1940

PUBLIC H E A L T H

The Age Selection of Mortality from Tuberculosis

in Successive Decades
By RALPH

M. F.

PICKEN,M.B., H.B., B.SC., D.P.H.,

Mansel Talbot Professor of Preventive Medicine, The University of Wales.

The title of this short article is borrowed without modification from the last, posthumously
published, article of the late Dr. W. H. Frost of
The Johns Hopkins School of Hygiene and Public
Health. 1 The reason for this plagiarism is that it
is simply an attempt to test against British data a
method of examination applied by Frost to figures
derived from the State of Massachusetts. His plan
was to follow up the generation, or "cohort " as
he called it, born in a decade, and examine its
experience of mortality from tuberculosis in each
subsequent decade. Frost quotes Andvord, a
Norwegian, as having studied U.S. mortality
statistics in this way in 1930, and it may be noted
that Greenwood in discussing an article by Hill
suggested this method z just about the time when
Frost appears to have begun to be interested in it.
It is, in fact, a specific appplieation of the general
study of relative mortalities in age-groups made
by Kermack, et al., in 1934,3 from which these
writers concluded that the improvement attainecl
at any particular time in the death-rates of the
various age-groups depends primarily on the date
of birth of the individuals concerned, and that it
is probable that the important determining factors
upon the health of an individual during his whole
subsequent life lie in his environment up to the
age of, say, 15 years.

and so on, and do the same for each subsequent

generation or cohort, the form of the curve is
remarkably constant and quite different from that
obtained by charting a cross-section of the population at different ages at any one time. The main
peak (for males) is now always in the relatively
young age-group 20 to 29 and the only difference
in the graphs of the successive decennial cohorts
from 1870 to 1910 is the steadily falling mortality
at all ages with the progress of the years. The
same is true for the female cohorts, although the
bias of the curve is much more toward youth.
It is easy to see that a constant form of curve for
each generation, combined with a steadily falling
toll of mortality at all ages in the successive
generations, would have the effect of pushing to
higher ages the peak of mortality when it is
charted against the population in age-groups
living at any one time.

Changes in Age-Distribution
The basic data are, of course, the age- and sexspecific death-rates at different times, a series of
cross-sections of the mortal effects of tuberculosis
upon the population at different ages living at
each of the times chosen for inspection. From
the Reports and Reviews of the Registrar-General
for England and Wales, Figs. 1 and 2 have been
prepared in order to illustrate for males and
Age-Changes of Tubereulosls in the U.S.A.
females the well recognised changes which have.
It should be noted that throughout the period taken place in the age-distribution of the mortality
1880 to 1930 studied by Frost the peak of mortality from tuberculosis (all forms) when annual death
from tuberculosis (all forms) among males moved returns are analysed in this way. The rates have
consistently to higher and higher ages both in the been taken out for 1882 and each succeeding
Registration States and in Massachusetts. At the tenth year up to 1932, but some years have been
beginning of this period the curve was far from omitted from the charts in order to make them
simple, for, in addition to the usual heavy less confusing to the eye. For the same reason the
mortality in early childhood and sharp decline rates at ages 0 to 4 and 5 to 9, which have dropped
followed by the main peak in adult life, it showed steadily and very rapidly, have not been charted.
a fall in middle age and then another pronounced From Fig. 1 it is apparent that the main peak of
rise in old age. This latter feature is absent from male mortality was moving to higher ages up to
the corresponding curves for England and Wales 1912, and that afterward there was a slight
and disappears in America in more recent years recession to younger ages and a quite new peak
with the advancing age of the main peak, at least at ages 20 to 24. In Fig. 2, a similar process is
so far as males are concerned. But when the cohorts revealed, the peak of female mortality definitely
are plotted out separately, that is to say, when we moving to a higher age up to 1902, but the transtrace the rate of mortality from tuberculosis to ference of the accent to ages 15 to 24 which is so
which the survivors of those born between 1870 characteristic of 1922 and 1932 began for females
and 1879 were subject when they were aged 10 to some time before 1912. That is the familiar story
19 in 1890, 20 to 29 in 1900, 30 to 39 in 1910 of the age-career of tuberculosis in this country.
145

APRIL

PUBLIC HEALTH

FIG. 1.-England and Wales : Male death-rates from

TubercuIosis (all forms) by age in certain years since 1882.

FIG.2.-England and Wales : Female death-rates from

Tuberculosis (all forms) by age in certain years since 1882.

The age-groupings of tuberculosis in Massachusetts

and the U.S.A. Registration States presented the
different picture already indicated, and the slight
post-war check to the fall of mortality in young
adult females was evanescent and much less
striking than it was here.

black figures. Figs. 3 and 4 show graphically the

result of this way of extracting the Brltish figures.
It will be seen that for those cohorts born well
before the end of last century, i.e., when the peak
of age-mortality for both sexes appeared to be
moving to higher ages, the age-groups consistently
most affected were 30 to 39 for males and 20 to 29
for females, and the form of the curves remained
fairly constant. Up to this point the British and
Massachusetts charts resemble one another, except
that 20 to 29 is the age-group most affected for
both sexes in Massachusetts. In the latter case,
however, this type of curve remains constant as
far as it has been possible to follow the cohorts of
the present century, whereas a very striking
change has come over both the male and female
mortality rates in the British cohorts of 1902 and
almost certainly of 1912. The peak for males has
retired for the first time to ages 20 to 29, and for
females it belongs much more pronouncedly to
this age than before.

Ape-Mortality in the Cohorts

The age-experience of tuberculosis when a
group of persons born in one decade is followed
iap throughout life can be traced in Table I. The
calendar years examined are the same as before,
but the age-groupings above age 10 are different,
so that the mortality from tuberculosis at ages
under 10 in 1882, 10 to 19 in 1892, 20 to 29 in
1902, and so on, represents roughly the subsequent
experience of the generation born during the ten
years before 1882. As neither the actual deaths
from tuberculosis nor the death-rates were stated
in such age-groups by the Registrar-General for
the earlier years, these rates are estimates but they
may be regarded as reasonably near the truth. A
cohort can thus be followed diagonally downward
from any age-group on the left-hand side of the
table, as is indicated for the cohort of 1882 by

Discussion
Frost suggested as tentative conclusions from his
study of the Massachusetts records that the

1940

PUBLIC H E A L T H

TABLE I.
DEATH-RATES PER 100,000 FROM TUBERCULOSIS (ALL
FORMS), FOR ENGLAND AND WALES, 1882 TO 1932, BY AGE

C~'IOB~ 1872

AND SEX.
Age.

1882

1892

1,902

1912

1922 1932

536

472

89

82
90
242
305
339
308
224

335
65
71

123
38
63
164
167

Ma&s :

0-4
5-9
10-19
20-29
30-39
40-49
50-59
60-69
Fema~s

113
290
368
386
347
255

202

195
56
67
159

265
315
300
229

240
241
196

188

286
69
95
159
188
180
141
107

170
54
95
136
166
132
107
93

103
40
90
147
119

206

177
142

84
24
47
116
118
142
148
107

0-4
5-9
10-19
20-29
30-39
40-49
50-59
60-69

417
87
170
298
322
275
196
140

384
85
18g
204
244
220

170
123

98

81
71

200

100,

67
25
68
124
88
63
53
46

/ O0~OR~ 1912

0,,.

advancing peak of mortality of our time does not

represent a postponement of risk, but is a residuum
of higher rates in earlier life; that constancy of
age selection in successive cohorts sug.gests rather
constant physiological changes in resistance with
age (cf. Kermack, et al., referred to above); and
that, if it is right to suppose that the frequency
and extent of exposure to infection has been
diminishing throughout these decades, there is no
indication that this has increased the risk of death
in adult life from lack of acquired immunity.
These appeared to be reasonable deductions from
his data, and he thought that the mortality
records of England and Wales bore them out.
They do up to the end of the 19th century,
but the rather sudden concentration on young
adults in more recent times which, in the case of
females at least, does not seem to be passing away
very rapidly in spite of the fall in the mortality at
all ages, is still unexplained. The fact that this
change became very manifest only after the War
of 1914-18 has naturally caused the two events to
be linked in our minds. From study of the
figures over a long series of years, the RegistrarGeneral, who is usually cautious in offering explanations, says in relation to the mortality from all
forms of tuberculosis, " T h e rise or arrested fall of
mortality at ages between 15 and 25 from 1913 to
1923 can be attributed to the immediate effects of
food shortage in some of the intervening years on
young adults." Again, in discussing similar variations in the mortality from respiratory tuberculosis,
he notes that "stationary periods of arrested fall

120-

f .,~0.,-

i z,t)...

'150..

160.-69

FIG. 3.--England and Wales: Male death-rates from

Tuberculosis (all forms) by age, in successive 10-year
cohorts.

.,~00 -

co~c0z" 18"lz

2oo-

8
COHO

100-

lO,-

I 20-

tjo-

~~

~.~

I 60-69

,s,a'E.-G R O ~

FIG. 4.--England and Wales : Female death-rates from

Tuberculosis (all forms) by age, in successive 10-year
cohorts.

147

PUBLIC H E A L T H
occurred both for male and female rates at ages
15 to 20 between the years 1926 and 1931, and it
may be significant that the persons concerned had
been children between the ages of 0 and 12 during
the period of food shortage in 1916-18. Similar
stationary or rising periods occurred in the rates
at ages 20 to 25 between the years 1930 and 1933,
the persons comprising these groups of the population having been children of ages 3 to 12 during
the 1916-18 period. ''* The association seems
striking when stated in this way, and here again
is the suggestion that a state of affairs is to be
explained by something experienced by the
affected persons some 10 to 20 years earlier. But
it is now evident that the arrest of the decline of
mortality among young females had begun well
before the War and the food shortage. Indeed if
the suggestions of Kermack, et al., and of Frost
are read into Charts 3 and 4, it would appear
reasonable to seek influences at the end of the
19th century, or early in the 20th, to account for
the change in the behaviour of tuberculosis among
both males and females.
It is not the object of this article to discuss these
possible causes. So far as this country is concerned
they have been exhaustively considered by Bradford Hill ~' and Hart and Wright, 5 but neither of
these elaborate statistical investigations appears to
me to offer a readily acceptable explanation of so
curious a phenomenon as this selective interruption in the otherwise continuous fall in the
mortality from tuberculosis. Sir Arthur MacNalty 6 mentions the possibility that the resumed
and accelerated decline of mortality among young
adults since 1933 may mean that the check we
have been discussing is now passing away. It is
perhaps worth noting, however, that the curve of
female age-mortality for 1937 (the latest year for
which figures are available) shows general conformity in shape with those for all the post-war
years. The death-rate in each age-group is falling
but there is no sign of reversion to the peak
formerly observed at ages 35 to 44, or still earlier
at ages 25 to 34. On the other hand there is some
evidence that the male curve is now resuming its
pre-war form. The influences, therefore, which
brought about the change in the relative mortalities at different ages from tuberculosis seem not
only to have begun to affect females earlier than
males, but also to be continuing longer to do so.

Summary
1. The curve of age-mortality from tuberculosis
(all forms) in England and Wales, when traced
throughout a generation or "cohort," differs from
the corresponding curve for a cross-section of the
population at any one time.
148

APRIL
2. The behaviour of this curve for successive
generations resembles that traced by F r o s t for
Massachusetts, up to the generations born about
the end of last century.
3. The curves for later generations, both male
and female, in England and Wales are markedly
affected by the special incidence on young adults
which began to be felt before the War of 1914-18,
but especially during and after it.
4. None of the explanations offered are very
satisfactory as to this phenomenon, which appears
to be persisting among females but gradually disappearing among males.
REFERENCES.

'Frost, W.H. (1939). Amer.J. Hyg., 80, 91.

~Hill, A. Bradford. (1936). 9~.Roy. Stat. Sot., 99, 247.
8Kermack, W. O., McKendrick, A. G., and McKin]ay,
P.L. (1934). Lancet, 1,698.
4Registrar-General for England and Wales, Annual
Statistical Review, 1936. Text,72-75.
5Hart, P. D'Arcy, and Wright, G. Payling (1939).
Tuberculosis and Social Conditions in England.
Nat. Assoc. Prev. Tub., London.
eMinistry of Health, Annual Rep. of the Chief M;O.,
1938, 133.

THE NATIONAL HOSPITAL BILL OF

THE U.S.A.
If the American Congress passes a Bill which is
now before it, extensive new powers will be given to
the Surgeon General in relation to hospitals. It provides for the erection of hospitals in the less opulent
rural areas by the Federal Government, to be leased
to the local community on condition that they are
operated and maintained according to standards laid
down by the Surgeon-General.
He is to be advised by a council of six leading
medical or scientific authorities appointed by himself
with the approval of the Federal Security Administrator. The council will not only help in formulating
standards, rules and regulations, but also conduct and
foster studies in the need for hospitals and in hospital
operation.
For the coming financial year an appropriation of
ten million dollars is provided for the purpose of the
Bill. The term "hospital" is defined as including
"the physical facilities for the prevention, diagnosis
and treatment of disease, and for the protection of the
public health," so that a wide variety of institutions
,nay be established by the operation of this measure.
The Royal Sanitary Institute invite the attendance
of members of the Society at a sessional meeting to
be held at 90, Buckingham Palace Road, S.W.1, on
Tuesday, April 16th, at 5 p.m., when the discussion
on "Food in War-Time" will be opened by Dr.
S. J. Cowell, Professor of Dietetics in.the University
of London. The chair will be taken by Professor Sir
Wilson Jameson.