via HeritageDaily: 17th- and 18th-century risk of disease through Migration

17th- and 18th-century risk of disease through Migration

HERITAGE March 3, 2014 – No comments
smallpox

The fate of migrants moving to cities in 17th- and 18th-century England demonstrates how a single pathogen could dramatically alter the risks associated with migration and migratory patterns today.

Cities have always been a magnet to migrants. In 2010, a tipping point was reached for the first time when, according to the World Health Organization, the majority of the world’s population lived in cities. By 2050, seven out of 10 people will have been born in – or migrated to – a city. One hundred years ago, that figure was two out of 10.

Today, cities are generally the safest places to live. If you live in one, you’re likely to be richer than someone living in a rural environment. If you’re richer, you’re likely to live longer. If you live in a city, you have better access to hospitals and healthcare, and you’re more likely to be immunised.

But that was not always the case. In 17th- and 18th-century England, city life was lethal – disproportionately so for those migrating from the countryside.

Dr Romola Davenport is studying the effects of migration on the health of those living in London and Manchester from 1750 to 1850, with a particular focus on the lethality of smallpox – the single most deadly disease in 18th-century England. In the century before 1750, England’s population had failed to grow. Cities and towns sucked in tens of thousands of migratory men, women and children – then killed them. It’s estimated that half of the natural growth of the English population was consumed by London deaths during this period. Burials often outstripped baptisms.

In 2013, cities are no longer the death traps they once were, even accounting for the millions of migrants who live in poor, often slum-like conditions. But will cities always be better places to live? What could eliminate the ‘urban advantage’ and what might the future of our cities look like if antibiotics stop working?

By looking at the past – and trying to make sense of the sudden, vast improvement in survival rates after 1750 – Davenport and the University of Newcastle’s Professor Jeremy Boulton hope to understand more about city life and mortality.

“For modern migrants to urban areas there is no necessary trade-off of health for wealth,” said Davenport. “Historically, however, migrants often took substantial risks in moving from rural to urban areas because cities were characterised by substantially higher death rates than rural areas, and wealth appears to have conferred little survival advantage.”

The intensity of the infectious disease environment overwhelmed any advantages of the wealthy – such as better housing, food and heating. Although cities and towns offered unparalleled economic opportunities for migrants, wealth could not compensate for the higher health risks exacted by urban living.

“Urban populations are large and dense, which facilitates the transmission of infectious diseases from person to person or via animals or sewage. Towns functioned as trading posts not only for ideas and goods but also for pathogens. Therefore, growing an urban population relied upon substantial immigration from rural areas,” explained Davenport.

“After 1750, cities no longer functioned as ‘demographic sinks’ because there was a rapid improvement in urban mortality rates in Britain. By the mid-19th century, even the most notorious industrial cities such as Liverpool and Manchester were capable of a natural increase, with the number of births exceeding deaths.”

Davenport has been studying the processes of urban mortality improvement and changing migrant risks using extremely rich source material from the large London parish of St Martin-in-the-Fields. The research, funded by the Wellcome Trust and the Economic and Social Research Council, is now being augmented with abundant demographic archives from Manchester, funded by the Leverhulme Trust.

For both cities, Davenport and colleagues have access to detailed records of the individual burials underlying the Bills of Mortality, which were the main source of urban mortality statistics from the 17th to the 18th century. These give age at death, cause of death, street address and the fee paid for burial, which enables them to study the age and sex distribution of deaths by disease. In addition, baptismal data allow them to ‘reconstitute’ families as well as to measure the mortality rates of infants by social status.

“The records themselves give only a bald account of death,” said Davenport. “But sometimes we can link them to workhouse records and personal accounts, especially among the migrant poor, which really bring home the realities of life and death in early modern London.

“Smallpox was deadly. At its height, it accounted for 10% of all burials in London and an astonishing 20% in Manchester. Children were worst affected, but 20% of London’s smallpox victims were adults – likely to be migrants who had never been exposed to, and survived, the disease in childhood. However in Manchester – a town that grew from 20,000 to 250,000 in a century – 95% of smallpox burials were children in the mid-18th century, implying a high level of endemicity not only in Manchester but also in the rural areas that supplied migrants to the city.

“So studying urban populations can tell us not only about conditions in cities but also about the circulation of diseases in the rest of the population.”

The greater lethality of smallpox in Manchester is, for the moment, still a mystery to researchers; but evidence suggests the potential importance of transmission via clothing or other means – as opposed to the person-to-person transmission assumed in mathematical models of smallpox transmission in bioterrorism scenarios. Although smallpox was eradicated in the late 1970s, both the USA and Russia have stockpiles of the virus – which has led to fears of their use by terrorists should the virus ever fall into the wrong hands. Data on smallpox epidemics before the introduction of vaccination in the late 1790s are very valuable to bioterrorism researchers because they provide insights into how the virus might spread in an unvaccinated population (only a small proportion of the world’s population is vaccinated against smallpox).

From 1770 onwards, there was a rapid decline in adult smallpox victims in both London and Manchester, which Davenport believes could be attributable to a rapid upsurge in the use of smallpox inoculation (a precursor of vaccination) by would-be migrants or a change in the transmissibility and potency of the disease. By the mid-19th century, towns and cities appear to have been relatively healthy destinations for young adult migrants, although still deadly for children.

“Smallpox was probably the major cause of the peculiar lethality of even small urban settlements in the 17th and 18th centuries,” said Davenport, “and this highlights how a single pathogen, like plague or HIV, can dramatically alter the risks associated with migration and migratory patterns.”

“The close relationship between wealth and health that explains much of the current ‘urban advantage’ is not a constant but emerged in England in the 19th century,” added Davenport. “While wealth can now buy better access to medical treatment, as well as better food and housing, it remains an open question as to whether this relationship will persist indefinitely in the face of emerging threats such as microbial drug resistance.”

Header Image : An 1802 cartoon of the early controversy surrounding Edward Jenner’s vaccination theory, showing using hiscowpox-derived smallpox vaccine causing cattle to emerge from patients. WikiPedia

Contributing Source : University of Cambridge

© Copyright 2014 HeritageDaily – Heritage & Archaeology News

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Doctors selling their practices – Jul. 16, 2013

A growing trend in the United States is to see less doctors practicing. We are seemingly suffering a brain drain of doctors who want to have their own private practice, but end up giving up their specialties to work for a hospital instead.

Top reasons that doctors are calling it quits:

1. Doctors are tired of the hassle of filing insurance claims

2.Doctors are tired of collecting payments from patients

3. Doctors want to only focus on medicine

4.The unknowns of Obamacare, though the problem of doctors bailing from their practice started long before the plan was put into place.

In a country that likes to tout itself as the most developed in the World, the United States is ranks 38th in the World for quality of health systems [World Health Organization 2000 report). Ironically, the United States also ranked 1st for expenditure per capita.  We spend the most but receive less care. Is it possible that a market driven health care system is the reason we are failing?

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Doctors selling their practices – Jul. 16, 2013.

docotrs selling practices cobb

Dr. Patrick Cobb sold his private oncology practice in December 2012. “It just wasn’t feasible for us to stay in practice,” he said.

NEW YORK (CNNMoney)

Doctors who own private practices are looking for a way out. Fed up with their rising business expenses and shrinking payouts from insurers, many are selling their practices to hospitals.

It’s happening nationwide and has picked up pace, said Tony Stajduhar, president at Jackson & Coker, a physician recruitment firm.

docotrs selling practices cobb

Experts say the number of physicians unloading their practices to hospitals is up 30% to 40% in the last five years. Doctors who sell typically become employees of the hospital, as do the people who work for them.

The reasons for the trend vary. Doctors are tired of the hassle of filing insurance claims and collecting payments from patients and want to only focus on medicine again, Stajduhar said.

Obamacare has also created more fear of the unknown. Doctors are worried that new regulations will add to their administrative work and require them to pour more money into their businesses, Stajduhar said.

Dr. Patrick Cobb, an oncologist in Montana, sold his 30-year group practice Frontier Cancer Center to a hospital in December. His practice was struggling for years even before health reform passed.

Changes in chemotherapy drug reimbursements badly hurt the business, he said. In cancer treatment, patients don’t buy the drugs themselves. Oncologists buy the drugs and then bill insurers for the cost. Medicare significantly reduced reimbursements in 2003 for chemotherapy drugs.

That was a turning point, said Cobb. “We spent millions on drugs that we bought directly from distributors. When reimbursements fell, our costs went up,” he said. Cobb and four other oncologists at the practice took pay cuts to offset declining revenues, but it wasn’t enough. In 2008, the practice closed one of its four locations.

Cobb and his partners looked for a buyer in 2012 and found one in Billings, Mont.-based St. Vincent Healthcare. The hospital system hired Cobb and the rest of the practice’s staff. “It just wasn’t feasible for us to stay in practice,” said Cobb.

The cycle of hospitals buying private practices has happened before. In the early 1990s, hospitals went on a buying spree as a way to get access to more patients, said Thomas Anthony, an attorney with Frost Brown Todd in Cincinnati. At the time, it was a sellers’ market and the deals were financially rewarding for doctors.

This time, the market dynamics are different. Doctors are eager to sell and might not be able to make as much as they did in the first wave of acquisitions, said Anthony.

But, for sure, hospitals are buying.

As more of Obamacare is put in place, hospitals are rushing to increase their market share in anticipation of millions more Americans getting access to health care. Buying practices is a quick way to do that, Anthony said. And more private practice doctors want to enjoy steady salaries and hours again as hospital employees.

Dr. Dwayne Smith, a bariatric surgeon, sold his group practice to a hospital two years ago. His practice was profitable but costs were creeping higher in recent years because of shrinking reimbursements.

Related Story: Why doctors can’t stay afloat

One big cost coming down the pike was tied to electronic medical records. Federal law gives physicians until 2015 to implement digital records technology or face a 1% reduction in Medicare payments.

“This would have been a very difficult investment for us,” said Smith.

Smith’s practice approached Cincinnati-based St. Elizabeth Healthcare in 2011 with an offer to sell. The hospital bought the practice and Smith became a hospital employee. He’s happy with the decision even though he has had to adjust to the loss of autonomy.

“My hours are better. I’m not spending hours on administrative work or worrying about my business,” said Smith.

The private practice model is very expensive to operate, said John Dubis, CEO of St. Elizabeth Healthcare. “That’s why it’s diminishing,” he said. Most of the 300 physicians employed by the hospital’s specialty physicians group have come from private practices.

Said Cobb, the oncologist: “We have a joke that there are two kinds of private practices left in America. Those that sold to hospitals and those that are about to be sold.”