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Note to Users NOTE TO USERS This reproduction is the best copy available. UMI THE EFFECTS OF SHORT-TERM LOCALIZED CELANGES ON THE DECLINE OF TUBERCULOSIS MORTALITY IN GIBRALTAR, 1860-1967 by Henry H.C. Choong .A Thrsis subrnitred in conforrnity with the requirements for the Degree of Doctor of Philosophy Ciraduate Depanment of Anthropoloizy Cniversirv of Toronto @ Copvrisht by Henp H.C.Choong ( 1999) National Library Bibiiotheque nationale du Cana& Acquisitions and Acquisitions et Bibliographie Services services bibliographiques 395 Wellington Street 395, rue Wellington Onawa ON K1A ON4 OicawaON K1AW Canada canada The author has granted a non- L'auteur a accordé une licence non exclusive licence allowing the exclusive permettant à la National Library of Canada to Bibliothèque nationale du Canada de reproduce, loan, distribute or seli reproduire, prêter, distn%uerou copies of this thesis in microform, vendre des copies de cette thèse sous paper or electronic formats. la forme de microfiche/nlm, de reproduction sur papier ou sur format électronique. The auîhor retains ownership of the L'auteur conserve la propriété du copyright in this thesis. Neither the droit d'auteur qui protège cette thèse. thesis nor substantial extracts hmit Ni la thése ni des extraits substantiels may be printed or otherwise de celle-ci ne doivent être imprimés reproduced without the author's ou autrement reproduits sans son permission. autorisation. The Effects of Short-Terni Localizeû Changes On the Decline of Tuberculosis .Mortality in Gibraltar. 1860-196'1. Ph.D.. 1999. Henry H.C.Choong Depanment of Anthropology. University of Toronto. ABSTRACT This thesis examines the decline of tuberculosis monality in Gibraltar from 1860 to 1967, and the historical processes that influenced the decline. using time-series analysis and i i fe-table methods. The time-series analysis showed that the decline of tuberculosis monalit v in Gibraltar occurred due to localised. short-tenn changes. Box-Jenkins ( XRIMA) analysis shows that the decline of tuberculosis monality in Gibraltar from 1860 to 1967 was predicated on shon-term local conditions operatine to influence yearly monality rates. and that rhe decline was not due to the natural cvcle of !he disease. Cross- correlation tùncrions indicate that the decline of tuberculosis monality in Gibraltar was slosely related to the overall monality decline before 1900. but deviated after 1900. The high correlation between overall monalitv and tuberculosis monality before 1900 is due ro the predominance of water-borne disease during that penod. whic h reduced resiaance ro tuberculosis Life-table techniques showed that the impact of tuberculosis on life cxpectancy changed correspondingly before and after 1900. Explanations for the decline of tuberculosis rnonalit y O T Gibraltar were souoht in its epidemiological, sanitary, housing and socio-medical hisron. Examination of the historical circumstances of the decline of tuberculosis mortality in Gibraltar showed that before 1900. the decline of ruberculosis monality could be attributed to successive improvements in sanitation and water supply. although there were no direct effons at reducing tuberculosis monality. .\fier 1900. the predominanr factor influencing the decline in tuberculosis monaiity was a reduction of crowding .. III ACKNOWLEDGEMENTS 1 would like to thank Dr. L.A. Sawchuk my thesis supervisor. for his invaluable advice and suppon in this research, both in the field and throu_phout the preparation of the thesis. I would also like to thank my thesis cornmittee: Dn.D.R. Besn. M. Latta F.J. Melbve. Depanment of Anthropology. University of Toronto. and Dr. D.A. Hemng, Depanment of Anthropology. McMaster University. My thanks also to the people of Gibraltar. including Dr C. Finlayson. Gibraltar Museum. and Mr. T.J. Finlayson, Gibraltar Government .Archivist. For technical assistance, 1 would like to thank K. Sevmour. M. Erskine. and J Johnson. For inspiration and advice in research. 1 would like to thank Dr. P.H.von Bitter. Department of Palaeobiology. Roval Ontario Museum. To the Company Drs R. Lew and C. Millward. P.T. Berkobin. A.S. Catey. Mv deepest gratitude goes to my familv for their love and support. and to Nghiêm Xi Trans. for being there. and for showing me life in between. TABLE OF CONTENTS CHAPTER 1: ISTRODUCTION 1. I hature and Scope of the Problem 1.2 Aetiolog of Tuberculosis I 3 lnterpretation of Tuberculosis Monaiity Trends 1 4 The Debate on the Cause of the Decline of Tuberci sis 1 5 The Decline of Tuberculosis in Gibraltar in the Context of the Debate 12 1 b The Specific Goals ofthis Study 1 7 Theorerical and Conceptual Framework CHAF'TER 2: GIBRALTAR: SETTING AND THE POPULATION 2 1 Geographv and Geology 2 3 Climate Z Z The -I'o\t n 2 J The Population of Gibraltar. 1704- 1967 1 900s I soos i 9QU5 CHAPTER 3: JIATERLALS 3 I Sources aiid I'vper of Data Csed -3 2 The Census 3 2 1 Consistent?. of Census Data 3 3 Civil Re~istrationof Deaths 3 4 Esrimating the Zumbers of Deaths from Tuberculosis from the Registers Some Considerations 3 4 1 Tuberculosis in Historical Records 3 4 2 Incompieteness of Xotification CHAPTER 4: ANALYTICAL METHODS 4.1 Choosing the Penod of Study 4.2 Calculation of Generai Mortality Rates and Tuberculosis Mondit): Rates 4.3 Time-Series Analvsis- Studying the Yearly Generai MonaIitv and Tuberculosis Monality Rates 4.3I The Concept of a Deteministic Trend 4 3.2 Box-Jenkins Method Parameters in the Model Model Selection: Autocorrelation and Partial .Irutocorrelations Esrimation of Parameters and Fitting the Model 4 5 3 Measuring the Impact of Histoncal Events on Monality 4 4 Life-Table .Analvsis- Measuring Tuberculosis Monality Differentials by Age and Sex 4 4 I Are-Speciiïc and A-e-and-Cause Specific Monalitv Rates 4 4 2 Ordina? Life-Table and Probabilitv of Dving -i 4 3 Cause-Drlered Life-Table .\nalysis CHAPTER 5: RESI'LTS 5 I Graphical and 'rime-Series Analysis i 1 I General Jlortality in Gibraltar- Trend and Overall Pattern i I 2 Tuberculosis Mortality in Gibraltar: Trend and Overall Pattern 5 I 3 Pulmonan. and Non-Pulmonary Tuberculosis Monality Patterns 5 1 4 Cornparison Between Tuberculosis. Overall Mortalitv Rates and Other Respiratory D iseases 5.1 5 Difference Between LMale and Fernale Overall Tuberculosis Monalit!. Rates 5 2 Bos-Jenkins .Analysis 5.2.1 Modeling the General Monality Pattern 5.7.2Modeling the Overall Tuberculosis Monality Pattern 5.2.3Modeling the Pulmonaq Tuberculosis Monality Pattern 5.3 internipted ARIMA 5 4 The Analvsis of Age-.And-Sex Specific Monality Rates Using Life-Table Techniques 5 4 1 Life-Expectancy and Monality Differentials by Age and Sex 5 4 2 Age-Specific Probabilities of Dying fiom Ai! Causes 5 4.3 Male Age-Specific Probabilities of Dying From Tuberculosis Pre- i 900 5 4 4 Male Age-Specific Probabilities of Dying From Tuberculosis. Pest- 1900 5 4 5 Female Age-Specific Probabilities of Dying from Tuberculosis~ Pre- 1900 5 5 5 Fernale Age-Specific Probabilities of Dying from Tuberculosis. POSI- 1900 5 6 Impact of Tuberculosis on Life Expectancy: Cause Deleted Life- Table Analvsis 5 6 1 Cornparison Between male and Female Differentials CHAPTER 6: THE DECLINE OF TUBERCULOSIS MORT.4L1TI' IN GIBRALTAR: AN INTERPRETATION O 1 Pre- 1900 The Period of High Background Monality in Gibraltar 6 1 2 Housing. Crowding. and the Spread of Disease 6 1 3 Development of Gibraltar's Health and Sanitary Lnfiastructure 6 1 4 Inadequate Water Supply and the Sewage S~stem 6 1 5 Type and Quality of Food during the Period of High Background Monality 6 16 Tuberculosis in the Period of Hiah Background Mortditv vii 6.1.7 Factors Influencing the Decline of Tuberculosis during the Period of High Background Mondity 6 2 Poa-1900. The Movement to Low Background Monality 6.7.1 Overcrowding and Living Conditions 6.2.2 Type and Qualitv of Food during the Period of Low Background Monality 6.2.3 Tuberculosis in Gibraltar afier 1900 6.2.4Factors Influencing the Decline of Tuberculosis during the Period of Low Background Mondity 6 2 5 Tuberculosis Notification & Detection 6 2.6 Post-Notification: Medical Oficers and Furtiier Measures against Tuberculosis 6 2 7 TB Schemes. Sanatoria and Isolation of Infected Persons 6 1 8 The Tuberculosis Scheme and the Sanitary Cornmissioners' Home O 2 9 Effectiveness of the Tuberculosis Scheme 6 2 10 Education lncreasing Awareness of Preventive Measures b 2 1 1 The Continumg Problems of Overcrowding 6 1 t 2 Housing Reforms and the Decline of Tuberculosis in the 1900s 6 2 13 Evaluatino the Impact of Post- 1900 Changes on Tuberculosis blonality Decline in Gibraltar 6 2 1-1 The Final Stage of the Decline in the Study Period: Poa-World War II Xleasures against Tuberculosis CHAPTER 7 COSCLCTSIONS REFERENCES LIST OF TABLES Table 1 Cause Deleted Li fe-Table Anal ysis. Tuberculosis Removed. Gibraltar Table 3 Cornparison of the Tuberculosis Monalitv Rates fkom Gibraltar and Selected Countries and Cities. 1881-85 Table 3 Cornparison of the Tuberculosis Monaiity Rates fiom Gibraltar and Selected Countries and Ciries, 190 1 -03 Tabk 4 Mean 3umber of Persons in Different Types of Apartments. Based on Censuses 137 Table 5 Percentage of Familv Occupancy by Nurnber of Rooms. Based On Ccnsuses 142 Table 6 Cornparison of relative Years of Life Gained from Removal of Respiraton Disease to Tuberculosis. Pre-and-Post 1900 144 LIST OF FIGURES Frontispiece Educational Poster aoainst the Dangers of Consumption In Nineteenth Century Gibraltar Fiyre 1 Graph of the decline of phthisis mortality in England and Wales 1838-94 Fisure 2 Map of Spain. Morocco, and Gibraltar Figure 3a Male population of Gibraltar in 1868, 1878, and 1891. 5-year cohons 3 1 Fisure 3b Female population of Gibraltar in 1868, 1878.
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