Milton Lewis

The Australian mortality decline: cause‐specific mortality 1907–1990

Abstract: This review describes the changes in composition of mortality by major attributed cause during the Australian mortality decline this century. The principal categories employed were: infectious diseases, nonrheumatic cardiovascular disease, external causes, cancer, ‘other’ causes and ill‐defined conditions. The data were age‐adjusted. Besides registration problems (which also affect all‐cause mortality) artefacts due to changes in diagnostic designation and coding are evident. The most obvious trends over the period are the decline in infectious disease mortality (half the decline 1907–1990 occurs before 1949), and the epidemic of circulatory disease mortality which appears to commence around 1930, peaks during the 1950s and 1960s, and declines from 1970 to 1990 (to a rate half that at the peak). Mortality for cancer remains static for females after 1907, but increases steadily for males, reaching a plateau in the mid‐1980s (owing to trends in lung cancer); trends in cancers of individual sites are diverse. External cause mortality declines after 1970. The decline in total mortality to 1930 is associated with decline in infection and ‘other’ causes. Stagnation of mortality decline in 1930–1940 and 1946–1970 for males is a consequence of contemporaneous movements in opposite directions of infection mortality (decrease) and circulatory disease and cancer mortality (increase). In females, declines in infections and ‘other’ causes of death exceed the increase in circulatory disease mortality until 1960, then stability in all major causes of death to 1970. The overall mortality decline since 1970 is a consequence of a reduction in circulatory disease, ‘other’ cause, external cause and infection mortality, despite the increase in cancer mortality (for males). (Aust N Z J Public Health 1998; 22: 37–44)

The Australian mortality decline: all-cause mortality 1788-1990

Abstract: This review describes the Australian decline in all‐cause mortality, 1788–1990, and compares this with declines in Europe and North America. The period until the 1870s shows characteristic ‘crisis mortality’, attributable to epidemics of infectious disease. A decline in overall mortality is evident from 1880. A precipitous fall occurs in infant mortality from 1900, similar to that in European countries. Infant mortality continues downward during this century (except during the 1930s), with periods of accelerated decline during the 1940s (antibiotics) and early 1970s. Maternal mortality remains high until a precipitous fall in 1937 coinciding with the arrival of sulphonamide. Excess mortality due to the 1919 influenza epidemic is evident. Artefactual falls in mortality occur in 1930, and for men during the war of 1939–1945. Stagnation in overall mortality decline during the 1930s and 1945–1970 is evident for adult males, and during 1960–1970 for adult females. A decline in mortality is registered in both sexes from 1970, particularly in middle and older age groups, with narrowing of the sex differential. The mortality decline in Australia is broadly similar to those of the United Kingdom and several European countries, although an Australian advantage during last century and the first part of this century may have been due to less industrialisation, lower population density and better nutrition. Australia shows no war‐related interruptions in the mortality decline. Australian mortality patterns from 1970 are also similar to those observed in North America and European countries (including the United Kingdom, but excluding Eastern Europe). (Aust N Z J Public Health 1998; 22: 27–36)

A workingman's paradise? Reflections on urban mortality in colonial Australia 1860-1900.

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The early alcoholism treatment movement in Australia, 1859-1939

Advancing ideas pioneered in the United States of America, Australian medical reformers and their lay supporters persuaded colonial governments in the late nineteenth century to recognize that alcohol dependence was a treatable disease. In practice, that recognition was only partial. While inebriates legislation was enacted, the state never provided sufficient resources for adequate specialized treatment facilities to be developed. By the 1930s, the first wave of enthusiasm for specific institutional treatment of alcohol dependence had receded, and the treatment movement was in decline. Reasons are suggested for the failure of the movement.

Alcoholism in Australia, the 1880s to the 1980s: from medical science to political science

The disease concept of alcoholism has been central to the response to alcohol-related problems in Australia. The history of alcoholism from colonial times to the present is discussed with reference to alcohol consumption, legislative action, inquiries by medical and other bodies, and services especially treatment services provided by government and non-government organisations. In the 1980s the position of the disease concept perspective has been declining while a wider politico-economic perspective has become established.

Sanitation, intestinal infections, and infant mortality in late Victorian Sydney.

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A Brief History of Human Dignity: Idea and Application

Although the explicit application of the idea of human dignity in international politics and law is very recent, its roots stretch back to the early stages of Western civilization. Two characteristics of the West are important as preconditions for the development of the idea: the West’s belief in the universal validity of its norms and its eventual basing of its norms in secular principles. Both Judeo-Christian monotheism and the Graeco-Roman world’s understanding of humankind underpinned a universalistic view of man’s unique place in the cosmos. Historical sociologist, Max Weber looked to the dual heritage of Christianity and Roman law for the origins of what he famously saw as the unique rationalistic character of Western social, economic, and political relations that ultimately led to modern capitalism and the bureaucratic nation-state. In Rome, the concept of dignity had moral, political, legal, and social meanings; the first referred to integrity or indifference to profit; the second in the Republican era was associated with those in high public offices like the various magistracies, the dignitates; it had another meaning, associated with high social rank; and in law it was applied strictly as ‘greater’ or ‘lesser’ in relation to rank and social condition. It is clear that in Rome dignity was not equally distributed. Roman law was a rational system of secular law, based on the authority of the collective will, the res publica, not on divine authority as interpreted from sacred texts. As Rome became the ruler of the known, civilized world, it adopted the stoic idea of a universal law of nature offering justice and order to all. Through reason, man is part of a rationally organized universe. Reason and nature are congruent. The law of nature is identified with reason and so society, too, is based on the rule of reason. Since all men were moved by ‘right reason,’ as Cicero and the Roman jurists who came after him saw it, there existed an ontological equality of humankind. This equality entailed a universal republic and the state was a moral enterprise devoted to the common good of citizens; not merely a framework for the pursuit of interests or for the exercise of an absolute sovereign will. 1

Medicine in colonial Australia, 1788-1900.

For the first five decades of European settlement in Australia, medical care for convicts and free settlers was provided by the Colonial Medical Service. After about 1850, as population and wealth grew markedly, there was significant professional development based on private practice. Except in Victoria, medical societies and journals did not become solidly established until late in the 19th century. The advent of local British Medical Association branches was an important factor in this consolidation. In the first few years of the colony, mortality was very high, but the common childhood infections were absent until the 1830s. From the 1880s, there was a sustained decline in mortality from communicable diseases, and therefore in aggregate mortality, while maternal mortality remained high. Australian practitioners quickly took up advances in practice from overseas, such as antisepsis and diphtheria antitoxin. They shared in the international growth in the status of medicine, which was conferred by the achievements of bacteriology in particular. From 1813, students were apprenticed in Sydney and Hobart and then travelled to Britain to obtain corporate qualifications. Medical schools were ultimately opened in the new universities in Melbourne (in 1862), Sydney (1883) and Adelaide (1885). The first female student was admitted to medicine in Sydney in 1885. Medical politics were intense. The outlawing of practice by unorthodox practitioners proved to be an unattainable goal. In the latter half of the 19th century, doctors saw chemists as unfair competitors for patients. The main medicopolitical struggle was with the mutual‐aid friendly societies, which funded basic medical care for a significant proportion of the population until well into the 20th century. The organised profession set out to overcome the power of the lay‐controlled societies in imposing an unacceptable contract system on doctors, even if, historically, the guaranteed income was a sine qua non of practice in poorer areas.

What do Australians want from medicine

First, taxi drivers expected that medicine would be able to save life in an emergency. If someone was haemorrhaging or choking, rescue should be available. Second, treatment would be available for less immediate but still life-threatening illnesses, such as acute pneumonia or meningitis, for which medical or surgical cures exist. The third expectation of Pellegrino’s taxi drivers was more subtle. Medical services should be available to individuals so that when confronted with a symptom or a medical problem, the anxiety for taking the next step in regard to that symptom or problem could be transferred to a person with medical skill and understanding. Thus, as Pellegrino put it, if I find a lump in my neck when I am shaving one morning, I expect to be able, in short order, to transfer my anxiety about what to do next to my doctor.There should be no long delays in obtaining management for such a fright. The fourth expectation was relief from pain and suffering, rather than overzealous intervention, when cure is impossible.

Why Historical, Cultural, Social, Economic and Political Perspectives on Mental Health Matter

We, the editors, have encouraged contributors to provide historical, cultural, social, economic and political perspectives on the development of mental health in the diverse nations of the Asia-Pacific region. Such a multi-pronged approach is required to understand this complex phenomenon. Most nations in the region were or became colonies of European powers. Just when psychiatry itself was being formed as a branch of medicine in Europe, it encountered non-Western cultures with deeply rooted, different approaches to mental disorders. Despite the subsequent growth of Western-derived psychiatry in such countries, cross-cultural issues remain significant for the current and future development of policy and services. Indeed, as those involved in the new effort to reduce the burden of untreated mental illness in low- and middle-income countries (LAMIC) realise, cultural appropriateness is central to success. In the last decade or so a debate has developed between epistemic and policy communities as to how best to do this. We believe it will advance understanding if we put the current situation in LAMIC, where globalisation is producing rapid, often disruptive, cultural, economic and social change, in a comparative historical context: the health effects, physical and mental, of this current transformation may be compared with the health impact of the ‘modernisation’ of the West in the nineteenth century. The rise of asylum psychiatry itself in Europe may be seen as an organised, expert response to the growth of mental disorders produced by the speedy, initially unregulated, impact of industrialisation and urbanisation on traditional ways of life, just as the rise of public health in the same era may be viewed as an organised, expert response to the growth of threats to physical health from ‘fevers’ and other communicable diseases. We need to apply what some health analysts have called the ‘re-socializing’ disciplines—history, anthropology, sociology and political economy—to understand more fully mental health in the Asia-Pacific region, and so, hopefully, to contribute more effectively to its promotion.