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By Thomas McKeown

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There is reason to believe that there was also a significant decrease of deaths from water- and food-borne diseases (discussed in chapter 7). Of the vector-borne diseases, plague had virtually disappeared before the beginning of the eighteenth STntury, and it is unlikely that malaria was ever an important cause of death in the British Isles; however, the decline of typhus undou btcdly contributed to the reduction of mortality in the pre-registration period. ·ro summarize: the decline of mortality since the end of the seventeenth century was d uc predominantly to a reduction of deaths associated with infectious diseases.

Moreover these examples of the mdl(:ctiveness of medical measures could be extended. For example, cholera vaccine required until recently by international regulations, **" alrnost useless; the reduction of mortality from diphtheria in the did not everywhere coincide with the introduction of immunizahon; and scarlet fever is an example of a disease whose variable history ;;*ppcars to have been independent of medical and other identifiable mfluences. Nevertheless, although there is no doubt that specific medical mea~tt~rcs have had little effect on the behaviour of many infections, the ~pwstion concerning the significance of changes in the character of the mft:·ctious diseases is too complex and too important to be dismissed v,irhout careful examination.

Of mortality from water- and food-borne diseases was delayed until the last clecaclcs or the nineteenth century. AlthotJgh cause of death was registered later in other countries of western Europe than in England and Wales, the evidence for Sweden, France and Ireland is conS>istcnt with the conclusion that deaths from water- and f(x)(i-borne diseases did not begin to decline until about the rnd of the nineteenth ccntury. " infections in the pre-registration period. The number of deaths from tuberculosis fdl rapidly from 18::;8, and this disease was associated with nearly half of the total decrease of the death rate during the second half of the nineteenth century.

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