Cuestionario autoadministrado

Our soldiers have already shown us Canadians how to die. It is up to the health authorities to show the people how to live

Robert Law, Acting Medical Officer of Health, Ottawa, 1918 (Legislative Assembly of Ontario 1919b:158)

The forty-year study period of this research encompasses two separate systems of disease classification used by the Registrar General of Ontario, reflecting the changing understanding of the concept of disease and illness in society in the late nineteenth century. From 1882 to 1897, a 5 class system was used based on the classification scheme of Dr. Farr and in 1898, the Registrar General switched to the Bertillon System of Classification of the Causes of Death (the precursor to the International Statistical Classification of Diseases, Injuries and Causes of Death (ICD), Legislative Assembly of Ontario 1900, O’Malley et al. 2005, Lilienfeld 2007). The system of Dr. Farr relied heavily on the miasmatic theory of disease causation while the Bertillon system is more reflective of the germ-theory, which was slowly gaining support in biomedical circles around the turn of the century.

The system of disease classification used until 1897 consisted of 5 classes. Influenza was included in the Class I – Zymotic diseases, under “Order 1. Miasmatic Diseases,

Miasmatici” (Legislative Assembly of Ontario 1883:42). According to Farr, the

“Miasmatic diseases (Order 1) are diffusible through the air or water, and are attended by fevers of various forms; the matter by which they are communicated is derived from the human body (as in small-pox) or from the earth (as in ague)” (Farr 1856:9). Therefore, influenza at the time of the Russian pandemic of 1890 was thought to be caused by inorganic emanations from the environment that manifested and reproduced in the blood and were transmissible between individuals (see Figure 2.1, Section 2.2).

Phthisis or consumption (tuberculosis) was frequently the most common cause of death during this period (Legislative Assembly of Ontario 1883-1898, 1919b) and a relationship between co-infection with tuberculosis and influenza has been suggested to

be related to high young adult mortality in 1918 (Noymer and Garenne 2000, Noymer 2009). Under the classification system of Dr. Farr, tuberculosis was in Class II, Constitutional Diseases, being those caused by “bad habit of body” being “sporadic; they are, sometimes discovered to be hereditary; they are rarely confined to one part, but before death ensues they affect several organs, in which new morbid products are often deposited” (Farr 1856:9).

The third class of disease encompassed the Local Diseases, or the “sporadic diseases, in which the functions of particular organs or systems are disturbed or obliterated with or without inflammation and its products; some of the diseases are hereditary” (Farr

1856:9). The Registrar-General of Ontario lists among these diseases “Epilepsy, Apoplexy, Convulsions, Paralysis, Insanity, Heart Disease, Congestion of the Lungs, Bronchitis, Pleurisy, Pneumonia, Disease of the Stomach, Liver and Kidneys, etc.” (Legislative Assembly of Ontario 1883:38). Thus, during the 1890 Russian pandemic in Ontario, those diseases which are described in this research as ‘pandemic related’ (influenza, pneumonia, and bronchitis), as well as tuberculosis, which was thought to exacerbate the effects of influenza infection, were not conceptually related diseases, being placed in three separate disease classes.

The implementation of the Bertillon System in 1898 saw causes of death separated into 13 separate groups (Legislative Assembly of Ontario 1900). The main causes of death in this study were still separated with influenza being a communicable disease, tuberculosis and scrofula among the Other General Diseases, and bronchitis and pneumonia being classified as Diseases of Respiration (Legislative Assembly of Ontario 1900). By 1918, the first two groups, Communicable Diseases and Other General Diseases had been collapsed into a single category of “General Diseases,” incorporating both influenza and tuberculosis into the same category (Legislative Assembly of Ontario 1919a). Pneumonia and bronchitis continued to be classified separately as local diseases of the lungs.

Except during the years 1890, 1892 and 1894, influenza, or la grippe, was paid very little attention in the Registrar-General’s reports (Legislative Assembly of Ontario 1883-1898).

The department was far more concerned with the diseases that were exacting the greatest toll on the province, such as measles, scarlatina (scarlet fever), typhoid, diphtheria, tuberculosis (phthisis or consumption), smallpox and with the possibility of a cholera outbreak in 1893. When the Act to Provide for the Registration of Births, Marriages and Deaths, 1869 was amended in 1896 through the Act Revising and Consolidating the Acts Respecting the Registration of Births, Marriages and Deaths, 1896, it was now required of each division registrar to make a monthly return (report) of the number of deaths from these specific contagious diseases that occurred in their district (An Act Revision and Consolidating the Acts Respecting the Registration of Births, Marriages, and Deaths,

1896, 17 11.4, Legislative Assembly of Ontario 1897:6). Even after the pandemic of 1890, influenza was not considered a serious enough disease to warrant monthly reports of deaths. Cases of influenza among the living were not made “notifiable” until after the 1918 pandemic, in 1923, when the Regulations for the Control of Communicable Diseases were approved by the Lieutenant-Governor in Council (Legislative Assembly of Ontario 1924). After this point, cases of influenza (specified as epidemic influenza) were required to be reported to the Medical Officer of Health or the Secretary of the local Board of Health. Far more people were infected with the virus than killed by it in both the influenza pandemics of 1890 and 1918. But, since influenza morbidity statistics were not kept in Ontario until 1923, all knowledge of the experiences of these epidemics must be gained at the individual level through the analysis of causes of death from the death records (an analysis of the history and completeness of these records is found in Chapter 3). However, since many people were infected in 1890 but few died (Valleron et al. 2010), this creates a natural experiment in which to test influenza-specific hypotheses concerning early life influences on later life health.

As seen through contemporary reports, the Government of Ontario was highly concerned with improving the state of public health in the Province during this period. Efforts to improve public health were abundant in England at the time, following on the establishment of the Office of the Registrar General through the Registration Act of 1837 (Legislative Assembly of Ontario 1889). The Registrar General of England in 1887 gave credit for the increasing interest in public health directly to the collection of the numbers and causes of death. Stating that “it is the registration of deaths, and of their causes that

has made sanitation possible” (Legislative Assembly of Ontario 1889:52). Similar emphasis on public health was seen in the United States resulting in the Medical Officer of Health for Toronto frequently interacting with his counterparts in England and the United States (MacDougall 1990).

There was no Canadian Board of Health until 1919. Federal and provincial responsibility was determined in the British North America Act, 1867 with the responsibility for local institutions being the purview of the provinces while the Federal Department of Agriculture was responsible for marine hospitals and quarantines (Health Canada 2009). After the First World War and the deaths incurred during the Spanish influenza pandemic, several pieces of legislation were passed that allowed for the creation of the national Department of Health (Bryce 1921). Prior to this point, health care in Ontario was overseen by the Provincial and Divisional Boards of Health, while tabulations of births, marriages, and deaths were the responsibility of the Registrar-General.

The Registrar-General was highly concerned with public health in the province, as it had a direct impact on the number of births, marriages, and deaths. His annual reports from 1882 to 1896 provide valuable insight into the state of health of the province during this time. For example, a constant concern was the ever-present cases of diphtheria in the province and the Registrar-General actively sought to reduce the number of deaths from this disease. When there were less diphtheria deaths in 1883 than in 1882, the Sanitary Inspector declared that this “was probably caused by the action of the Provincial Board of Health, lately established in this Province, which encouraged the formation of Local Boards of Health and also disseminated information respecting sanitary measures, and thus caused precautions to be taken to prevent the spread of this and other contagious diseases” (Legislative Assembly of Ontario 1884:43). Based on the miasmatic idea that disease was caused by decay and unsanitary conditions, the purpose of the Boards of Health was to clean up the environment so as to maintain health. The kinds of initiatives undertaken by the boards included milk and water sanitation, food inspection, demolishment of the slums, vaccinations, and concerns with high levels of poverty, overcrowding, and infant and maternal mortality (MacDougall 1990:11).

Concerned with high rates of infant mortality in Toronto, Dr. Helen MacMurchy wrote about the issue in 1910. She noted the relationship between poverty and infant mortality in the city, stating that “where the mother works, the baby dies. Nothing can replace maternal care. The destruction of the poor is their poverty” (1910:17). This was thought to be due to the inability of the working mother to nurse her child, since breast-milk replacements at the time were unreliable (1910:17). The Registrar-General kept statistics concerning the numbers and rates of infant mortality and illegitimate births per year (Legislative Assembly of Ontario 1883-1898). The high levels of deaths among illegitimate children are now thought to be caused by poverty, social stigma, lack of access to resources, young age of the mother, and lack of breastfeeding (Kok et al. 1997). Yet, public health officials during this time period were cognizant that illegitimate children had higher mortality than legitimate children (The Lancet 1918:303).