The Deadly Truth: A History of Disease in America

Gerald N Grob

Harvard University Press, $35/£23.50, pp 349

ISBN 0 674 00881 2

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At a recent bioethical meeting, Beat Sitter-Liver from the Swiss Academy of Humanities and Social Sciences said that the concept of finitude (a term borrowed from the philosopher Martin Heidegger, meaning the limits of human existence) was virtually non-existent in the United States. For example, Americans seem to think that the possibilities of medicine are unlimited. Gerald Grob's history of disease in the United States echoes this assumption. He writes, “In our modern Western culture we have grown accustomed to the belief that all things are possible and that humans can completely control their destiny.” But such faith “is at best harmless and at worst a dangerous utopian illusion,” he adds.

Grob, who teaches medical history at Rutgers University in New Jersey, calls his book “a product of nearly three decades of teaching and research.” This claim is substantiated by abundant references and meticulously researched statistics on life expectancy, morbidity, and mortality dating from before the arrival of Columbus to the present day.

The focus is on infectious diseases. Mortality patterns among indigenous people before Columbus seem to differ significantly from those found in Europe and Asia. There were no catastrophic epidemics but people were more susceptible to malnutrition and injuries. The discovery of the Americas in 1492 had tragic consequences. Grob says, “The European conquest … had relatively little to do with military prowess or superior technology; it was largely the result of the ravages of disease.” As a result of imported infections such as measles, smallpox, plague, and typhus, by 1617 the Amerindian population of La Florida (a region that included the entire south east of the present United States) was perhaps 5% of the total alive a century earlier. English settlers decreased the number of native North Americans through the introduction of liquor.

In the 18th century American colonies had lower morbidity and mortality rates than densely populated European capitals. But by the end of the century the situation began to change as epidemics of measles, malaria, and “throat distemper” (the 18th century term for diphtheria) were recorded in New England. Acute and chronic infections were the major causes of death, whereas the impact of chronic degenerative illnesses was insignificant “because of the youthful nature of American society,” where the median age was about 16.

Contrary to the popular belief that health and income are directly related, the rise in the standard of living in 19th century United States was accompanied by increases in morbidity and mortality. This is explained by the spread of endemic infectious diseases (tuberculosis in particular) in overcrowded and unhygienic urban environments. For example, almost a quarter of all deaths in New York City in 1804 are thought to have been caused by tuberculosis and other pulmonary disorders.

During the wars that America fought in the 19th century more men perished from infections than were killed in battle. For example, nearly two thirds of 600 000 deaths during the Civil War were from disease.

The death rate from infections fell by 600% between 1850 and 1920. But Grob doubts that this dramatic decline in mortality might be attributed to advances in medical science. He concludes that strictly medical therapies did not play a significant part in changing disease patterns (when chronic degenerative diseases began to replace acute infections). Antibiotics and vaccines were introduced only after 1940.

The leading cause of mortality in the United States today is heart disease (in 1998 it accounted for 31% of all deaths). The author criticises the risk factor theory as an explanation for the rise of chronic heart disease since 1900 and mentions recent theories that some infections may be responsible.

It is obvious that Americans are living longer and healthier lives than a century ago but Grob says that “the precise reasons for the changes in mortality and morbidity rates (and therefore life expectancy) remained murky.”

The central theme of this thought provoking and somewhat pessimistic book is our inability to predict the consequences of our actions: “Confidence in our ability to control the world should be tempered by a wise scepticism and recognition of our limitations.” A lesson to bear in mind in more than just medical matters.