In the recent elaboration of key premises in WPR ( KEYNOTE ADDRESS – CAROL BACCHI – 17 August 2022) I emphasize the importance of cultivating a genealogical sensibility. The argument supporting this proposition is that we need to consider how we have got “here” from “there” because such a focus makes it possible to question the present. Foucault (1990) calls this approach “a history of the present”. Importantly, a genealogical sensibility resists the temptation to offer a strict chronology of developments, which can lead to a sense of inevitability. For Foucault (1977), relying on Nietzsche, genealogies are records of discontinuity, of twists and turns, of skeletons in the closet (if you will). A genealogical sensibility therefore keeps a sharp eye open for tensions and debates around crucial issues. To those who find this detail dull, I apologize. My training as a historian means I love this stuff!

The history of the current standardized death certificate is long and complicated, and way beyond the purview of a Research Hub entry. Some of the research in this entry is original, but mostly I draw on secondary sources. I bring particular attention to contestatory frames of reference. As a uniting theme, I highlight debates about the countervailing influences of biology and environment on human development. To undertake this task, following Dean (1999: 178), I identify the forms of knowledge that make COD thinkable, the techniques that discover it, the technologies that seek to govern it and the political rationalities and programs that deploy it.  Keep your eye open for these knowledge and other practices, and for resonances with (not replicas of) contemporary developments!

Bills of Mortality, John Graunt and “Shop-Arithmetique”

Bills of Mortality were produced in late 16^th century London, primarily to monitor cases of the plague and to institute quarantine where needed. Parish clerks kept the statistics. Causes of death other than plague were recorded from about 1604 (Connor 2022: 2). 

A London draper, John Graunt (1620-74), produced a systematic study of the Bills of Mortality in 1662. He applied what he described as “the Mathematiques of my Shop-Arithmetique” – his book-keeping skills – to the data. His tables indicate sharp differences in annual death rates between what Graunt called “Acute” or “Epidemical” diseases and those which he described as “Chronical”, a distinction that can be traced to the time of Hippocrates. 

Graunt drew attention to the poor health and reduced longevity of those living in large geographical regions, a phenomenon that became known as the “Urban Penalty”. In his words, 

I considered, whether a City, as it becomes more populous, doth not, for that very cause, become more unhealthfull, I inclined to believe, that London now is more unhealthfull, then heretofore, partly for that it is more populous, but chiefly, because I have heard, that 60 years ago few Sea-Coals were burnt in London, which now are universally used. For I have heard, that Newcastle is more unhealthfull than other places, and that many People cannot at all endure the smoak of London, not onely for its unpleasantness, but for the suffocations which it causes.  (Graunt 1662 in Connor 2022: 5)

(I feel tempted to say: “plus ça change, plus c’est la même chose”.)

Graunt tied the importance of demographic and epidemiological data to the need to keep Government and Trade “certain and regular”, with consequent benefits for peace and prosperity (Connor 2022: 6). He expressed misgivings about the effectiveness of quarantine against contagion: “That the troublesome seclusions in the Plague-time is not a remedy to be purchased at vast inconveniences” (Connor 2022: 6), a view that may sound familiar. 

Graunt’s friend and colleague, William Petty, coined the term “Political Arithmetic” to describe the connection between demography and government. Defined by Charles Davenant (1656-1714) as “the art of reasoning by figures, upon things relating to government”, this thinking is considered the forerunner of economics as a discipline (Hoppit 1996 in Connor 2022).

The Power of Statistics

The other form of knowledge implicated in the evolving enthusiasm for COD accounting is statistics. Moriyama (2011: 10) traces the “triggering event leading to the first ICD [International Classification of Diseases]” to “the unlikely Great Exhibition of 1851 held at the Crystal Palace in London”. At that event numerous nations displayed their industrial products. Visiting statisticians pursued the idea of comparing national statistics, which led to the First International Statistical Congress at Brussels in 1853. Moriyama reports: “By this time, a systematic review seems to have occurred of subjects that could be candidates for international statistical comparison”, including “Causes of Death”. 

Following a proposal at the 1853 Congress to produce a uniform nomenclature of diseases, which was needed to tabulate “causes of death”, William Farr and Jacob Marc D’Espine were charged with developing classifications. Farr (1807-1883) was a physician employed as a British government statistician (Alharbi et al. 2021: 4). D’Espine was a Swiss statistician. D’Espine’s list grouped causes according to their nature, that is, as “gouty, herpetic, hematic”, etc. Farr divided diseases into three classes:

the first for those that occur endemically or epidemically, in other words, the communicable diseases, which provided an index of salubrity [health or well-being]. The second class was for those diseases that arise sporadically—these he subdivided anatomically into diseases of the nervous system, respiratory organs, etc., ending with a group for those of uncertain location such as tumors, malformations, debility, sudden death, and old age.  (Moriyama 2011: 10)

According to the president of the committee overseeing the project, classification of groups of the diseases had only secondary importance: “the main point was to produce a list of morbid entities frequent enough to merit the attention of the statistician, enabling comparison of data on known morbid entities” (Moriyama 2011: 11; emphasis added). In the event, Farr’s list, which included the principle of classifying diseases by etiology followed by anatomic site, survives in the present classification. As Armstong (2021: 1621) points out, the nineteenth century decision to separate epidemic, sporadic/pathological and violence as causes of death has continued to underpin the classification of death into the 21^st century.

In this classification model, epidemics supersede deaths from pathological causes as “underlying cause of death”. At the First Revision Conference on the International List of Causes of Death in 1890, Jacques Bertillon, Chief of Statistics for the City of Paris, prepared a guide for medical officers responsible for determining COD. His third rule stipulated: 

When among the two causes of death there is a transmittable disease, it is preferable to assign the death to it, for statistics of infectious diseases are particularly interesting to the sanitarian [whom we shall meet shortly CB], and it is important that they shall be as complete as possible. (in Moriyama 2011: 30)

This privileging of epidemic disease as underlying cause of death continued into the twentieth century. In 1958 Carl Erhardt, Director of the Bureau of Records and Statistics, Department of Health, New York, endorsed this thinking: “In populations with high mortality and short life expectancy, death is most often caused by infectious or communicable disease. Under such circumstances, the cause of death can often be expressed as a single term” (Erhardt 1958: 163). This convention explains the WHO (2020: 3) directive to doctors and coroners to list COVID-19 as the “underlying cause of death” (see previous entry 30 May 2023).

Sanitation and COD

The mid-19^th century proved to be a pivotal time for discussions around COD. In 1837 the Registration Act was passed in England. It included provisions for inquiry into causes of death. In 1839 William Farr, whom we have already met, became compiler of abstracts in the Registrar-General’s office. He developed and analyzed mortality statistics to do with the conditions of sanitation and health in England (Moriyama 2011: 2). Farr drew direct links between environmental factors and health/death. Registration districts were characterized by “degrees of insalubrity”, depending on whether they exceeded the established standard of 17/1000 deaths. Mortality in excess of this rate was “assumed to be due to defects in the environment” (Eyler 1987: 343). 

Farr’s 1837 mortality report included a comment on 63 deaths resulting from “starvation”: “Hunger destroys a much higher proportion than is indicated by the registers in this and every country, but its effects, like the effects of excess, are generally manifested in the production of diseases of various kinds” (in Whitehead 2000: 87). “Natural death”, in his account, could be accelerated by “want and privations” (in Armstrong 2021: 1621). 

Eyler (1976) notes that health reformers and sanitarians accepted a view that health, disease, death, and physical and moral conditions were joined in an indissoluble link. In Farr’s (1875 in Eyler 1976: 336) explanation:

There is a relation betwixt death and sickness. … There is a relation betwixt death, health, and energy of body and mind. There is a relation betwixt death, birth, and marriage. There is a relation betwixt death and national primacy. … There is a relation betwixt the forms of death and moral excellence or infamy. 

The Medical Officer to the Privy Council, John Simon (1857-58 in Eyler 1975: 336), added to Farr’s list a supposed relation between infant mortality and the causes leading to racial degeneration. In this ordered world where everything linked up so neatly, statistics promised to provide an effective tool to “elucidate the complex dependency of health on manner of life”. A driving force in this discussion was Florence Nightingale, who aimed to demonstrate statistically how improved sanitary conditions and better schooling reduced mortality, illness, and even criminal behaviour (Moriyama 2011: 11).

There were tensions among the sanitation campaigners. The well-known first secretary to the Poor Law Board and later Commissioner of the General Board of Health, Edwin Chadwick, objected to Farr’s inclusion of the category “starvation” in the Bills of Mortality. Chadwick argued that it was impossible for a person to starve to death in London. “The notion that poverty itself was the cause of illness was, for Chadwick, unthinkable” (Corbett 1999). Chadwick had served as private secretary to Jeremy Bentham, the utilitarian philosopher. The Benthamite prescription for pauperism was deterrence: “The pain of the workhouse was to be greater than the pain of poverty and poor relief” (Corbett 1999).

It is too simple to paint Farr as a proponent of the social determinants of health and Chadwick as the defender of the evil workhouse. As Armstrong (2021: 1621) points out, Farr’s focus on “external agents”, such as “intemperance, cold, want, and effluvial poisons”, did not disrupt the dominant biomedical or pathological explanation of death with its focus on “disease entities”. All that Farr accomplished, and it is no mean accomplishment, was to highlight the range of influences in people’s environments that cause disease. This theme – whether it is possible to disrupt “the pathological explanation” in death certificates – is taken up in the next Research Hub entry.

In addition, it is useful to consider how Farr’s statistical frame of reference placed limitations on his social analysis.  He wanted to make statistical inferences and believed this could not be done with the small numbers that would be produced in a detailed classification. Hence, he did not provide specific rubrics for diseases that were rare in England (Moriyama 2011: 10), imposing an Anglo-Celtic analytic lens.

Challenges to “salubrity” 

The opposition to our sanitarians, which developed later in the century, came from several quarters. On one side were the anti-vaxxers (yes, indeed). The Reverend and Mrs William Hume-Rothery led the National Anti-Compulsory Vaccination League. Their targets were the Compulsory Vaccination Acts of 1867, 1871 and 1874 (we are talking about smallpox here). Mrs Hume-Rothery questioned male domination of medicine, especially male tyranny over female patients. She strongly objected to the proposal to give qualified practitioners the sole right of signing death registers. State medicine, she claimed, threatened personal liberty and morality: “It seemed a conspiracy of a greedy profession against the public”. Her National Anti-Compulsory-Vaccination Reporter carried the following articles: 

“The Swedish Small-Pox Statistics Fraud: The Real Truth of the Matter,” 1882, 5:25-29 

“How Pro-Vaccinators Manipulate Statistics,” 1883, 7:195-97, 214-16

 (see Eyler 1976: 347-348)

Other opponents of the sanitary reformers, clearly with very different arguments, were local medical authorities. They voiced no objections to the role of physicians in public policy but, based on their experience, they expressed doubts that death rates were a good test of the healthiness of their respective districts. According to Eyler (1976: 348), this opposition signalled “the growing medical domination of the public health movement”. The president of the Society of Medical Officers of Health asked the Statistical Society of London in 1874 if death rates could be lowered with sanitary reform: “Would it do away with the overcrowding that was one of the necessary conditions of the existence of people in large towns?” (Eyler 1976: 348).

The chief challenge to mortality rates as measures of community health was that “Implicit in the program of these social pathologists is the belief that length of life reveals quality of life” (Eyler 1976: 354). In reaction, a demand for compulsory registration of sickness became common, led by the International Statistical Society, the Epidemiological Society, and a joint committee of the Social Science and the British Medical association (Eyler 1976: 354). It was 1911 before national compulsory registration of contagious diseases was enacted. 

“National primacy”, COD and eugenics

The identified relation Farr makes “betwixt death and national primacy” (see above), and Simon’s reference to “racial degeneration”, noted earlier, suggest links between the development of COD accounting and the eugenics movement. In previous work – actually in my previous life as a historian – I explored the complex variations in Australian eugenic thought between 1900 and 1914 (Bacchi 1980). Of some interest to the topic at hand is the distinction I identified between so-called positive eugenicists and negative eugenicists. The former put their faith for improving the “race” (and they did speak in these terms) in environmental change and the latter in biological interventions, including compulsory sterilization of the so-called “feeble minded”. At first glance, there appears to be a clear dispute between those who promoted environmental and those who offered biological explanations for human development. However, the two groups shared a belief in the prominent place of biology but, according to our “positives”, there remained some room to move. While the priority placed on national/racial improvement needs to be recognized, it is important to keep an eye open to divergence and contradiction, and just plain messiness, “to show that things ‘weren’t as necessary as all that’” (Foucault 1991: 76). 

As an example, Professor Raymond Pearl (1879-1940) from Johns Hopkins University, was an avid supporter of the eugenics movement in the early 1900s. But in 1925 he wrote a book condemning the movement as unscientific. Professor of the Blomberg School of Public Health, he was a founder of biometry, the application of statistics to biology and medicine. He used his statistical studies to demonstrate the connection between smoking and death, and to trace the varying times of death for body organs, useful in current transplantation. He was highly critical of the International Classification of Causes of Death, describing it as “not primarily a biological classification”. He proposed modifying the list to group all causes of death under the heads of the several organ systems of the body:

We are now looking at the question of death from the standpoint of the pure biologist, who concerns himself not with what causes a cessation of function, but rather with what part of the organism ceases to function, and therefore causes death. (Pearl 1921: 491) 

As a “pure biologist”, Pearl endorsed a view of the body as machine, though he was far from impressed by the nature of evolution: “The workmanship of evolution, from a mechanical point of view, is extraordinarily like that of the average automobile repair man” (Pearl 1921: 516). Hence, he questioned some of the strategies of the eugenicists. Since a brown-eyed man and a brown-eyed woman might have blue-eyed children, he could see no “guarantee that a wealthy, intelligent, tall, and handsome couple would not have children who grew up to be poor, stupid, short, and ugly” (Hendricks 2006). However, while on occasion he questioned the class bias of eugenics, he continued to express racist and anti-Semitic views.

Pearl supported birth control as a public health measure, targeting what eugenicists referred to as the “differential birth rate” (Bacchi 1980: 208). His expressed goal was to reduce the high birth rate in many non-industrialized countries and in lower income groups within the industrialized world, indicating a continuing class-based prejudice. He held out hope that child welfare might provide a useful direction to reduce the general death rate, with his focus primarily on education:

Ignorant and stupid people must be taught, gently if possible, forcibly if necessary, how to take care of a baby, both before and after it is born. It seems at present unlikely, that mundane law will regard feeding cucumber to a two months’ old baby, or dispensing milk reeking with deadly poison makers, as activities accessory to first-degree murder. (Pearl 1921: 494). 

At the same time Pearl endorsed public hygiene initiatives:

… if that final Judgment Seat, before which so many believe we must all eventually appear, dispenses the even-handed justice which in decency it must, many of our most prominent citizens who in the financial interests of themselves or their class block every move towards better sewage disposal, water and milk supply, and the like, or force pregnant women to slave over a washtub and sewing bench that they may live, will find themselves irrevocably indicted for the wanton and willful slaughter of innocent babies. (Pearl 1921: 495). 

With all this, he finally concludes that biology trumps environment: 

It furthermore seems to me that the results presented in this paper add one more link to the already strong chain of evidence which indicates the highly important part played by innate constitutional biological factors as contrasted with environmental factors in the determination of the observed rates of human mortality. (Pearl 1921: 516)

I have offered Pearl, not as a confused and bombastic biologist, but to illustrate that, when it comes to causes of death, the picture is complicated. At the same time Pearl’s work illustrates the primary focus in death certificates on biology in one form or another – a focus either on disease entities, or on organ systems. Efforts to bring factors from outside that framework to bear on conceptions of death causation (COD) fight an up-hill battle. In the last entry in the series (next entry), I concentrate on interventions designed to bring awareness of the social determinants of health to the discussion of COD. 

References

Alharbi, M. A., Isoudard, G. and Tolchard, B. 2021. Historical development of the statistical classification of causes of death and disease. Cogent Medicine, 8:1, 1893422, DOI: 10.1080/2331205X.2021.1893422 

Armstrong, D. 2021. The COVID-19 pandemic and cause of death. Sociology of Health & Illness, DOI: 10.1111/1467-9566.13347

Bacchi, C. 1980. The nature-nurture debate in Australia, 1900-1914. Historical Studies, 19(75): 199-202. 

Bowker, G. C. 1996. The History of Information Infrastructures: The Case of the International Classification of Diseases. Information Processing & Management, 32(1): 49-61.  

Connor, H. 2022. John Graunt F. R. S. (1620-74): The founding father of human demography, epidemiology and vital statistics. Journal of Medical Biography, DOI: 10.1177/09677720221079826. 

Corbett, S. 1999. Review: C. Hamlin, Public Health and Social Justice in the Age of Chadwick Britain 1800-1854.  Health Promotion International, 14(4): 381-382. 

Dean, M. (1999). Governmentality: Power and rule in modern society. London: Sage.

Erhardt, C. L. 1958. What is “The Cause of Death”?  Journal of the American Medical Association (JAMA), 168(2): 161-168.

Eyler, J. M. 1976. Mortality Statistics and Victorian Health Policy: Program and Criticism. Bulletin of the History of Medicine, 50(3): 335-355. 

Farr, W. 1875. Letter to The Registrar-General on the Mortality in the Registration Districts of England during the Years 1861-70, Supplement to the Thirty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England, 1875 [C. 1 155-1]. XVIII, pt. 2] 

Foucault, M. 1977. Nietzsche, genealogy, history. In D.F. Bouchard, (Ed.), Language, counter-memory, practice: Selected essays and interviews. 

Ithaca: Cornell University Press.  

Foucault, M. 1990. The concern for truth. In L.D. Kritzman (Ed.), Michel Foucault: Politics, philosophy, culture. Interviews and other writings, 1977–1984, 1st edition 1988, A. Sheridan, (trans.). New York: Routledge.

Foucault, M. 1991. Questions of method. In G. Burchell, C. Gordon, P. Miller (Eds.), The Foucault effect: Studies in governmentality. Chicago: University of Chicago Press.   

Graunt, J. Natural and political observations mentioned in a following index, and made upon the bills of mortality. London: John Martin, 1662.

Hendricks, M. 2006.  Raymond Pearl’s “Mingled Mess”, Johns Hopkins Magazine. Available at: https://pages.jh.edu/jhumag/0406web/pearl.html

Hoppit J. 1996. Political arithmetic in eighteenth-century England. The Economic History Review New Series, 49: 516–540.

Moriyama, I. M. 2011. History of the Statistical Classification of Diseases and Causes of Death. Centers for Disease Control and Prevention, National Center for Health Statistics.

Pearl, R. 1921. The Biology of Death – IV. The Causes of Death. The Scientific Monthly, June. 

Simon, J. 1857-58. Introductory Report by the Medical Officer of the [General] Board of [of Health], Papers Relating to the Sanitary State of the People of England, [2415]. XXIII, xxvii. 

Whitehead, M. 2000. William Farr’s legacy to the study 

of inequalities in health. Bulletin of the World Health 

Organization, 78(1): 86–87.

World Health Organization (WHO) 2020. International guidelines for certification and classification (coding) of COVID–19 as cause of death. https://www.who.int/publications/m/item/international-guidelines-for-certification-and-classification-%28coding%29-of-covid-19-as-cause-of-death