The company of the dead: part one

The forgotten spectre of childhood mortality

Just minutes from Parliament, tucked in between the motorway and the office of the Ministry of Education, is a part of the old Bolton Street Cemetery. For those who don’t mind the company of the dead, it’s a quiet refuge, a place to eat your lunch with the sun on your back and grass at your feet. There’s a seat I like there, just past the footbridge over the motorway, where I often sit, considering the little cluster of graves in front of me as I eat.

One thing that’s immediately apparent about this cemetery, which dates from 1840, is that there are many more graves of young children than in a modern cemetery. For some, the cause of death is recorded, such as the six children of the Wallace family – William, Marian, John, George, Alice and James – who all died of scarlet fever in 1865, or Charles Seed, aged twelve, accidentally shot by a friend. For others, the cause of death is not recorded – Violet Arthur, aged seven months; Amy and Sidney Seed, aged four months, and one year, seven months; Emma Hall, aged fourteen; Alfred Edmonds, aged four; Katherine and Mabel Fitzgerald, aged thirteen and four. The gravestone for William Tinney and his wife Lucy also records the names, but not ages, of five of their young children who died – Lucy, Ernest, Olive, Henrietta and Percival.

It’s a potent reminder that this was a very different world. These days, we aren’t used to children dying. But back then, childhood was a dangerous time. In New Zealand prior to 1880, just over one in ten babies died before they were a year old, based on official figures; and these figures are an underestimate, because babies who died within a day or two of being born were often not recorded, and Maori births and deaths were not officially recorded at all until 1913. In some years, the figures were significantly higher – in 1864 in Auckland, two out of every ten babies died, while in 1875, the overall infant mortality was three out of every twenty. These figures are only for infant mortality; mortality for children under five, and even those under ten, was also very high.

While these figures seem shocking, New Zealand was considered one of the countries with a lower death rate for infants and children. In 1900, one in five babies born in North America died before their first birthday. A survey which looked at historical infant and child mortality across 43 different cultures around the world found that, on average, one quarter of children died before the age of one, and one half died before the age of fifteen. Hunter-gatherer society had similar infant and child mortality rates. However in some places and at some times, the figures have been much worse. Figures for the colony of Hong Kong in the late nineteenth century indicated that from six to nine out of ten Chinese babies born there died before their first birthday.

Precise data on the causes of death aren’t so easy to find however. For babies who were dying a century or more ago in New Zealand, a specific cause of death often wasn’t stated. However, infant mortality in most European countries was largely the result of infectious diseases, particularly diarrhoeal diseases, and the evidence suggests New Zealand was similar. Diarrhoeal diseases were (and still are) largely the result of pathogens picked up from contaminated food and water. Other infectious diseases included outbreaks of measles (responsible for the unusually high mortality rate in New Zealand in 1875), typhoid, smallpox, whooping cough and scarlet fever.

How we moved from the historical average of one in four children dying before their first birthday to the remarkably good health most children enjoy today is the result of many different factors. However the most important are the three major advances in the control of infectious disease in the nineteenth and twentieth centuries.

Infant and childhood mortality first began to decline in wealthier countries, including New Zealand, well before 1900. This period coincides with our growing understanding of the “germ theory” of disease, and the work of men like Louis Pasteur and Joseph Lister, who transformed our understanding of the origin of many diseases. Finally, we realised the importance of hygiene and sanitation. Sewage treatment was introduced in cities, and people began to use soap to wash their hands and bodies, as opposed to their clothing. (I should note that I’m writing this very much from a European perspective – soap was used much earlier in the Middle East, for example).

The second advance was the discovery and widespread introduction of antibiotics. Diseases such as scarlet fever, the disease which claimed the life of the six Wallace children buried in the Bolton Street Cemetery, could now be easily and effectively treated. These days, antibiotics are becoming less effective as bacteria develop resistance, but that’s a story for another time.

The third advance was vaccination – a practice which is much older than commonly thought. There is evidence that a form of vaccination against smallpox were used in China many centuries before the first modern vaccine, also against smallpox, was developed by Edward Jenner at the end of the eighteenth century. Nearly a century later, the next important advance in vaccines was Pasteur’s vaccine against rabies. Within the next fifty years, a number of other vaccines were developed, including some against major childhood diseases such as diphtheria.

In New Zealand, vaccination was slow to take hold – although the smallpox vaccine was available and, in theory, compulsory from 1863, vaccination rates were very low, around 1% by 1916. By the late 1920s, they were rising, but still well under 50%. The vaccine against diphtheria was introduced in 1922, and was routinely offered for children under seven from 1941, but by the 1950s vaccination rates were still below 70%.

It was polio which finally turned the tide. In the early twentieth century, polio proved to be the most intractable of the childhood diseases. While the other diseases picked up from contaminated water declined due to improved hygiene, polio appeared to become more common. It didn’t – it just hadn’t been noticed much among all the other infant fevers and diarrhoeal diseases. Most babies caught it, and those that survived were immune for life. Immune women then passed a degree of immunity to their babies in the womb and through breast milk. As a result, polio usually only caused a mild illness in babies.

When conditions became healthier, more babies survived without having come into contact with polio. And then, once they were weaned, they felt the full force of the infection, which could affect the central nervous system and causes paralysis. Although polio was actually less common in the early twentieth century than it had been previously, it caused many more people to die or suffer permanent paralysis.

Polio had come to be a greatly feared disease in New Zealand by the 1950s, and managing epidemics required school closures and other quarantine restrictions now familiar to us all. My mother has a memory of Christmas in 1947, where the children of Hamilton, instead of travelling into the city to see Santa, stood along a designated route, six feet apart, and watched Santa being driven by (a story I’ve been able to verify thanks to a Master of Arts thesis from the University of Canterbury). So, when a vaccine became available in the late 1950s, the uptake was swift. By 1962, 97% of children received at least one dose of the oral vaccine.

New Zealand began a programme of routine childhood vaccination for other diseases in 1960, with vaccines for diphtheria, tetanus and whooping cough. Measles and rubella were added by 1970. Once-devastating diseases of childhood were vanquished, and we could celebrate a new life knowing that, barring extraordinary misfortune, we could look forward to watching that child survive, and thrive.

Despite the great benefits of vaccination, to both individuals and societies, there are some worrying clouds on the horizon. There will always be those who cannot be directly protected by vaccines – very young babies or those with compromised immunity, who can succumb to a disease whether they have been vaccinated or not. In order to protect these vulnerable people, vaccination rates need to be high enough to prevent the diseases circulating, a concept known as herd immunity. For highly contagious diseases such as measles and whooping cough, the threshold for herd immunity is 92-94%. And that’s a threshold New Zealand is struggling to meet.

By the 1980s, vaccination rates were still below 80% in many parts of New Zealand. They have risen since then and have, at times, reached levels of around 93%, but this is still low compared to other countries with a similar level of wealth. However our vaccination rates are now actually declining, and have been since 2015. At the end of last year, just 88% of five year olds had received all of the recommended vaccines.

New Zealand is one of a number of countries which have seen a decline in vaccination in the last five years. Both the western Pacific region and the Americas have seen a drop in vaccination rates of around 5%. Brazil, Libya, Samoa and Venezuela have seen drops of more than 20%, and seven other countries have had more than a 10% reduction in vaccination.

What’s going on? Why, when we have a cheap, effective and safe method of preventing many deadly diseases, are we not using it? And what does this mean for a world in the grip of Covid-19, when our best hope for a return to a normal life is the development of a vaccine?

There’s no simple answer to these questions, and the answer for New Zealand is not necessarily the same as for Bolivia or Jordan. So I’m going to leave that until next week, when I will look more closely at what is going wrong, and, with any luck, find some countries which are getting it right.

The Turnstone
The company of the dead: part two
On one of my many bookshelves, there’s a small, tatty book with the unlikely title “Pomp and Pestilence”. The dust jacket is plain, no illustration, just words and blocks of black, white and red. The font of the main title reminds me of the Nevil Shute novels I enjoyed reading some years ago – a clue to the age of the book, which was first published in …
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