Preliminary findings by Sakari Saaritsa, currently visiting LSE, and colleagues Eero Simanainen and Markus Ristola suggest that ambulatory nurses had a more significant role in reducing mortality than doctors in rural Finland a century ago. Qualitative evidence suggests that superior capacity to influence behaviour in communities mattered more than treatment or advanced medical knowledge in the pre-biomedical context.
The importance of public health measures for the secular mortality decline in Western populations has been a constant subject of debate in economic and social history. The effects of falling mortality on various aspects of economic and social life, including fertility, capital accumulation and economic growth, were highly significant. The monetary value of the life-years gained may have matched the value of goods and services produced over the same period. The role of public intervention in this achievement is therefore an important question.
The project contributes on a key subject, the effect of introducing modern health professionals where there previously were none – in this case, rural Finland in the late 19th and early 20th century. Our data allows us to discern the association between the supply of different service modalities (diverse types of doctors, ambulatory nurses, and their combinations) and overall mortality decline in the long run.
Our study connects to a new body of econometrically oriented literature on public health, mapping “what worked”, and what possibly did not. While this has mostly validated significant effects from a range of public health interventions, like sanitation, health education or parasite eradication, researchers have also started to identify heterogeneity in findings. Some studies have questioned previous estimates or claims about the success of prominent historical interventions, like water purification and anti-tuberculosis campaigns, finding instead zero or very small effects from previously acclaimed public actions. However, research analyzing the effects of different types of interventions in specific historical contexts still remains somewhat limited.
Our findings lend support to the insight that the role of doctors may have been limited in pre-biomedical contexts. However, longer term interpersonal contact by nurses was more effective. The figure shows our estimates of the effect of hiring a nurse on the crude death rate in Finnish rural municipalities in 1880-1938. This interpretation is also supported by qualitative evidence. We are also able to show that proximity to the population may have mattered in terms of effectiveness for doctors as well. This suggests that lack of effective therapies may not have been decisive, but rather the ability to successfully influence behaviour mattered. The findings are preliminary, as the study is currently still ongoing.
This project is one of several I’m working on around health, education and disease. Others include:
- “The Anthropometrics of War, Famine and Development: Helsinki schoolchildren, 1910-1932” (with Joël Floris and Tuuli Hurme). This paper is based on a novel anthropometric data on 17 000 early 20th century primary school children from Helsinki. The data will be used to e.g., analyse the effects of major historical shocks, in particular the Finnish Civil War of 1918 and the disruptions in food supply in 1917-1919, on the nutritional status and growth patterns of children in different positions.
- ”Death Around the Kitchen Table: Inequality, Urban Habitat and Disease Avoidance during a Typhoid Epidemic in a Finnish City, 1916” (with Jarmo Peltola and Henri Mikkola). We use exceptionally multidimensional data on the socioeconomic status, location, physical habitat and self-reported behaviour of infected people during a 1916 typhoid epidemic in a city in Finland to identify the determinants of the timing of contagion. Applying survival analysis to c. 2800 cases, we are able to show that elementary disease avoidance behaviour was directly constrained by physical habitat, even in the context of a considerable information campaign. Centralized water purification initiated during the epidemic levelled the playing field by socializing the cost of prevention.
- “The health effects of primary education during the epidemiological transition” (with Heidi Hirvonen). This project will analyse the effect of the expansion of primary education on health in the context of a historical developing country with an unfinished epidemiological transition and dependence on disease avoidance rather than limited therapeutic medicine. Primary schooling has been suggested to function as a conduit for knowledge of basic disease avoidance behaviour. In Finland, qualitative studies of the curriculum of schools have suggested that hygiene, bodily discipline and cleanliness were a significant part of the education. However, no quantitative analysis of actual health effects has previously been attempted.
- “The impoverished insophisticate: Human and economic development in Finland, 19th-20th centuries”. This paper is based on a deconstruction and reconstruction of the Historical Human Development Index of Finland and selected Scandinavian countries, particularly Sweden. The point is to show divergence in what is usually presented as a common narrative, as Finnish economic development and catch-up was not based on an early accumulation of human capital.
An event study graph describing the impact of nurse hiring on log Crude Death Rate in Finnish rural municipalities, 1880-1938.
I’ll be glad to speak with anybody with mutual interests while at the LSE and in London. This also applies to students with e.g., thematically related dissertation projects, as I do realize not many people are working on Finland!