childhood epidemics and the demographic landscape of the åland archipelago

145 Pages·2017·1.7 MB·English

by  Erin Miller

CHILDHOOD EPIDEMICS AND THE DEMOGRAPHIC
LANDSCAPE OF THE ÅLAND ARCHIPELAGO
______________________________________________________
A Dissertation
presented to
the Faculty of the Graduate School
at the University of Missouri-Columbia
______________________________________________________
In Partial Fulfillment
of the Requirements for the Degree
Doctor of Philosophy
______________________________________________________
by
ERIN LEE MILLER
Dr. Lisa Sattenspiel, Dissertation Supervisor
MAY 2018
The undersigned, appointed by the dean of the Graduate School,
have examined the dissertation entitled
CHILDHOOD EPIDEMICS AND THE DEMOGRAPHIC
LANDSCAPE OF THE ÅLAND ARCHIPELAGO
presented by Erin Lee Miller,
a candidate for the degree of
Doctor of Philosophy,
and hereby certify that, in their opinion, it is worthy of acceptance.

Professor Lisa Sattenspiel
Professor Todd VanPool
Professor Mary Shenk
Professor Enid Schatz
Associate Dean James Mielke, University of Kansas
ACKNOWLEDGEMENTS
This research was made possible by the aid and support of many friends, family, and
colleagues over the years.
I would first like to express my deepest appreciation to my committee chair
Professor Lisa Sattenspiel. Without her guidance and support over the years, this
dissertation would not have been possible. As a mentor, Dr. Sattenspiel has always had an
open door and willingness to provide support for whatever path her students chose. I also
owe thanks to my Dissertation Committee members, Professor Todd VanPool, Professor
Mary Shenk, and Professor Enid Schatz, for their insight, guidance, and time through the
research and writing process. The dedication of these professors has enriched my life
professionally and inspired me personally.
I owe special thanks to Associate Dean James Mielke (who also served on my
Dissertation Committee) for providing archival records from Åland, Finland for the
purposes of this research. I am grateful to Dr. Mielke and Dr. Kari Pitkänen (University of
Jyväskylä, Finland) for working with me to better understand the archival records and the
history of the Åland Islands. Dr. Pitkänen is owed additional thanks for providing
translation references and assistance in the early stages of this project. In addition, I would
like to thank Associate Professor Corey Sparks (University of Texas at San Antonio) for his
instruction in adapting demographic methods for historical populations and encouragement
during the dissertation process.
I am also deeply grateful for the family and friends who provided the motivation and
support needed to make it through graduate school. I would like to thank my parents;
whose love and support are always with me. They provided financial, mental, and moral
support through this long, and sometimes difficult, journey. Thank you to my sister, and
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best friend, who is always there for me no matter how far apart we are. To Kate Trusler, my
inspiration fairy, who took time out of her days to provide encouragement and laughter
with a few simple texts. Finally, to other family, friends, and colleagues who provided advice
and support during this process, thank you.

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TABLE OF CONTENTS
ACKNOWLEDGMENTS ........................................................................................................................................... ii
LIST OF FIGURES ..................................................................................................................................................... v
LIST OF TABLES ...................................................................................................................................................... vi
ABSTRACT ............................................................................................................................................................... vii

CHAPTER 1: INTRODUCTION ............................................................................................................................. 1

CHAPTER 2: USING AN ANTHROPOLOGICAL FRAMEWORK TO EXPLORE HISTORICAL
EPIDEMICS ................................................................................................................................................................. 6
Sociocultural Approaches to Health and Disease ................................................................................ 7
Critical Medical Anthropology and the Social Determinants of Health ................................. 9
Syndemic Theory .................................................................................................................................... 11
Physical/Biological Approaches to Health and Disease................................................................. 12
Transition Theory: Perspectives from Demography and Epidemiology ............................. 14
Demographic transition theory ................................................................................................. 14
Epidemiological transition theory ........................................................................................... 17

CHAPTER 3: THE ÅLAND ARCHIPELAGO ................................................................................................... 22
Åland Households and Communities: An Overview ....................................................................... 26
Pre-20th Century Åland, Finland: Demography, Mortality, and Epidemiology .................... 29

CHPATER 4: MEASLES ........................................................................................................................................ 37
The Biology of Infection ............................................................................................................................. 38
Syndemic Interactions ................................................................................................................................ 40
Comparing Measles and Smallpox ......................................................................................................... 43
Measles Epidemiology: Quantitative Studies .................................................................................... 46

CHAPTER 5: THE ARCHIVES OF ÅLAND ..................................................................................................... 50
Translating Causes of Death ..................................................................................................................... 52
Understanding Archival Data in Demographic Research ............................................................. 55
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CHAPTER 6: METHODS ...................................................................................................................................... 57
Graphic Analyses: Identifying Epidemics and Non-epidemics .................................................. 58
Age-specific Death Rates: Bridging Gaps in Data ............................................................................. 59
Excess Mortality and Frequency Analysis .......................................................................................... 62
Demographic Impacts of Epidemic Mortality ................................................................................... 65

CHAPTER 7: RESULTS ........................................................................................................................................ 67
Age-specific Death Rates ............................................................................................................................ 70
Excess Mortality and Frequency Analysis .......................................................................................... 73
Long-term Demographic Consequences of Epidemic Mortality ................................................ 83

CHAPTER 8: DISCUSSION AND CONCLUSIONS ........................................................................................ 93
Excess Mortality ............................................................................................................................................ 94
Infant mortality ...................................................................................................................................... 95
Excess mortality at ages 1-9 .............................................................................................................. 96
Excess mortality for individuals 50 years and older ................................................................. 97
Demographic Impacts of Epidemic Mortality ................................................................................... 99
Implications, Limitations, and Conclusions .................................................................................... 104

REFERENCES ....................................................................................................................................................... 107

APPENDIX A: Cause of Death (COD) Translations: Some Examples ............................................. 124
APPENDIX B: Age-specific Death Rates by Study Period Only ........................................................ 125
APPENDIX C: Infant Mortality Rate Confidence Intervals ................................................................ 128
APPENDIX D: Life Tables ................................................................................................................................ 130

VITA ......................................................................................................................................................................... 136

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LIST OF FIGURES
Figure Page
3.1 Map showing position of Åland, Finland in northern Europe ................................................ 23
3.2 Map of the Åland Islands parishes ..................................................................................................... 25
4.1 Disease stages: Comparisons of measles and smallpox ............................................................ 45
5.1 Sample of data from the Finström parish death register ......................................................... 51
7.1 Graphic analysis of measles and smallpox deaths in Åland, Finland 1780-1850 ........... 68
7.2 Infant mortality rates for Åland, Sweden, and Finland ............................................................. 70
7.3 Age-specific death rates in Åland, Finland by study period .................................................... 72
7.4 Proportionate mortality ratio by cause of death category ...................................................... 77
7.5 Population pyramid comparing 1816-17 baseline with measles epidemic ..................... 84
7.6 Population pyramid comparing 1816-17 baseline with smallpox epidemic ................... 85
7.7 Expected age at death 1815-1830 ..................................................................................................... 87
7.8 Crude death rates and generalized fertility rates 1815-1830 ................................................ 88
7.9 Male excess mortality for selected age groups ............................................................................. 90

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LIST OF TABLES
Table Page
5.1 Examples of abbreviations in the recorded causes of death for Brändö Parish ............. 54
5.2 Cause of death categories and descriptions ................................................................................... 55
6.1 5-year age-specific census population estimates from the Åland Islands ........................ 61
6.2 Number of deaths by cause of death category .............................................................................. 64
7.1 Excess mortality ratios for the Åland archipelago ...................................................................... 74
7.2 Chi-square analysis of categories of death ..................................................................................... 76
7.3 Sample translations for Other/unknown category ..................................................................... 79
7.4 Identifiable causes of death in Other category for ages 1-4 .................................................... 80
7.5 Identifiable causes of death in Other category for ages 5-9 .................................................... 81
7.6 Identifiable causes of death in Other category for individuals aged 50+ .......................... 82
7.7 Average life expectancy at selected ages ........................................................................................ 86
7.8 Excess male mortality by age group and study period ............................................................. 90

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CHILDHOOD EPIDEMICS AND THE CHANGING DEMOGRAPHIC
LANDSCAPE OF THE ÅLAND ARCHIPELAGO
Erin Lee Miller
Dr. Lisa Sattenspiel, Dissertation Supervisor
ABSTRACT
Historically, the introduction of childhood diseases such as measles or smallpox
resulted in the infection of nearly every susceptible individual in a community. While
smallpox has long been considered the deadlier of the two childhood diseases, research has
shown that the immune response to measles infection results in immune suppression that
can last for weeks or even months. Higher mortality during measles epidemics has typically
been associated with completely susceptible populations; however, in Åland, Finland―a
population that experienced regular epidemics of both childhood diseases―mortality from
all causes during the 1820-21 measles epidemic was 25% higher than that experienced
during the 1823-24 smallpox epidemic. Excess mortality surrounding measles epidemics
suggests that this disease may have larger impacts on the demographic history of
populations than previously thought.
This study uses archival records to investigate syndemic interactions between
measles and other diseases during a 19th century measles epidemic in the Åland Islands,
Finland. Comparisons to smallpox and a non-epidemic period indicated greater than
expected mortality for individuals aged 5 to 9 years and over 50 years; though neither
epidemic had long-term demographic consequences. These results are consistent with
deaths from secondary infections due to measles-induced immune suppression, but not
conclusive. The unknown impact of measles exposure on adults with antibodies, and the
variety of other diseases and symptom descriptions, indicates that the possibility of co-
occurring epidemics cannot be ruled out.
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CHAPTER 1: INTRODUCTION
Throughout history, infectious disease has shaped populations and societies and
spurred research from multiple fields to uncover the underlying causes and factors that
influence the spread of disease within and between populations. While initial studies were
more concerned with understanding the biology of infection, each study of health or disease
has provided another aspect of the epidemic puzzle, highlighting the complex interactions
that contribute to the spread and impact of infectious diseases. Anthropologists and other
social scientists have been increasingly called upon to explain social and cultural processes
which contribute to the distribution, spread, or overall impact of a disease—an approach to
epidemiology with human behavior as a central theme that stands at the intersection of
many disciplines, including, for example, biology, ecology, demography, geography, and
politics (Janes et al., 1986).
Infectious disease research from the fields of epidemiology, anthropology and other
disciplines, both current and historically situated, informed efforts that led to the
eradication of smallpox and the reduction in prevalence and successful management of
numerous other infectious diseases, including measles. Prior to vaccination, measles was
estimated to cause over 2 million deaths across the globe, primarily in children under 5
years of age (WHO, 2018). Yet, measles vaccination campaigns have not had the same
success as was seen with smallpox, due, in part, to social and cultural factors such as
religious objections to vaccination or a fear of the vaccine itself.
The global incidence of measles fell by 78% between 2000 and 2008 (WHO, 2011),
but in the first half of 2011, the United States reported the largest number of measles cases
in more than a decade; 45% of these cases occurred in adults aged 20 years or older (CDC,
2011). With the introduction of vaccination, measles has predominantly been a health
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