CHILDHOOD EPIDEMICS AND THE DEMOGRAPHIC LANDSCAPE OF THE ÅLAND ARCHIPELAGO ______________________________________________________ A Dissertation presented to the Faculty of the Graduate School at the University of Missouri-Columbia ______________________________________________________ In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy ______________________________________________________ by ERIN LEE MILLER Dr. Lisa Sattenspiel, Dissertation Supervisor MAY 2018 The undersigned, appointed by the dean of the Graduate School, have examined the dissertation entitled CHILDHOOD EPIDEMICS AND THE DEMOGRAPHIC LANDSCAPE OF THE ÅLAND ARCHIPELAGO presented by Erin Lee Miller, a candidate for the degree of Doctor of Philosophy, and hereby certify that, in their opinion, it is worthy of acceptance. Professor Lisa Sattenspiel Professor Todd VanPool Professor Mary Shenk Professor Enid Schatz Associate Dean James Mielke, University of Kansas ACKNOWLEDGEMENTS This research was made possible by the aid and support of many friends, family, and colleagues over the years. I would first like to express my deepest appreciation to my committee chair Professor Lisa Sattenspiel. Without her guidance and support over the years, this dissertation would not have been possible. As a mentor, Dr. Sattenspiel has always had an open door and willingness to provide support for whatever path her students chose. I also owe thanks to my Dissertation Committee members, Professor Todd VanPool, Professor Mary Shenk, and Professor Enid Schatz, for their insight, guidance, and time through the research and writing process. The dedication of these professors has enriched my life professionally and inspired me personally. I owe special thanks to Associate Dean James Mielke (who also served on my Dissertation Committee) for providing archival records from Åland, Finland for the purposes of this research. I am grateful to Dr. Mielke and Dr. Kari Pitkänen (University of Jyväskylä, Finland) for working with me to better understand the archival records and the history of the Åland Islands. Dr. Pitkänen is owed additional thanks for providing translation references and assistance in the early stages of this project. In addition, I would like to thank Associate Professor Corey Sparks (University of Texas at San Antonio) for his instruction in adapting demographic methods for historical populations and encouragement during the dissertation process. I am also deeply grateful for the family and friends who provided the motivation and support needed to make it through graduate school. I would like to thank my parents; whose love and support are always with me. They provided financial, mental, and moral support through this long, and sometimes difficult, journey. Thank you to my sister, and ii best friend, who is always there for me no matter how far apart we are. To Kate Trusler, my inspiration fairy, who took time out of her days to provide encouragement and laughter with a few simple texts. Finally, to other family, friends, and colleagues who provided advice and support during this process, thank you. iii TABLE OF CONTENTS ACKNOWLEDGMENTS ........................................................................................................................................... ii LIST OF FIGURES ..................................................................................................................................................... v LIST OF TABLES ...................................................................................................................................................... vi ABSTRACT ............................................................................................................................................................... vii CHAPTER 1: INTRODUCTION ............................................................................................................................. 1 CHAPTER 2: USING AN ANTHROPOLOGICAL FRAMEWORK TO EXPLORE HISTORICAL EPIDEMICS ................................................................................................................................................................. 6 Sociocultural Approaches to Health and Disease ................................................................................ 7 Critical Medical Anthropology and the Social Determinants of Health ................................. 9 Syndemic Theory .................................................................................................................................... 11 Physical/Biological Approaches to Health and Disease................................................................. 12 Transition Theory: Perspectives from Demography and Epidemiology ............................. 14 Demographic transition theory ................................................................................................. 14 Epidemiological transition theory ........................................................................................... 17 CHAPTER 3: THE ÅLAND ARCHIPELAGO ................................................................................................... 22 Åland Households and Communities: An Overview ....................................................................... 26 Pre-20th Century Åland, Finland: Demography, Mortality, and Epidemiology .................... 29 CHPATER 4: MEASLES ........................................................................................................................................ 37 The Biology of Infection ............................................................................................................................. 38 Syndemic Interactions ................................................................................................................................ 40 Comparing Measles and Smallpox ......................................................................................................... 43 Measles Epidemiology: Quantitative Studies .................................................................................... 46 CHAPTER 5: THE ARCHIVES OF ÅLAND ..................................................................................................... 50 Translating Causes of Death ..................................................................................................................... 52 Understanding Archival Data in Demographic Research ............................................................. 55 iv CHAPTER 6: METHODS ...................................................................................................................................... 57 Graphic Analyses: Identifying Epidemics and Non-epidemics .................................................. 58 Age-specific Death Rates: Bridging Gaps in Data ............................................................................. 59 Excess Mortality and Frequency Analysis .......................................................................................... 62 Demographic Impacts of Epidemic Mortality ................................................................................... 65 CHAPTER 7: RESULTS ........................................................................................................................................ 67 Age-specific Death Rates ............................................................................................................................ 70 Excess Mortality and Frequency Analysis .......................................................................................... 73 Long-term Demographic Consequences of Epidemic Mortality ................................................ 83 CHAPTER 8: DISCUSSION AND CONCLUSIONS ........................................................................................ 93 Excess Mortality ............................................................................................................................................ 94 Infant mortality ...................................................................................................................................... 95 Excess mortality at ages 1-9 .............................................................................................................. 96 Excess mortality for individuals 50 years and older ................................................................. 97 Demographic Impacts of Epidemic Mortality ................................................................................... 99 Implications, Limitations, and Conclusions .................................................................................... 104 REFERENCES ....................................................................................................................................................... 107 APPENDIX A: Cause of Death (COD) Translations: Some Examples ............................................. 124 APPENDIX B: Age-specific Death Rates by Study Period Only ........................................................ 125 APPENDIX C: Infant Mortality Rate Confidence Intervals ................................................................ 128 APPENDIX D: Life Tables ................................................................................................................................ 130 VITA ........................................................................................................................................................................