mortality. A more stable,more 'modern' mortality regime prevailed in the mixed-farming regions nearthe Baltic than in the grainlands of the Volga basin.

Mortality variation was also evident within provinces. For example, inMoscow gubemia the crude death rate (CDR) averaged 42.3 per 1000 for 1885—96. However the 13 uezdi (districts) of the province had rates ranging from36.2 to 54.6.7 Further study is obviously needed to explain wide mortalityvariations at both the inter-and intra-provincial levels.

As was true in other countries, urban death rates tended to be significantly

7 E. A. Osipov, I. V. Popov and P. I. Kurkin, Russkaya zemskaya meditsina (Moscow, 1899),326.

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Deaths (Thousands)

187

0

1874 1882 1884

Year

' Kurland

FIG. 4. Deaths in two Baltic provinces, 1870-1885.

Source: Ekk, Opyt, 28-9.

higher than rural ones well into the nineteenth century. B. N. Mironov hasused archival collections of ecclesiastical registries to construct rough urbandeath rates for the period from 1830 to 1869. During the 1830s urban ratesaveraged 44.3 per 1000, compared to 33.4 for all of European Russia. Urbanrates were 48.2 in the 1840s, 49.0 in the 1850s, and 51.3 in the 1860s. For theoverwhelmingly rural region as a whole, the comparable figures were 38.1,37.7. and 37.9. By the end of the century the situation had reversed.8 Aselsewhere in Europe, urban rates tended to fall more rapidly than rural ones.The timing of this reversal is not clear from the available published data, butprobably took place in the 1880s. As is evident from Figure 5, by at least theearly 1880s Moscow province, a predominantly rural area but with growingindustrial towns, had a substantially higher mortality rate than did the cityitself. Mortality in Odessa, another relatively progressive city, roughly para-lleled Moscow's. By 1896-97 rural rates averaged 32.9 per 1000; urban ratesstood at 28.3.9 In 1911-13, rural rates had fallen to 26.5, but the city rates hadreached 23.9. Still, rural CDRs remained lower than urban ones in 22 of the50 provinces.10

The health of cities remains an underexplored topic in Russian history. It is

8 B. N. Mironov, Russkii gorod v 1740-1860godu (Moscow, 1990), 58-60; 250.9 S. A. Novoselskii, 'Obzor glavneishykh dannykh po demografii i sanitarnoi statistikh Rossii',

in Kalendar dlya vrachei (St Petersburg, 1916), 62.10 A. G. Rashin, Naselenie Rossii za 100 let (1811-1913gg) (Moscow, 1956), 249.

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188

Rate/1000

K. David Patterson

66

so

ao

l_ _ 1 _ ! I _ 1 _ I I 1 . I I I I I I I I I I I I I I I 1 I

1870 1873 1876 1879 1882 1885 1888 1891 1894 1897 1900 1903 1906

Year

—•— Moscow City - + - Moscow Province "*" Odessa

FIG. 5. Crude death rates in Moscow, rural Moscow province, Odessa.

Source: Kurkin, Tablitsy, 27; 62.

interesting to note that births exceeded deaths in Odessa as early as 1868,11

but St Petersburg showed negative natural growth until after 1884. St Peters-burg, 'the unhealthiest capital in Europe', had much higher rates than mostother major cities right up until the First World War.12

Since vital data were collected by clergymen, religion is a useful, thoughinexact, surrogate for ethnicity in the absence of ethnic-specific mortality data.Figure 6 illustrates crude death rates for the five major religious groups.'Lutherans' apparently embraces all Protestants; it is not clear whether schis-matic groups are aggregated with the Orthodox. In any case, patterns areevident. Orthodox citizens of European Russia, primarily Slavs, suffered farhigher mortality than any other group, even the very poor Tatar and BashkirMoslems. Lutherans, concentrated in the Baltic provinces and in Moscow andSt Petersburg, did well as might be expected from their location, as did theCatholics of the west. Jews had by far the lowest rates.

Some of the differences among religious-ethnic groups are illuminated byage-specific data. Figure 7 shows death rates by age groups for 1892 and 1894.

11 Patricia Herlihy, 'Death in Odessa: a Study of Population Movements in a Nineteenth-Century City', Journal of Urban History, 4, 4 (1978), 437.

12 James H. Bater, 5r. Petersburg: Industrialization and Change (Montreal, 1976), 312. See alsoMichael F. Hamm, (ed.) The City in Late Imperial Russia (Bloomington, 1986).

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Orthodox

Lutherans

Catholics

Moslems

Jews


\ I

- - - -- - - I I I -- - - 1

0 5 10 15 20 25 30 3 5 40 Crude Death Rate/1000

Male Female General

FIG. 6. Average annual crude death rates hy sex and religion, 1896-1897. Source: Novoselskii, 'Ohzor ' , 1916, 60.

Rates are consistently higher for 1892 which, as noted above, was charac- terized by famine and epidemics in much of the empire, especially the southeast. While age-specific data must be used with caution, it is obvious that a very high proportion of deaths took place among infants and young children.

Infant mortality rates (IMRs) for European Russia, shown in Figure 8, were, by any standard, very high. A modest downward trend is evident, particularly by the late 1890s, but improvement was small. I t is possible that more complete death registration among very young infants masked real progress, at least in some localities.

Mortality rates for intervals within the first year are shown in Figure 9. Again, while caution on age reporting is in order, it is clear that a substantial proportion of deaths occurred in the first month. Many of these deaths were due to prematurity, low birth weight, and/or congenital defects. Orthodox babies were baptized 2 or 3 days after birth;I3 some of those dying before the ceremony were not counted, hence lowering the reported rates. Deaths after six months were often associated with weaning and/or infections, most com- monly diarrhoeas of various aetiologies.

Infant death rates displayed enormous variation by religion, as shown for two periods in Figure 10. Orthodox babies perished at roughly twice the rate of Jewish infants and were far more vulnerable than babies in other groups, including Moslems. David Ransel notes that the astonishing gap between

" Olga Sernyonova Tian-Shanskaia. Village I@ in Late Tsarist Ructia. David L. Ransel (ed.) (Bloomington, 1993). IS; Stephen P. Dunn and Ethel Dunn, The Peasants of Central Russia (New York, 1%7). 95.

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Rate/1000

300

200

10O

0 S 10 IS 20 26 30 35 40 48 50 55 60 65 70 75 80 85 90

—-189J —I—189*

FIG. 7. Death rates by age group, 1892 and 1894.

Sources: Brokhaus-Efron, v.37; 'Rossiya', 103.

Rate/1000320

300 - .

280

260 -

240

220

2001867 1871 1875 1879 1883 1887 1891 1896 1899 1903 1907 1911

Year

Infant Mori. Rate

FIG. 8. Infant mortality rates in European Russia, 1867-1911, and trend line.

Source: Novoselskii, 'Obzor', 1916, 64-5.

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Death Rate 110

1881

Year

0-1 Monlh 1-0 Monlh. 0 8-8 Month. 8-12 Month.

F I G . 9. Infant death rates per 1000 b y age in months, 1889-1893. Source: Dvizhenie Naselenie. 1890. 91, 92.

Rater per 1000 a 0 0

260 - - - -

200 - - -- -- 240 - - . _ - 220 - -- ---.-

200 -, --.-

1690-97 1800-04

Period

F I G . 10. Average anwual itrfatrt death ruta by religiotr, 1896-1897; 1900-1904. Source: Novoselskh, 'Obzor' , 1916, 60; 66.

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Moslem and Orthodox rates was independent of geography. For example, in1896-97 in Kazan province the Moslem rate was 161 per 1000; the Orthodoxrate in the same gubernia was 304. Rates in Penza province were even moredivergent; 140 for Moslems and 342 for rural Orthodox. Similar disparitieswere observed in mixed villages. Contemporary doctors at first suspected thatregistration irregularities caused the differences, but close study showed thatmullahs were accurately reporting Moslem births and deaths.14

Breast-feeding customs explain some of the differences among religiousgroups. Protestant, Catholic, and especially Jewish mothers had high rates ofbreast feeding and tended to delay the introduction of solid food and weaning.Moslem women followed a similar pattern and did much less heavy field workthan their Slavic counterparts, both before and after childbirth. Jewish womenwere also less likely to engage in farm work, reducing risks to fetal, neonatal,and maternal health. Matrilocal residence and perhaps a greater receptivity tomedical assistance may also have enhanced the survival chances of Jewish in-fants. Orthodox conceptions rose during the fall harvest season, so births peakedin the early summer. Mothers frequently left their children at home to work inthe fields. Breast feeding was often interrupted and solid foods were introducedvery early. The soska, a cloth pacifier filled with bread and pre-chewed by agrandmother or other care-giver, was a deadly source of bacteria, especially inwarm weather. Summer diarrhoea was a major killer of Orthodox infants.Moslem children were weaned later and did not display a summer mortalitypeak but, as will be discussed below, had higher death rates at older ages. Inaddition, Slavic women had lower mortality than their Moslem neighbours,perhaps because of the greater toll of lactation on Tatar and Bashkir mothers.16

Russian public health leaders were very interested in seasonal mortalitychanges and statistical publications often contain extensive tabulations of vitalevents by month and season. While this concern was certainly not peculiarlyRussian, the harsh climate seems to have created an unusual degree of interest.A typical pattern of deaths by month for European Russia is shown in Figure11. There were, as might be expected, some excess deaths in winter, butsummer was the deadliest season. September and October, months of harvestand feasting, were the healthiest. The summer peak was due to the remarkableheaping of infant and toddler deaths in the warmest months, shown in Figure12. The major problem, as in Europe and the USA,17 was weanling or

14 David L. Ransel, 'Infant Care Cultures in the Russian Empire', in Barbara Evans Clements,Barbara Alpern Engel, and Christine D. Worobec (eds.) Russia's Women: Accommodation, Resis-tance, Transformation (Berkeley, 1991), 123-7.

15 Ransel, 'Infant-Care', 116-18; Mary Matossian, 'The Peasant Way of Life', in Wayne S.Vucinich (ed.) The Peasant in Nineteenth-Century Russia (Stanford, 1968), 22-23; Nancy M.Frieden, 'Child Care: Medical Reform in a Traditionalist Culture', in David L. Ransel (ed.) TheFamily in Imperial Russia (Urbana, 1978), 236-59.

16 Ransel, 'Infant-Care', 124-30; Ransel, 'Mothering, Medicine, and Infant Mortality in Russia:Some Comparisons', Occasional Paper No. 236, Kennan Institute for Advanced Russian Studies,(Washington, 1990).

17 See, for example, Rose A. Cheney, 'Seasonal Aspects of Infant and Childhood Mortality:Philadelphia, 1865-1920', Journal of Interdisciplinary History, 14(1984), 561-85.

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Mortality in Late Tsarist Russin: A Rerot~naissance 193

P e r c e n t of D e a l h s

F I G . 1 1 . Deaths by month as percenta,ge of all deaths, average.for 1890- 1894 Source: Brokhaus-Efron, v.37, ' R o s s i y ~ ~ ' . 104.

Index of Deaths 2 0 0 ,

Month

@ A g e 1-2 -

Age 2 - 5

FIG. 12. Itidex of i t f h rind tltild d e a t h by mot~t i t , 1900- 1904; mc,art= 100.

Source: Novoseiskii, 'Obzor ' . 1916, 68.

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summer diarrhoea, caused by a wide range of bacteria and viruses, probablyincluding normally commensal bacteria which became pathogenic in weakenedinfants. Older infants and toddlers crawling in the dirt also had ample oppor-tunity to acquire helminths like ascaris and trichuris. Toddlers aged 1 to 2showed a less-pronounced pattern of summer mortality, and older childrenwere at greater risk in the winter, being vulnerable to measles, colds, and otherair-borne infections in their crowded houses.

Infant mortality, like general mortality, showed great regional variation.For the period 1867-81, when European Russia had an average IMR of 271per 1000, the pattern on Map 4 is quite similar to that for general mortality.Lowest rates were in the Baltic, the west, and the south. Rates were higherin a broad swath of territory in central and eastern Russia. The nationalaverage in 1886-97 was 274. Higher rates along the Volga in this period mayrepresent improved registration in provinces like Astrakhan, as well as theimpact of the 1892 famine. Map 5 is quite similar to the earlier one, except fora substantial decline in Moscow province. By 1908-10 (Map 6) the averageIMR had fallen to 253 per 1000; many provinces had registered modest gains,but Baltic, Belorussian, and Ukrainian babies still enjoyed a marked advantage.Rural IMRs tended to exceed urban ones.

Local IMR data for the cities of Moscow and St Petersburg and for Moscowprovince, which surrounded but did not include the city, are displayed inFigure 13. Rural rates trended downward, but displayed considerable annualvariation and remained well above the cities until the turn of the century. Dataon more regions would be necessary to compare this perhaps early date foran urban-rural crossover of IMR curves with other European countries. FallingIMRs were no doubt due in part to the extensive efforts of rural doctors, asthe Moscow zemstvo was unusually well-funded and active concerninghealth.18 Within the province, annual average IMRs among the thirteen dis-tricts ranged from 304 to 487 during the decade 1885-94, while the provincialaverage was 358.19 Again, differences among and within provinces requirefurther study, as do the experiences of specific ethnic and socio-economic groups.

Infants who managed to survive to their first birthday were still in consider-able danger, as Russia had the highest child death rates in Europe. Figure 14shows average child death rates to age 5 for European Russia and selectedprovinces for three periods. In much of European Russia, fewer than half ofall babies lived to age 5. There was some improvement over time, but on theeve of the First World War, the toll remained comparable to the most destituteThird World nations today. Not surprisingly, children did best in Balticprovinces like Estland and in the western and southern gubernii. The highfigures for Moscow province may be partly due to unusually efficient datacollection. Saratov, a grain-producing province on the lower Volga withmany large estates, had a generally harsh mortality regime.

18 Peter F. Krug, The Debate Over the Delivery of Health Care in Rural Russia: The MoscowZemstvo, 1864-1878', Bulletin of the History of Medicine, 50 (1976), 226-41.

19 Osipov, Popov, and Kurkin, Russkaya zemskaya meditsina, 326.

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Average Infant Mortality Rates11.000, 1908-10

[7 125 -150 0 151 - 200 / 201 - 250 0 251 - 300 301 - 3 5 0 351 - 400 1 401 - 450

,MAP 4.

Child mortality by age and religion for 1900-04 is shown in Figure 15. Toddler rates (ages 1-2) were extremely high for all groups, suggesting poor sanitation and nutrition and vulnerability to childhood diseases. Moslem rates surpassed Orthodox ones by ages 2-3, perhaps reflecting greater poverty as well as residence in the epidemiologically vulnerable Volga basin. Jewish children, like Jewish infants, enjoyed the lowest death rates, with Lutherans and Catholics occupying their familiar intermediate positions.

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K . David Patterson

Average Infant Mortality Rates11.000, 1867-81

As was common in almost all countries, Russian girls enjoyed substantial survival advantages over boys. The gap was especially high for infants. In 1894 baby boys died at a rate of 37.5 per 1000; the rate for girls was 31.5. For ages 1-5, the rate for boys was 67; for girls, 63. Differences were smaller for older children, but females retained an advantage until a d u l t h ~ o d . ~ ~

I Brokhaus Efron, v. 37, 'Rossiya'. 103

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hlortality in Late Tsarist Russia: A R~connaissance 197

Average Infant Mortality Rates11,000, 1886-97

0 125 -150 0 151 - 200 201 - 250 251 - 300- 301 - 3 5 0 3 5 1 - 400 401 - 45')

M ~ I J f r .

What diseases killed Russians? Cause-specific reports are scattered and late, despite the efforts of some zemstvos and city governments to collect such data as early as the 1860s. Physicians and Interior Ministry officials compiled information on some specific epidemics and diseases. An 1867 law required reporting cause-specific morbidity and mortality in St Petersburg and its

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198 K. D a v i d Patterson

Rate/1000 Live Births

188.3 1886 1889 1892 1895 1898 1901 1904 1907 1910 1913

Year

A Moscow-Clty M o s c o w - ~ r o v l n c e 'St Petersburg

F I G . 13. Infant mortality rates, Moscow city, Moscou) province, and St Petersburg. Source: Rashin Naselenie, 235; Kurkin, Tablitsy, 79.

FIG. 14. Average annual child death rates (0-S), European Russia and selected provinces.

Source: Rashin, Naselenie, 198-9.

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Mortulity in Late Tsarist Russia: A Reconnaissance 1 99

Age Group

Orthodox - < - - - -

7 I

Lutheran - I

Catholic - I

I - L Moslem -- - --- Jewish : -

I I 1 1 I --

I 0 1 0 20 30 40 50 60 70 80 90 100

Death Rate

1-2 Years - L A 3 - 4 Years

2 - 3 Years

4 -5 Years

FIG. 15. Average child death rates by religion, 1900-1904. Source: Novoselskii, ' O b z o r ' , 1916, 67.

environs; this requirement was extended to several other major cities in 1872.~' National data were collected on standardized cards from 1889, but often depended on lay diagnosis and the dubious cooperation of suspicious peasants. Morbidity data are especially incomplete. Deaths themselves were fairly com- pletely reported, but the listed cause or causes must often have been guesses. It is clear, however, that Russia was still in the first phase of what Omran has called the epidemiological transition: infectious diseases were the leading causes of death.=

Childhood diseases must have been especially poorly recorded. Measles and scarlet fever (scarlatina) were almost universal among Russian children and few specific epidemics are recorded. Reported measles cases ranged from about 160.000 to 400,000 annually from 1890 to 1902, with peaks every four years.u Diphtheria apparently became more common during the nineteenth century. During the 1870s and 1880s most cases were reported in cities, but there were many destructive rural epidemics. For example, in 1868 the disease killed almost 1100 children, about one third of those aged 10 or under, in one district in Voronezh province. During the next two years some 2800 children

2' K. G. Vasil'ev and A. E. Segal. Istoriya epidemii v Rossii (Moscow, 1%0), 216, n.3. In addition to sources cited for specific diseases. morbidity and mortality data were collected from 0. V. Baroyan, Itogi poluvekovoi bor'by s intktsiyami v S S S R i nekoforie akfual'nie voprosy sovremen- noi epidemiologii (Moscow. 1%8), and a number of issues of the annual medical report for the Empire: Russia, Ministerstvo Vnutrennykh Del, Upravlenie Glavnago Vrachebnago Inspectora, Otchet o sosfoyanie narodnago zdraviya i organizartii vrachebnoi pomoshchi v Rossii (St Petersburg).

Abdel R. Omran, 'The Epidemiological Transition: A Theory o f the Epiden~iology of Po ulation Change'. Milbank Memorial Fund Quarterly, 49 (1971). 38. ' Vasil'ev and Segal. Istoriya. 297.

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under 10 died from diphtheria in three districts in the Don Cossack Oblast;in some villages half the children died. Thousands of young lives were lost inan epidemic in Poltava province during the 1870s.24 Case reports for diphtheriaand scarlatina for the entire Empire are shown in Figure 16; the overwhelmingmajority were in European Russia. Rising incidences are probably due, at leastin part, to better reporting. The introduction of effective therapy for diphtheriamay have encouraged parents to bring sick children to clinics.

Mortality totals for six important diseases are shown Figures 17, 18, and19. Unfortunately, they include deaths in the Polish provinces and part ofCaucasia, but the general pattern is clear. Deaths from childhood diseases:diphtheria, measles, pertussis, scarlatina, and to some extent smallpox, de-clined, as did typhus, which primarily attacked adults. Smallpox was pre-ventable by vaccination, and the authorities made serious efforts to extendcoverage during this period. Diphtheria case mortality was dramaticallyaffected by serum therapy. In 1891-4, hospital case mortality averaged 30.7per cent; by 1902-5 it had fallen to 12.2 per cent and twice as many cases weretreated.25 Other diseases in the group were not amenable to specific medicalintervention.

Smallpox was widespread in seventeenth-and eighteenth-century Russia,and remained fairly common throughout the Tsarist period. In western Europesmallpox became largely a childhood disease during the eighteenth centuryand there is some evidence that the same transformation was taking place inRussia. For example, from 1771 to 1779, 75 per cent of some 1800 smallpoxdeaths in St Petersburg were among children aged 10 and younger.26 Morethan a century later, 56 per cent of the smallpox cases seen at hospitals andclinics in Moscow province were among children aged 5 and under.27 Inocu-lation was introduced by Catherine the Great in 176828 and Jennerian vacci-nation began in 1801. Despite continuing efforts by the Ministry of Interior,total vaccinations were only two thirds of the number of births as late as 1845.There were problems with vaccine quality, incompetent vaccination techniques,and false reporting by poorly-trained inoculators. By 1900, reported vacci-nations numbered 82 per cent of births. Vaccination was made compulsoryfor school children in 1885, railroad workers in 1892, and army recruits onlyin 1899. Lagging vaccination rates allowed some 100-200,000 cases and tensof thousands of deaths annually through the late nineteenth century. Wherevaccination was carried out efficiently, there were, however, excellent results.In Moscow province, which had a somewhat better record on smallpox thanEuropean Russia as a whole, rural incidence rates averaged about 8.4 cases per10,000 from 1883-1913; rates in the well-vaccinated city of Moscow were a

24 Vasil'ev and Segal, Istoriya, 294—5.2 5 P. I. Kurkin, Sanitamo-Statistkheskiya tablitsy, (Moscow, 1910), 11; 19.2 6 Vasil'ev and Segal, Istoriya, 166.2 7 Osipov, Popox, and Kurkin, Russkaya zemskaya meditsina, 312-13 . From 1883 to 1896,

12,455 cases were recorded.2 8 John T. Alexander, Catherine the Great: Life and Legend (New York, 1989), 146-8.

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,Clorrality in Late Tsarist Russia: A Rrconnaissance 20 1

FIG. 16. Diphtheria and scarlatina morbidity rates, entire empire, 1890-1913.

Sources: Vasil'ev and Segal, 299-300; Baroyan, 16.

0

Deaths (Thousands) 1 4 0 ;

I ! I I . I ! I 1 1 1 1 1 1 1 1 1 1 ~

Russia, Poland, Part of Caucasia

~ l ~ h l h e r l a ~ e a s l e a ~ e r t u a m l a

1890 1893 1896 1899 1902 1905 1908 1911

Year

FIG. 17. A v e r a p annual deahsfrom diph~heria, measles and pertussis, 1891-1934

Source: Novoselskii, 'Obzor' , 1916, 69-70.

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Deaths (Thousands) 1 2 0 ,

if&l ' - t & I , "C 1 - 1

'pe*-es . P ~ F - : ~ O O 3 2 0 ~ - o s IBCP-10 1 ~ 1 0 - 1 4

Russia, Poland, part of Caucasia

smallpox Scalat lna 0 ~ y p h u a

FIG. 18. Average annual deaths from smallpox, scalatina and typhus, 1891-1914. Source: Novoselskii, 'Obror' , 69-70, Russia, Otchet.

Thousands

4 0 0 - -

3 5 0 -

Russia, Poland, part of Caucasia

Frc. 19. Total deaths and trend line, six infectious diseases, 1891-1914. Source: Novoselskii, 'Obzor' , 1916, 69-70.

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i n 3 5 l s a a l n 8 7 lC98 1qPQ l P O O '201 1832 1P03 1334 1205 1638 'F37 1 2 G 8

Year

M o s c o w 81. Petermburg

1 FIG. 20. T y p h o i d f e v e r death rates per 10 ,000 , Moscow and S t Petersburg, 1895-1908 . I Source: Kurkin, 61; Ferman, 35; Russia, Otchet.

tenth of those in the countryside.29 As in western Europe and in ~ i n i a n d , ~ vaccination may have substantially reduced smallpox cases and deaths in the decades before the First World War.

Plague epidemics swept the Russian lands during the mid-fourteenth century and reappeared several times over the next several centuries, killing some 100,000 people in 1770-72.3' Endemic plague foci existed among rodent populations of the southeastern steppes, but the disease was demographically insignificant during the nineteenth century and early twentieth century. Plague was carefully monitored, and prompt application of quarantines and case isolation protected European Russia from this menace.'*

Cholera first struck Russia a glancing blow in 1823. Beginning in 1829, five pandemics swept the Empire, often crossing Russia to attack western Europe. Each of these outbreaks started several 'cholera years' before the disease died out. Cholera was less destructive in the western, Baltic, and far-northern provinces and was generally most serious in the southeast and in central Russian and Ukrainian provinces. Moscow and St Petersburg were often hard-

r, Vasil'ev and Segal, Istoviya. 286-9. A. J. Mercer, 'Smallpox and Epidemiological-Demographic Change in Europe: The Role

of Vaccination', Population Studies, 39 (1985). 287-307; K. J. Pitkinen, J. H. Mielke, and L. B. Jorde, 'Smallpox and its Eradication in Finland: Implications for Disease Control'. Population Studies, 43 (1989). 95-1 1 . '' John T. Alexander. Bubonic Plague in Early Modem Russia; Public Health and Urban Disaster

(Baltimore. 1980). 258. 32 Vasil'ev and Segal, Istoriya, 226-46.

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hit. Cholera killed about 200,000 people in 1831; almost 700,000 in 1848, andover 100,000 in 1853, 1855, 1871, and 1872. In 1892, a famine year, choleraclaimed almost 300,000 victims, mostly in the Volga valley and the south. Aslate as 1910, cholera killed over 100,000 persons and St Petersburg lived upto its embarrassing reputation for bad health. Slow improvements in watersupply and sewers helped other cities avoid the worst consequences of the1905-13 cholera years; the countryside bore the brunt of the pandemic.33

Another water-borne disease, typhoid fever, was a serious problem in bothurban and rural environments. It was often confused with typhus until the1860s and even as late as 1890, statistics are scarce, except for some cities.Figure 20 shows case-specific death rates for Moscow and St Petersburg from1895. Moscow, which invested heavily in water and sewer systems, had farlower rates than the imperial capital. Odessa averaged 7.5 deaths per 10,000in 1879-80, but from then until 1900 its rate fell to Moscow's low levels,oscillating between 2.5 and 3.2. Improvement was closely linked to betterwater and sewers. The situation was much worse in rural areas; typhoidmortality for all of European Russia ranged from 19.7 to 24.7 per 1000 from1902-04 and peaked at 30.6 per 1000 in 1906 for the entire country.34

Typhus, a louse-borne disease associated with poverty, dirt, and crowding,had long been a scourge in Russia. It was a particular problem in the flop-houses and dormitories housing the millions of seasonal migrants to Russia'scities. Typhus flourished in times of disorder and population movement, suchas during and immediately after the Crimean War of 1853-56, the Russo-Turkish war of 1877-78, and the famine of 1892. In most years, reported casesranged from 50,000 to 100,000, with a case-mortality rate of c. 10-20 per cent.Typhus was primarily a disease of adults. It was not a major demographicfactor until the Civil War and famine years of 1918-22, when the greatesttyphus epidemic in history killed some 2.5-3 million people.35

A more serious and perhaps more surprising threat to Russia's populationwas another insect-born disease, malaria. Primarily the relatively low-fatalityvivax variety, it was especially common in the Caucasus and Central Asia,where Russian soldiers often suffered morbidity rates as high as British andFrench troops in Africa. In European Russia, malaria was particularly com-mon along the lower Volga and the Black Sea coast, but it penetrated far intothe Ukraine and central Russia, especially along river valleys, Sporadic casesoccurred in St Petersburg and its environs and on occasion in far-northernArkhangelsk. In many years, malaria was the single most reported disease inRussia. Although under-reporting was known to be extensive, from 2.2 to

3 3 K. David Patterson, 'Cholera Diffusion in Russia, 1823-1923' , Social Science and Medicine, 38(1994), 1171-91.

3 4 Kurkin, Tablitsy, 61 -2 ; Herlihy, 'Death in Odessa ' , 429-32; Ye. A. Ferman, Smertnost' otbryushnago lifa v C.-Peterburge za 12 let s 1895po 1906god (St Petersburg, 1907), 35. St Petersburg'sability to finance public works was hampered by the tax-exempt status ofextensive Imperial, govern-ment, and ecclesiastical properties in the city. I am grateful to John Hutchinson for this point.

3 5 K. David Patterson, 'Typhus and its Control in Russia, 1870-1940', Medical History, 37(1993), 3 6 1 - 8 1 .

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3.8 million cases were tabulated annually. A special investigator thought thatthe true total in 1903 was about 5 million; others thought this figure tooconservative. The hardest-hit province over the years was probablyAstrakhan, whose average official case rate from 1896 to 1901 was 228 per1000. Other provinces along the Volga, and some away from it like Tambovand Penza, also had extremely high rates. Although cities along the Volgasuffered, malaria was primarily a rural disease. Case mortality was generallyless than 1 per cent, but malaria's seasonal peaks coincided with the plantingand harvest periods and sickness had a substantial economic impact. Malaria'scontribution to infant and child mortality was almost certainly under-esti-mated. In addition, malaria suppresses the immune system, making bothchildren and adults more vulnerable to other infections. Russian scientists didsome very competent and extensive studies of malaria but, except for quininedistribution, little was done to control the disease.36

Tuberculosis was a major killer in Russia, as it was elsewhere in Europe andNorth America, and was of great concern to the medical profession and healthofficials. For 1890-92, Russia had an official pulmonary tuberculosis death rateof 4 per 1000, well above Sweden's 2.3, Ireland's 2.0, or England's 1.7. In the1890s, Moscow's rate of 4.6 per 1000 and St Petersburg's 4.1 were well aboveOdessa's 2.5, and equalled or exceeded a long list of other major cities, suchas Berlin (2.3), Budapest (4.1), Brussels (3.1), London (1.8), New York (2.5),Paris (3.9), and Stockholm (2.6).37 From 1896 to 1913, Russia's recorded caserates rose steadily from 2.2 to 5.3 per 1000.38 Standards for diagnosing andreporting tuberculosis varied, so international comparisons must be treatedwith caution, as must the apparently rising incidence of the disease in Russia.Incidence was falling in Russia's northern neighbours, Sweden and Finland,from the 1860s.39 Still, tuberculosis was a major public health problem andprobably was getting worse. Cities were foci for the infection of the villages;urbanization and growing employment in mines and factories contributed toa deteriorating situation.

V

To summarize, crude mortality rates in European Russia declined modestlyafter the famine and epidemic year of 1892. The decline was erratic, bothspatially and temporally. Mortality was lower in the Baltic, western, andsouth-central regions, which enjoyed not only lower average death rates, buta more stable demographic regime, relatively free of the famine and epidemic

3 6 Mary S. Conroy , 'Malaria in Late Tsarist Russia', Bulletin of (he History of Medicine 56 (1988),41 -55 ; Vasil'ev and Segal, Istoriya, 3 0 2 - 1 1 ; Richard Johnson , 'Malaria and Malaria Control in theUSSR, 1917-1941 ' , (unpublished P h . D . thesis, George town University, 1988), 22-38 .

3 7 Kurkin, Tablitsy, 6 4 - 5 .3 8 Rashin, Naselenie, 209-10.3 9 Bi Puranen, 'Tuberculosis and the Decline of Mortal i ty in Sweden' , in R. Schofield, D .

Reher, and A. Bideau (eds.) The Decline of Mortality in Europe (Oxford, 1991), 100-1 .

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crises which continued to afflict the high-mortality areas of central Russia, theremote northeast, and the lower Volga. Infant mortality was far higher thanin any other country in Europe or North America. Geographical variation wassignificant and followed a pattern similar to that for general mortality. IMRsbegan a modest, erratic decline in the late 1890s.

In general, Russia's mortality regime more closely resembled that ofeighteenth-or even seventeenth-century western Europe than its nineteenth-century contemporaries. With some regional variation, especially in the rela-tively prosperous Baltic lands, Russia had extremely high morality and stillexperienced substantial crisis mortality from famines and epidemics.

Reasons for Russia's high mortality are easy to list, but the contributions ofindividual factors are difficult to assess. Russia was, like its neighbours Norwayand Sweden and its own Grand Duchy of Finland, a poor, predominantly ruralcountry with a harsh climate. The Scandinavian lands, however, had muchlower crude and infant mortality rates, with a more pronounced decline overtime and, except for a catastrophic period of bad harvests around 1869 inFinland, far fewer crises.40 Russia had much lower literacy rates than itsLutheran neighbours. Despite its autocratic government, Russian local admini-stration was much weaker, even after the zemstvo reforms. This was eventrue of Finland which, although under Tsarist control, retained a measure oflocal autonomy and much of its administrative, religious, and educationalheritage from the pre-1809 days of Swedish rule.

An inefficient, conservative autocracy with a poorly-developed system oflocal government, massive rural and urban poverty, urbanization, industriali-zation, weak public health and medical establishments, and widespread illiteracyobviously all contributed to high death rates. The harsh climate was also afactor. Long, cold winters forced people to stay indoors for long periods incrowded, poorly-ventilated homes, creating ideal circumstances for the trans-mission of respiratory and ocular diseases. In hot, dry summers, especially inthe grain-producing steppes of the south and southeast, local water suppliessometimes dried up, forcing people to crowd around a few potentially con-taminated sources. Gastro-intestinal diseases flourished during the summer,especially among the young.

Russians were also highly mobile, facilitating the diffusion of infectiousdiseases. Commerce along the rivers and railroads grew rapidly; the greatervolume and speed of travel allowed diseases like cholera to spread morerapidly.41 Peasants, who usually did not have enough land to support them-selves in their villages, moved by the millions in seasonal migratory flows towork in the cities in winter and on the southern grain harvest in the early fall.Throngs of pilgrims congregated in religious centres and even larger crowdsattended trade fairs, such as the great international fair at Nizhni-Novgorod.

40 Jacques Vallin, 'Mor ta l i ty in Eu rope from 1720 to 1914: L o n g - T e r m T r e n d s and Changes inPatterns by Age and Sex' , in Schofield, el ai. (eds.) The Decline, 3 9 - 4 3 ; O iva Turpe inen , 'Fertili tyand Mor ta l i ty in Finland Since 1750', Population Studies, 33 (1979), 101-14.

41 Pat terson, 'Cholera Diffusion. '

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Russia was open to cholera, plague, and other epidemics from Central Asiaand the Caucasus. Long-distance travel and rural-urban circulation ensuredthat tuberculosis, typhus, and venereal diseases moved from city to village.

Many peasants who did not migrate had to seek day-labour near their homesworking in the fields of noble landowners or wealthier neighbours. A strongassociation between high infant mortality and estate agriculture has beendescribed in Sweden and Germany, with the extensive employment of nursingmothers in agricultural labour a key variable.42 The situation in Russia maybe similar. Although many Baltic peasants had too little land to supportthemselves and had to work on estates, some were largely or entirely self-sufficient on mixed farms. This probably is a factor in their low IMRs incomparison with peasants of the southern and southeastern grainlands.

The trend was, however, despite the crisis of 1892, toward a more modernmortality regime. The contributions of specific diseases to declining mortalityare not clear at this stage of research, but as the eminent contemporary publichealth leader S. A. Novoselskii observed, falling mortality was caused by thelessening toll from infectious diseases.43 Mortality from some diseases, likesmallpox, diphtheria, and perhaps malaria, was lessened by direct medicalmeasures. Plague was kept in check and slow improvements in sanitationreduced water-borne diseases in most cities and on military posts. Respiratoryinfections like pneumonia and influenza claimed a substantial but poorly-measured number of victims, especially during the 1889-90 influenzaepidemic.44 A key question is what was happening to the causes of death, both'named' diseases and the ill-defined respiratory afflictions and diarrhoeas,which killed so many infants.

The causes of declining mortality are multiple and can be little more thanenumerated at this stage of research. Rural and urban sanitation, the washing,ventilation, and drainage described by Riley as 'medicine of the environment',which helped control insect vectors and filth-borne diseases in parts of westernEurope in the eighteenth century,45 were in little evidence in Russia for mostof the 1800s. The dedicated efforts of zemstvo physicians46 and their counter-parts in Russia's cities had limited therapeutic impact, although some progresswas achieved in the last two decades of the period. Doctors were activeadvocates of sanitary reform and worked hard at health education for the

42 Robert Lee, 'Mortal i ty Levels and Agrarian Reforms in Early 19th Century Prussia: SomeRegional Evidence' , in T o m m y Bengtsson, Gunnar Fridlizius, and Rolf Ohlsson (eds.) Pre-Industrial Population Change: The Mortality Decline and Short-Term Population Movements (Stock-holm, 1984), 161-90.

43 S. A. Novoselskii , 'K voprosu o snizhenii smertnosti i rozhdaemost i , ' in L. E. Polyakov(ed.), Demografiya i statistiki (Moscow, 1978), 122-6. Originally published in 1914.

44 K. David Patterson, Pandemic Influenza, 1700-1900: A Study in Historical Epidemiology (Totowa,NJ, 1986), 5 1 - 7 .

45 James C. Riley, The Eighteenth-Century Campaign to Avoid Disease ( N e w York, 1987).46 O n the medical profession, see Nancy Mandelker Frieden, Russian Physicians in an Era of

Reform and Revolution, 1856-1905 (Princeton, NJ, 1981); and John F. Hutchinson, Politics and PublicHealth in Revolutionary Russia, 1890-1918, (Baltimore, 1990).

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public. Their work on non-lethal conditions, including a heavy load of ophthal-mological cases, gave them some credibility with the peasants.

McKeown hypothesized that improved nutrition was the crucial factor inBritain's nineteenth-century mortality decline. His views have been effectivelychallenged,47 but Hoch has recently suggested that Russia's mortality declinewas largely due to better diet. Arguing in the context of a long debate overtrends in peasant living standards, he uses falling mortality to support hiscontention that the peasants produced and consumed more food.48 While theremay have been some nutritional improvement, it was probably small andconcentrated among more prosperous groups. And, since many diseases areunaffected by improved nutrition, diet probably played a relatively small role.

Other trends also contributed. Education standards and literacy levels wererising slowly, probably with a positive impact on health education efforts oflocal government bodies and medical groups. Indeed, Novoselskii gave pri-mary credit to rising literacy and the efforts of doctors, particulary the zemstvophysicians.49 The state, assisted by the new railroad system, did a better jobin alleviating famines by the last third of the century. Even in 1892, despitevociferous public criticism of its efforts, the regime's response to the faminewas fairly effective.50

VI

Russia was still in the first phase of Omran's epidemiological transition? butmortality was falling and there were signs that at least some infectious diseaseswere declining. The state was providing rudimentary medical care, the begin-nings of urban sanitation, and enough domestic tranquility to discourageepidemic and famine crises. Wars were fought on the periphery of Russia, but,with the minor exception of the Crimean conflict, the country was sparedwidespread war from the Napoleonic invasion of 1812 until August 1914. Asmall mortality peak in 1905, probably stimulated by the Russo-Japanese Warand internal disorders, and the 1910 spurt caused by cholera showed that crisismortality was still possible. Progress continued after the fall of the Tsaristregime, although the new Soviet state experienced appalling mortality crisesdue to war, famine, and epidemics from 1918-22, and again in the early tomid-1930s as a consequence of collectivization, forced-draft industrialization,and the purges. Political factors were largely responsible for these demo-graphic horrors.

Kunitz has described the western mortality decline in three phases: thecontrol of plague and other great epidemics; the control of infections such as

47 T h o m a s M c K e o w n , The Modem Rise of Population (London , 1976); S imon Szreter, ' T h eImportance of Social Intervent ion in Britain's Morta l i ty Decline c. 1850-1914: A Re-interpretat ionof the Role of Public Heal th ' , Social History of Medicine, 1 (1988), 1-37; Szreter, 'Mor ta l i ty inEngland in the Eighteenth and Nine teenth Centur ies ; A Reply to Sumi t G u h a , ' Sofia/ History ofMedicine, 7 (1994), 269 -82 .

48 Hoch , 'Peasant Standard of Living ' , 4 2 - 7 5 .49 Novoselski i , 'K voprosu ' , 126-7 .50 Richard G. Robbins , J r . , Famine in Russia, 1891-1892 ( N e w York , 1975).

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tuberculosis and diarrhoeal diseases by economic and nutritional improve-ments; and the control of mortality from non-infectious causes.111 WesternEurope generally had passed through the first phase by the beginning of thenineteenth-century, although southern Europe lagged a bit.52 Mortality ratesgenerally stagnated until the mid-1800s, when a slow decline based on im-proved living standards and public health measures began to reduce the tollfrom many infections. Infant mortality declines generally started a few decadeslater, near the end of the century.33

Russia lagged a century or so behind. Flinn argued that in the west, strongergovernments were able to assure internal peace, guard against plague, andpromote new food crops by the late seventeenth century, thus taming mortalitypeaks.34 Plague devastated central Russia in the 1770s, a century after it ceasedto be a major factor in the west. The Russian state was not strong enough toprovide internal peace and effective famine relief until the nineteenth century.The potato, an important new food crop, did not begin to spread until afterfamines in the 1830s and 1840s. While the evidence is unclear, populationgrowth, urbanization, and better transportation were probably making di-seases such as measles and smallpox into childhood infections during the1800s. With the containment of crises in the late nineteenth century, Russia'smortality stabilized at a high level due to general poverty and backwardness.Despite some progress in overall and even infant-child mortality, Russianpoverty and illiteracy retarded advances against what Kunitz characterizes asthe infectious diseases amenable to control by better living standards. "Still, aswith industry, agriculture, education, and politics, there were slow improve-ments in Russia's health conditions in the last decades of the Tsarist period.What might have happened if the First World War and the Bolshevik Revo-lution had not intervened is unknowable, but the real advances of the Sovietera were based on pre-revolutionary foundations.

Much more research in published and archival sources is necessary to testthe generalizations suggested here. Studies of individual provinces, districts, andcities, with due attention to the classic epidemiological variables of age, gender,ethnicity, and socio-economic status are essential. Astrakhan and Saratov, liigh-mortality provinces on the lower Volga, would be especially interesting formalaria and epidemics. Central industrial provinces like Moscow or Kostromawould illustrate the health consequences of rural-urban circulation. Researchon major cities would add to our knowledge of Russian urban history.

51 Stephen J. Kunitz , 'Speculations on the European Morta l i ty Decline ' , Economic History Re-view, 36 (1983), 349-64 . See also Roger Schofield and David Reher, 'The Decline o f Mor ta l i tyin Europe ' , in Schofield, el al. (eds.) The Decline, 1-17; and Kunitz, 'Mor ta l i ty C h a n g e inAmerica , 1620-1920' , Human Biology, 56 (1984), 559 -82 for similar views.

52 Graziella Caselli, 'Heal th Transi t ion and Cause-Specific Morta l i ty ' , in Schofield, et « ' ( e d s ) ,The Decline, 6 8 - 9 .

53 Vallin, 'Mor ta l i ty in Europe from 1720 to 1914', in Schofield, et al. (eds.) The Decline, 4 9 -52; R. I. W o o d s , P. A. Watterson, a n d j . H . W o o d w s i d . 'The Causes of Rapid Infant Mor ta l i tyDecline in England and Wales, 1861-1921 P a n I', Population Studies, 42 (1988), 3 4 8 - 5 3 . Therewas great variation within and be tween countr ies .

54 Michael W. Flinn, The European Demographic System, 1500-1820, (Bal t imore, 1981), 5 5 - 8 ;95-8.

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Culture is a crucial health variable, even in conditions of dire poverty. Whydid Jews enjoy such low death rates? Was there something protective aboutLutheran concerns with neatness and cleanliness? Do local cultural differencesamong or within Russian or Ukrainian districts help explain differences? Onlydetailed local studies can address such questions. Perhaps research on the Balticprovinces, with mixed local, German, Jewish, and Russian populations and,presumably, relatively good records, would be especially profitable. The cen-tral and southern Volga provinces, with Russian, Finnic, German, and Tatarpopulations, are another possibility.

Infant and child mortality requires special attention along the lines pioneeredby Ransel. Feeding practices must have been a crucial variable. Ethnic andregional cultural values must also have been significant, as Imhof has dramati-cally demonstrated for nineteenth-century Germany.55 It is interesting to notethat IMRs in Russia begin to fall, albeit slowly, at roughly the same time asthose in England, France, and many other western countries.

Work on the impact and control of specific diseases is also important. Giventhe importance of regional and urban-rural differences in a relatively smallcountry like England,56 it is evident that Russia experienced a number of veryuneven demographic and epidemiological transitions. Why did some districtsand/or provinces do significantly better than others? Were differences causedby broad economic, geographical, or cultural factors, or were initiatives ofindividual officials or doctors sometimes a determining factor for a particularplace? Given Russia's poverty it seems logical to expect that the medicalprofession, using the new methods of the day and acting as therapists, edu-cators, and public health reformers, played a relatively important role. Howeffective were those dedicated and hard-working zemstvo physicians? In thelate twentieth century, aggressive state and medical intervention can producemajor health improvements, even in very poor populations.57 Zemstvo doc-tors and their urban colleagues obviously had much less advanced technologyat their disposal, but one hopes that they made a difference.

The Russian mortality experience must be evaluated in a comparative con-text embracing eastern and central Europe. During the disasters of the CivilWar and collectivization, comparisons with places like India seem appropriateeven in the twentieth century.58 An understanding of Russian mortality willbe a significant contribution to our knowledge of the epidemiological anddemographic transformations of the last two centuries.

55 Arthur Imhof, 'The Amazing Simultaneousness of the Big Differences and the Boom in the19th Century —Some Facts and Hypotheses about Infant and Maternal Mortality in Germany,18th to 20th Century', in Bengtsson, et al. (eds.) Pre-Industrial Population Change, 191-220.

56 Robert Woods and P. R. Andrew Hindle, 'Mortality in Victorian England: Models andPat te rns ' , Journal of Interdisciplinary History, 18 (1987), 40—3.

57 A m a r t y a Sen, ' T h e E c o n o m i c s o f Life and D e a t h ' , Scientific American, 268 (1993), 4 0 - 7 . Sencites examples from South Korea, Costa Rica, China, and Kerala State, India.

58 Michelle B. McAlpin, 'Famines, Epidemics and Population Growth: The Case of India',Journal of Interdisciplinary History, 14 (1983), 351-66; David Arnold, 'Social Crisis and EpidemicDisease in the Famines of Nineteenth-century India', Social History of Medicine, 6 (1993), 384-404.

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Documents

Mortality in Late Tsarist Russia: A Reconnaissance