MALTA, MOTHERHOOD, AND INFANT MORTALITY: INTEGRATING BIOLOGICAL AND SOCIO-CULTURAL INSIGHTS by Leah Claire Walz A thesis submitted in conformity with the requirements for the degree of doctorate of philosophy Graduate Department of Anthropology University of Toronto © Copyright by Leah Claire Walz 2008 Malta, Motherhood, and Infant Mortality: Integrating Biological and Socio-cultural Insights Doctorate of Philosophy 2008 Leah Claire Walz Department of Anthropology University of Toronto Abstract Because infants are the most vulnerable members of a community, their deaths – and the resulting infant mortality rate (IMR) – are said to signal more fundamental problems that are likely to affect the general health of a community. However, a focus on proximate- and intermediate-level risk factors in epidemiological analyses presents a decontextualized picture and ignores the role of larger forces on health, disease, and illness. In response to this trend, this project will contribute to a revitalization of the use of infant mortality as an index of larger social problems by tempering statistical analyses with critical reflection regarding the effects of the liminal position of Malta within the British imperial system, prior to the Second World War. In addition, by bringing together several analytic approaches which often proceed in parallel, rather than in dialogue – historical epidemiology, social history, and the analysis of colonial discourse – this dissertation highlights the problematics of knowledge production at both the theoretical and methodological level. As a result, my work is not just about Malta, one moment in history, the calculation of infant mortality rates, or the disentanglement of various determinants of infant mortality in this context; it is about the dynamics and repercussions of power differentials and of social, economic, and political inequalities, as they define and structure health outcomes and experiences. Specifically, I will show that fluctuations in international tensions affected Malta’s population on a number of levels because of the island’s importance as a British military and naval base and its location in ii the middle of the Mediterranean. I will demonstrate how Malta’s “strategic position” restricted political and economic development in the island and articulated with colonial perceptions of the Maltese as “Other” and Malta as “overpopulated.” Finally, I will argue that international tensions, Malta’s location within Empire, and perceptions of the island and its inhabitants in the early twentieth century affected the ways in which infant deaths were explained and understood and the strategies of intervention initiated in the island to curtail infant mortality – all of which had a tremendous impact on the rates at which infants in Malta died. iii Acknowledgments Writing a dissertation is something of a paradox: it can be a lonely and isolating process, but it cannot be done alone or in isolation. Despite the hours I spent by myself, typing away at my desk, with not even a window to remind me that there was a world beyond the screen before me, the influence of those who were involved in my life and work during this period was monumental. First of all, I must thank my supervisor, Dr. L.A. Sawchuk. When I applied to the University of Toronto, I had no idea what I wanted to do, and unfortunately – so he tells me – my letter of application made that abundantly clear. Yet Larry fought to have me accepted into the PhD program, he was a friend to me when I knew next to no one, and he gave me the freedom to embark on a project that I found stimulating, despite his reservations about me being “seduced by the dark side”. If Larry had not decided to bring me along to London, Gibraltar, and Malta to assist him in his research, if he had not introduced me to the joys of archival research, and if he had not given me unfettered access to the astonishing amount of data and materials that he had collected over the years, I would never had been able to write the dissertation that follows. And for that I will always be grateful. I would also like to extend my appreciation to Charles Farrugia and the staff at the National Archives of Malta at Santo Spirito, who patiently entertained my requests for countless documents over the course of many months. Similarly, I am indebted to the staff at the University of Malta, particularly those in the Melitensia section, as well as Father Reuben Deguara for assisting me in accessing invaluable sources of information. For making me feel at home in Malta, and for welcoming me into their lives, I cannot thank my “Maltese family” enough; George, Joanna, Antonia, Gius, Alex, and Paul, I couldn’t have asked for a warmer welcome, a more comfortable place to live, or a more giving family than you guys! Back at the University of Toronto, two members of my doctoral committee, Bonnie McElhinny and Michael Schillaci, were an enormous help to me; their careful reading of my dissertation, attention to detail, and thoughtful insights made a world of difference. Richard Lee and Tina Moffat, my fifth reader and external examiner, made the defence a little less painful by expressing their excitement about the kind of anthropology that I’m trying to do. In addition, I owe a great deal to the Comparative Program on Health and Society, for providing me with office space and financial support and for introducing me to a community of scholars similarly committed to interdisciplinary dialogue. Finally, thanks to Audrey and Gail – pictures of efficiency and professionalism out at UTSC, and both delightful to boot – and to Natalia, for enduring my never-ceasing inquiries and for always taking the time to help. Beyond the world of academia, I would not be where I am today without the friends and colleagues who I encountered along the way, particularly my “ladies” and the gang at the “pub” (you all know who you are!), who kept me sane during this long long journey by sharing their thoughts, their lives, their time, or their beer. And a final thanks goes out to my parents: mom and dad, you raised me to love reading and learning, you supported and encouraged me when I was my own slave-driver and toughest critic, and you believed in me even when I was plagued with self-doubt. I hope that I’ve made you both very proud. iv Table of Contents List of Tables ……………………………………………………………………… viii List of Figures …………………………………………………………………….. ix List of Appendices ………………………………………………………………… xi Chapter 1 – The Meaning of Infant Mortality ………………………………….. 1 The Importance of Infant Mortality…………………………………………. 4 A Study of Infant Mortality in Malta ………………………………………... 12 Chapter 2 – Materials, Methods, and Theoretical Orientation ……………….... 17 Historical Demography and Epidemiology …………………………………. 20 Grounding in Qualitative Analyses ………………………………………….. 29 Materials and Data Sources …………………………………………………. 33 Chapter 3 – The Location of Malta ……………………………………………… 42 History of Colonization ……………………………………………………... 45 Malta’s Economic Profile …………………………………………………… 49 Malta’s Political and Constitutional Development Following British Colonization …………………………………………………………………. 58 Maltese Italianità …………………………………………………………….. 75 Maltese Identity: Roman Catholic …………………………………………... 79 The Maltese Language ………………………………………………………. 87 Maltese Ethnology …………………………………………………………... 90 Conclusion …………………………………………………………………... 95 Chapter 4 – The Discovery of Infant Mortality …………………………………. 98 The Calculation of Infant Mortality …………………………………………. 99 Tracking Infant Mortality …………………………………………………… 100 Imperial History and the Need for Labourers and Soldiers …………………. 106 Attention to Infant Mortality in Malta ………………………………………. 110 The Social Construction of the Child and of Motherhood …………………... 111 Maltese Mothers …………………………………………………………….. 115 Maltese Women and Work ………………………………………………….. 119 Maternal Responsibility and Mother-blame ………………………………… 126 v Chapter 5 – Interventions in Malta and Abroad ………………………………... 129 Medical Services in Malta …………………………………………………... 131 The Regulation of Midwives ………………………………………………... 139 Infant Welfare Centres and Home Visiting …………………………………. 146 Hierarchies of Knowledge and the Rationalization of Infant Care …………. 150 The Scope and Effects of Infant Welfare Programmes ……………………... 156 The Justification of Colonial Rule …………………………………………... 162 Chapter 6 – The Perils of Overpopulation ………………………………………. 168 The Influence of Malthus ……………………………………………………. 170 Attention to Population Size, Density, and Growth …………………………. 171 The Relationship between Population and Health …………………………... 177 The Relationship between Population, Health, and Economics …………….. 186 Malthusian Language and Logic in Malta ………………………………. 190 Overpopulation, Infant mortality, and Hierarchies of Citizenship ………….. 196 Conclusions …………………………………………………………………. 200 Chapter 7 – Risky Decisions at the Level of the Family ………………………… 204 The Village of Casal ………………………………………………………… 207 Infant Mortality in Casal ……………………………………………………. 209 Birth Order ………………………………………………………………….. 215 Family Size …………………………………………………………………. 216 Birth Spacing ………………………………………………………………... 224 The Effects of Breast-feeding and Weaning ………………………………… 228 Maternal Instinct, Maternal Ignorance ………………………………………. 237 Maternal Ignorance in Malta ………………………………………………… 240 Apathy and Fatalism in Malta ……………………………………………….. 242 Tradition versus Modernity …………………………………………………. 248 Pathways of Causality and Correlation ……………………………………… 249 vi Chapter 8 – Regional and Socioeconomic Variation in Infant Mortality