Aging Populations and the Determinants of Older Adult Health

McEniry, Mary

doi:10.1007/978-94-007-6979-3_1

Mary McEniry²

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Abstract

There was a dramatic improvement in life expectancy during the twentieth century, especially for those born between the 1930s and 1960s, primarily due to reductions in infant and child mortality. Widespread public health interventions including advancements in medical technology helped alleviate poor early life conditions – serious infectious diseases, poor nutrition, and harsh living environments – by reducing exposure to disease and treating it more effectively. In some developing countries, this happened largely in the absence of improved standards of living. The dramatic increase in life expectancy was one of the demographic transitions of the early twentieth century and partially explains the growth of aging populations throughout the world, in particular in low- and middle-income countries in the early twenty-first century. This growth is projected to increase the burden of disease due to chronic conditions such as adult heart disease and diabetes—conditions which in some instances originate in early life—as populations age.

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Notes

1.
Preston (1976).
2.
Riley (2008).
3.
Demographic, epidemiological, and nutritional transitions are related concepts. Development and urbanization leads to a shift from rural, low life expectancy and high fertility to urban, higher life expectancy and lower fertility. Infectious diseases in early life become less dominant and chronic diseases at older ages more dominant. Diets change to those with higher concentrations of saturated fats and sugar. A more sedentary lifestyle may then lead to health problems such as obesity.
4.
Kinsella and He (2009) and Kinsella and Velkoff (2001).
5.
Barker and Osmond (1986) and Elo and Preston (1992).
6.
Murray and López (1996), Lim et al. (2012), and Murray et al. (2012).
7.
The categorization of countries into low-, middle-, and high-income used throughout the book is based on the World Bank (2011).
8.
National Research Council (2001).
9.
Kinsella and Velkoff (2001).
10.
United Nations (2002).
11.
UN (2002).
12.
Palloni et al. (2004).
13.
De Vos and Palloni (2001) and Palloni (2002).
14.
Mesa-Lago (1994), Barrientos (1997), and Klinsberg (2000).
15.
Barceló, Aedo, Rajpathak, and Robles (2003).
16.
Amos, McCarty, and Zimmet (1997), Beaglehole and Yach (2003), King, Aubert, and Herman (1998), Murray and López (1996), Nikolic, Stanciole, and Zaydman (2011), and World Health Organization (WHO) (2000a, 2000b).
17.
Kinsella and He (2009).
18.
Leeder, Raymond, Greenberg, Liu, and Esson (2004).
19.
Reddy (2009).
20.
Prentice (2009).
21.
King, Aubert, and Herman (1998).
22.
Monteiro, Conde, Lu, and Popkin (2004) and WHO (2000a).
23.
Popkin (1998).
24.
Abegunde, Mathers, Adam, Ortegon, and Strong (2007).
25.
Barceló et al. (2003), Reddy (2009), and WHO (2005, 2008).
26.
Kuh and Ben-Shlomo (2004).
27.
National Research Council (2001).
28.
See for example WHO (2006).
29.
Preston, Hill, and Drevenstedt (1998).
30.
Crimmins and Finch (2006).
31.
Davey Smith and Lynch (2004), Elo and Preston (1992), Gunnell, Davey Smith, Holly, and Frankel (1998), Hertzman (1994), Lundberg (1991), and Wadsworth and Kuh (1997).
32.
Elo and Preston (1992).
33.
Huxley, Neil, and Collins (2002) and Joseph and Kramer (1996).
34.
There is a large literature from the fields of demography and biology indicating early life conditions are important to older adult health. See for example Almond and Currie (2010), Alter (2004), Barker (1998, 2002), Barker, Thornburg, Osmond, Kajantie, and Eriksson (2010), Bengtsson and Lindstrom (2000, 2003), Bengtsson and Mineau (2009), Blackwell, Hayward, and Crimmins (2001), Case and Paxson (2010); Costa (2002), Crimmins and Finch (2006), Davey Smith et al. (2000), Davey Smith, Hart, Blane, and Hole (1998), Davey Smith and Lynch (2004), Doblhammer (2004), Elo and Preston (1992), Eriksson, Forsen, Tuomilehto, Osmond, and Barker (2001), Ferrie, Rolf, and Troesken (2009), Finch and Crimmins (2004), Floud, Wachter, and Gregory (1990), Forsdahl (1978), Gagnon and Mazan (2006), Gluckman and Hanson (2006); Johnson and Schoeni (2007, 2011), Newnham and Ross (2009), Haas (2008), Hayward and Gorman (2004), Hertzman (1994), Gunnell et al. (1998), Kuh, Power, Blane, and Bartley (2004), Lundberg (1991), Leon, Davey Smith, Shipley, and Strachan (1995), Leon and Davey Smith (2000), Otero-Rodríguez et al. (2011), Palloni (2006), Peck and Lundberg (1995), Regidor, Guitiérrez-Fisac, Calle, Navarro, and Domínguez (2002), Svensson, Broström, and Oris (2004), van den Berg, Lindeboom, and Portrait (2006), Wadsworth, Hardy, Paul, Marshall, and Cole (2002), Wadsworth and Kuh (1997), and Wickrama, Conger, and Abraham (2005).
35.
Since the Elo and Preston (1992) article and the Barker (1998) book, the list of studies conducted in the developing world has grown. See for example Beltrán-Sánchez, Crimmins, Teruel, and Thomas (2011), Brenes (2008), Brenes-Camacho and Palloni (2011), Campbell and Lee (2009), Crimmins et al. (2005), Davis, Campbell, and Lee (2009), Godoy, Goodman, Levins, Caram, and Seyfried (2007), Huang and Elo (2009), Huang, Soldo, and Elo (2011), Kohler and Soldo (2005), Martorell, Stein, and Schroeder (2001), McEniry (2011b), McEniry and Palloni (2010), McEniry, Palloni, Dávila, and García (2008), Monteiro, Moura, Conde, and Popkin (2004), Monteverde, Norhonha, and Palloni (2009), Moore et al. (1999), Palloni, McEniry, Dávila and García Gurucharri (2005); Palloni, McEniry, Wong, and Peláez (2006), Sichieri, Siqueira and Moura (2000), Schooling et al. (2011), Schroeder, Martorell, and Flores (1999), Victora et al. (2008), Xu et al. (2009), Zeng, Gu, and Land (2007), Wen and Gu (2011), and Zhang, Gu, and Hayward (2010). In addition, there are now numerous studies conducted on children in the developing world. See for example Van Ewijk, Painter, and Roseboom (2013), Yajnik and Dshmukh (2008) and the recent review article (McEniry, 2012).
36.
Popkin, Horton, and Kim (2001) and Barker (1998).
37.
Crimmins and Finch (2006).
38.
Barker (1998) and Kuh and Ben-Shlomo (2004). There are also several critiques of the Barker hypothesis in regards to the importance of other life course factors that may explain health (Huxley, 2006; Huxley, Neil, & Collins, 2002; Joseph & Kramer, 1996). Small sample sizes have been a problem in some studies, and some have shown weak or no associations between under-nutrition in utero and later adult health (Kannisto, Christensen, & Vaupel, 1997; Stanner et al., 1997).
39.
Barker (2005), Barker, Forsén, Uutela, Osmond, and Eriksson (2001), Barker, Eriksson, Forsen, and Osmond (2002), Barker (1995), Eriksson et al. (2001), Gardiner (2007), Godfrey and Barker (2000); Osmond and Barker (2000), Osmond, Barker, Winter, Fall, and Simmonds (1993).
40.
Barker et al. (2001) and Barker (1995).
41.
See for example Marmot and Elliott (2005).
42.
Popkin et al. (2001).
43.
Bateson et al. (2004).
44.
Dziadek (2006), Fall and Sachdev (2006), Forrester (2006), Waterland (2006), Whitelaw and Garrick (2006), and Wu, Bazer, Cudd, Meininger, and Spencer (2004).
45.
Heijmans et al. (2008).
46.
Pembrey et al. (2006).
47.
National Institute on Aging (2009).
48.
Heijmans, Tobi, Lumey, and Slagboom (2009).
49.
Aboderin et al. (2002), Kuh and Ben-Shlomo (2004), Otero-Rodríguez et al. (2011), Rockwood and Mitnitski (2007), and Power, Kuh, and Morton (2013), O’Rand and Hamil-Luker (2005).
50.
Aboderin et al. (2002), Coleman, Ruth, and O’Hanlon (2004), Harper, Lynch, and Davey Smith (2011), Kuh and Ben-Shlomo (2004), Kuh (1999), and Pickles, Maughan, and Wadsworth (2007).
51.
Popkin et al. (2001).
52.
See for example FAO (2004), Popkin (2006), Schmidhuber and Shetty (2005), Lim et al. (2012), Woolf and Aron (2013), and Basu, Yoffe, Hills, Lustig, and Wagner (2013).
53.
De Schutter (2012).
54.
Case and Paxson (2010).
55.
Almond and Currie (2010), van den Berg, Doblhammer, and Christensen (2009), Harper, Lynch, and Davey Smith (2011), Bengtsson and Mineau (2009), Davey Smith and Lynch (2004), Elo and Preston (1992), Forsdahl (1978), Hertzman (1994), Lundberg (1991), Wadsworth et al. (2002), and Wadsworth and Kuh (1997).
56.
See for example Otero-Rodríguez et al. (2011).
57.
Barker (1995, 2001, 2005) and Barker et al. (2001, 2002).
58.
Kuh and Ben-Shlomo (2004).
59.
Popkin et al. (2001).
60.
See for example Huang and Elo (2009), Huang, Soldo, and Elo (2011), and Zeng, Gu, and Land (2007).
61.
Almond and Currie (2010) and Wilkinson and Marmot (2003).
62.
Davey Smith et al. (1998), Elo, Martikainen, and Myrskylä (2010), and Hayward and Gorman (2004).
63.
Painter et al. (2006), Ravelli et al. (1998), and Roseboom et al. (2000).
64.
Garnier, Grynspan, Hidalgo, Monge, and Trejos (1997), Rosero-Bixby (1991), and WHO (2000b).
65.
Bishop, Corbin, and Duncan (1997).
66.
See for example, Palloni et al. (2007).
67.
One exception is van den Berg et al. (2009).
68.
Omran (1971) and Preston (1976).
69.
Palloni (1981) and Palloni et al. (2007) .
70.
Cutler and Meara (2001) and Cutler, Deaton, and Lleras-Muney (2006).
71.
Costa (2005).
72.
Arriaga and Davis (1969).
73.
Crimmins and Finch (2006) and Finch and Crimmins (2004).
74.
Barker and Osmond (1986).
75.
Delaney, McGovern, and Smith (2009).
76.
Center for Disease Control and Prevention (2001).
77.
Ford et al. (2007).
78.
Ramasubban (2008) suggests that large developing countries such as India with many different languages and traditions may have encountered more difficulty in implementing successful public health interventions than large developed countries such as the US.
79.
See for example the description of the Rockefeller Foundation’s effort to combat disease throughout the world in the early twentieth century (Farley, 2004).
80.
Farley (2004).
81.
Preston (1976).
82.
Riley (2005a) identifies the beginning of the health transition in the US and the Netherlands towards the later part of the nineteenth century. This transition was earlier for England and Wales.
83.
Preston (1976).
84.
Palloni and Wyrick (1981) and Preston (1976).
85.
Palloni and Wyrick (1981) and Preston (1976).
86.
Diaz-Briquets (1981).
87.
Birn (2005), Diaz-Briquets (1981), and Mazzeo (1993).
88.
Diaz-Briquets (1981).
89.
Cuba is an interesting case because in the early twentieth century its IMR and caloric intakes were similar to that of Argentina and Uruguay but with lower life expectancy (Diaz-Briquets, 1981; Lannoy, 1963).
90.
McEniry (2009c).
91.
Garnier et al. (1997), Jiménez de la Jara and Bossert (1995), Palmer (2003), Rigau Pérez (2000), and Rosero-Bixby (1991).
92.
Barclay (1954) wrote extensively on Taiwan in the early twentieth century.
93.
Beinart and Dubow (1995).
94.
Riley (2005b) contains a comprehensive description of timing of mortality transitions.
95.
Rodríguez de Romo and Rodríguez de Pérez (1998).
96.
Bishop et al. (1997) and West India Royal Commission (1945).
97.
Riley (2005b).
98.
Banister (1987), Campbell (1997), MacPherson (2008), and Xizhe and Zhigang (2000).
99.
Hull (2008), Nitisastro (1970), Pardoko (1984), and Widjojo (1970).
100.
Dyson (1997), Guha (2001), and Ramasubban (2008).
101.
Guha (2001) and Khan (1984).
102.
Patterson (1979, 1981).
103.
See for example López-Alonso (2007).
104.
Fogel (2004).
105.
Almond and Currie (2010).
106.
Godoy et al. (2007), López-Alonso and Porras Condey (2003), and Meisel and Vega (2007).
107.
Horiuchi and Preston (1988).
108.
Preston (1976) and Palloni et al. (2007).
109.
Palloni et al. (2007).
110.
Palloni et al. (2007).
111.
Crimmins and Finch (2006).
112.
Popkin et al. (2001).
113.
Barker et al. (2001) and Barker (1995).
114.
Palloni et al. (2006).
115.
Mostly from annual reports from the Health Commissioner of Puerto Rico, published articles in Puerto Rican public health journals, and published books during the early twentieth century, but also from Ayala and Bernabe (2007) and Steward et al. (1956) who provide a broader context of the events that occurred during the 1930s–1940s in Puerto Rico.
116.
Palloni et al. (2005).
117.
US Census Bureau (1932).
118.
The US census (US Census Bureau, 1932) defined “rural” as communities with fewer than 2,500 inhabitants. Using the US census definition, 78 % of Puerto Rico’s population was identified as rural in 1920 and about 72 % in 1930. Only the municipalities of San Juan, Bayamón, and Ponce had predominantly urban populations in 1920. By 1930, Cataño and Mayagüez had become predominantly urban as well although Bayamón became more rural than urban.
119.
Allen and Hunt (1914), Ashford and Gutiérrez Igaravidez (1911), Clark (1930), Mountin, Pennell, and Flook (1937), and Rigau Pérez (2000).
120.
US Census Bureau (1932).
121.
Clark (1930).
122.
Today, Puerto Rico is divided into 78 municipios governed by an elected mayor and legislative assembly. The current location of municipios, for the most part, conforms to how Puerto Rico was divided in the late 1920s-early 1940s.
123.
Rosario (1930, page 565).
124.
Bureau of Vital Statistics (1926).
125.
Clark (1930), Morales Otero and Pérez (1939), Morales Otero et al. (1937, 1939).
126.
Clark (1930).
127.
Morales Otero and Pérez (1939), Morales Otero et al. (1937, 1939).
128.
Rosario (1930, pages 549 and 551).
129.
US Census Bureau (1932).
130.
Clark (1930, pages 123–124), Fernós Isern (1932), Mountin et al. (1937) and US Census Bureau (1932).
131.
Rosario (1930, page 563).
132.
Cook, Axtmayer, and Dalmau (1943).
133.
Cook et al. (1943) examined three typical diets in Puerto Rico: continental (Puerto Ricans that followed US dietary habits); caterer (urban areas); and country (rural areas). A typical continental diet included: juice, cream, sugar, coffee (breakfast); egg and toast, sugar, milk, banana, iced tea, lime juice (lunch); avocado, plantain, fried cabbage, potato cake, fried pork chops, cream, butter, sugar, pineapple ice cream, cake, coffee (dinner). A typical urban diet included chicken meat, potatoes and gravy, macaroni, polished rice, red kidney beans (lunch) and fried bread meat, stewed eggplant, polished rice, and rice soup (dinner). A typical rural diet included polished rice, red kidney beans, pork, onions, chick peas, salted cod fish, olive oil, annatto seeds, lard, salt, sugar, garlic, black pepper, yautías (a root), sweet potato, tomatoes, and pigeon peas.
134.
WHO (2012).
135.
Robinson and Suárez (1947).
136.
See annual reports to the health commissioner of Puerto Rico (Fernós Isern, 1932, 1933, 1946, n.d.; Garrido Morales, 1935, 1936, 1937, 1939, 1940, 1941; Ortiz, 1927, 1929, 1931), Clark (1930), and Gayer, Homan, and James (1938).
137.
Bary (1923).
138.
Payne, Berríos, and Martínez Rivera (1929).
139.
Robinson and Suárez (1947).
140.
Rosario (1930).
141.
Clark (1930, page 50).
142.
Food and Agriculture Organization of the United Nations (1985) Agroclimatological Data for Latin American and the Caribbean. Average annual precipitation for Puerto Rico: 1471 mm (57.91 in). Maximum precipitation: 162 mm. Minimum precipitation: 62 mm. Average annual temperature: 25.6 °C (78.1 °F). Maximum temperature: 30 °C. Minimum temperature: 21.2 °C.
143.
Rigau Pérez (2000).
144.
Clark (1930).
145.
Morales Otero and Pérez (1939) and Morales Otero et al. (1937, 1939). A US dollar per day in 1930 was not enough to sustain a living for a family. Rosario (1930, page 563–564) provides several examples of the purchasing power of earning less than $1 per day: (1) A coffee farm with a full time worker making 60 cents per day with his wife and eight children. The 60 cents were sufficient to buy food for lunch (3 lb of corn meal, half of a pound of cod fish, salt) and supper (two and a half pounds of rice, beans, salt pork, sugar) with eight cents left over which had to be saved for Sunday purchases of food when the man was not working. If he worked only a half of a day he could only buy lunch and no supper for the family. (2) In contrast, because wages in the sugar region were higher, a family of four in the sugar region with 75 cents per day could purchase for a single meal 4 lb of sweet potatoes, olive oil, sugar, codfish and coffee leaving an average of 44 cents for other meals and for Sunday; a family of five in the sugar region could potentially have a reserve of 46 cents left for other meals and for Sunday after purchasing a pound of rice, lard, cigarettes, two pounds of sweet potatoes, and coffee; and a family of eight with similar wages spent 35 and a half cents on food for a single meal with the remaining for purchasing food for other meals and for Sunday.
146.
Clark (1930), Morales Otero et al. (1937, 1939); Morales Otero and Pérez (1939), and Pérez (1941).
147.
Almond and Currie (2010).
148.
Although only a small percentage of housing was provided rent free (Rosario, 1930, page 554).
149.
Clark (1930).
150.
Clark (1930).
151.
Scarano and White (2007).
152.
Clark (1930).
153.
Scarano and White (2007).
154.
Morales Otero and Pérez (1939) and Morales Otero et al. (1937, 1939).
155.
Farley (2004).
156.
Fernós Isern (1932) and Ortiz (1931).
157.
See annual reports to the health commissioner of Puerto Rico(Fernós Isern, 1932, 1933, 1946, n.d.; Garrido Morales, 1935, 1936, 1937, 1939, 1940, 1941; Ortiz, 1927, 1929, 1931).
158.
In 1924–1925, IMR, neonatal and post neonatal mortality rates in Puerto Rico were 148.6, 43.3, and 105.4 per 1,000 live births, respectively. Neonatal deaths accounted for about 29 % of total IMR (Fernós Isern, 1928). In 1924 for the state of New York excluding New York City, comparable numbers were: 69, 40.74, and 28.29, with about 59 % of the total IMR being neonatal mortality (Fernós Isern, 1928). In 1921–1925 in England and Wales, comparable numbers were: 76, 33.4, and 42.6 with about 44 % neonatal mortality (Barker & Osmond, 1986). In 1928–1938 in England and Wales, comparable numbers were: 61.7, 30.9, and 30.8 with 50 % being neonatal mortality (Woolf, 1947).
159.
Fernós Isern (1925, 1928).
160.
Fernós Isern (1928).
161.
Fernós Isern and Rodríguez Pastor (1930). Wegman, Fernández Merchante, and Kramer (1942) also found that in the rural municipio of Ciales, a very high percentage of mothers who used the public health unit breastfed for up to 6 months (page 237). They noted two unusual facts about IMR in Puerto Rico: (1) there was a rapid decline in neonatal mortality rates (first month of life) but not a corresponding rapid decline in post neonatal mortality rates (1st month through the 11th month of life); (2) there was higher IMR in western and coastal regions and lower IMR in central and eastern regions (page 244).
162.
Fernós Isern and Rodríguez Pastor (1930) and Phelps (1928).
163.
Examples of municipios with high malaria rates were Barceloneta, Fajardo, and Ponce (Earle, 1925). The annual reports of the health commissioner frequently mentioned municipios with lower and higher malaria rates. See for example Fernós Isern (1932, 1933, 1946, n.d.), Garrido Morales (1935, 1936, 1937, 1940, 1941), and Ortiz (1927, 1929, 1931).
164.
See Fernós Isern and Rodríguez Pastor (1930), although they note that mortality from congenital disability was decreasing by the late 1920s.
165.
Hill (1926) describes hookworm infection in early twentieth century Puerto Rico as a chronic condition in the rural areas that was not seasonal. A high prevalence of hookworm infection does not reflect severity; severity is measured by worm burden (number of worms). Historical records describe a high severity in certain regions and municipios of Puerto Rico especially in the coffee regions. In the mountainous interior of the island, infestation averages were estimated at 500 parasites per person whereas in the coastal areas estimates were closer to 200 per person. The severity of the infection in other regions is not clear. Nevertheless, the high infestation averages confirm that hookworm infection was a serious health issue in Puerto Rico during the late 1920s–1930s. In terms of the effect of hookworm infection on maternal health, Gilles and Ball (1991) point out that hookworm infection in mothers may cause nutritional problems for the developing child, although hookworm infection alone may not be as serious as other nutritional factors which affect disease (Gilles & Ball, 1991).
166.
Morales Otero et al. (1937, page 460).
167.
The highest rates were in coffee cultivation areas, with an average infestation rate of 90 % and an extremely high prevalence of hookworm disease—a disease prevalent in Puerto Rico since 1530 (Daengsvang, 1932; Hill, 1926; Howard, 1928). It is difficult to identify the severity of hookworm disease since the worm burden is important in terms of morbidity risks for the mother. A pregnant woman could be infected but not have a high worm burden, but even low worm burdens can lead to anemia (Hill, 1926).
168.
WHO (2011a).
169.
Fernós Isern and Rodríguez Pastor (1930).
170.
Ortiz (1929, page 134).
171.
As a way of comparison, Corsica in France in the 1950s had an endogenous mortality of 26.4 per 1,000 and a stillbirth mortality of 19.9, for a total perinatal mortality rate of 46.3 per 1,000, 43 % of which was stillbirths (Pressat, 1961).
172.
Early research on the distribution of deaths during the first year of life (Bourgeois-Pichat, 1952; Galley & Wood, 1999) shows that neonatal mortality rates (deaths during the first month of life) are strongly associated with non-environmental or endogenous causes. Endogenous infant mortality is defined as “cases in which the child bears within itself, from birth, the cause resulting in its death, whether that cause was inherited from its parents at conception or acquired from its mother during gestation or delivery” (Bourgeois-Pichat, 1952). Barker and Osmond’s (1986) classic geographical analysis in England and Wales in the 1960s showed strong positive associations between neonatal mortality and adult mortality due to coronary heart disease. Nearly 80 % of overall neonatal mortality was due to congenital causes. Endogenous mortality thus became an important clue as to the source of early life conditions which led to adult mortality. Barker later concluded that, “coronary heart disease is associated with past infant mortality because it originates in conditions in utero, rather than poor conditions in childhood, though these contribute” (Barker, 2002, page 309).
173.
According to Ortiz (1927, page 99): “Three hundred and twenty-one physicians are practicing in Porto Rico, according to our records. The estimated population of the Island is 1,417,646. The average number of persons for each physician is about 4,500. Considering that of these 321 physicians 113 are practicing in San Juan and about 25 in Ponce, the second largest city in the Island, there are only 183 left for the rest of the Island or an average of 6,829 people for each physician. This situation is particularly serious in small towns.”
174.
Mountin et al. (1937).
175.
See for example Jana et al. (1994) and Guyatt and Snow (2004).
176.
Ayala and Bernabe (2007), Perloff (1952), and Steward et al. (1956).
177.
Fernós Isern (1932, 1933, 1946, n.d.), Garrido Morales (1935, 1936, 1937, 1939, 1940, 1941), and Ortiz (1927, 1929, 1931).
178.
Belaval (1945).
179.
Ortiz (1929).
180.
Farley (2004).
181.
Fernós Isern (1932, 1933, n.d.), Garrido Morales (1935, 1936, 1937, 1939, 1940, 1940, 1941), and Ortiz (1931).
182.
See for example the annual reports of the health commissioner of Puerto Rico in the late 1920s and 1930s (Fernós Isern, 1932, 1946, n.d.; Garrido Morales, 1936, 1937, 1939, 1940); Ortiz, 1927).
183.
Fernós Isern (1932, 1933, 1946, n.d.), Garrido Morales (1935, 1936, 1937, 1939, 1940, 1941), and Ortiz (1927, 1929, 1931).
184.
Fernós Isern (1932) and Garrido Morales (1941).
185.
Historical sources refer to the high percent of B. coli (later renamed E. coli; see Todar’s Online Textbook of Bacteriology, 2008) in water supplies during the early 1930s (Fernós Isern, 1932, 1933, 1946; Garrido Morales, 1940, 1941; Ortiz, 1931). See also United States Environmental Protection Agency (2010).
186.
Rigau Pérez (2000).
187.
Fernós Isern (1932, 1933, 1946, n.d.), Garrido Morales (1935, 1936, 1937, 1939, 1940, 1941), Ortiz (1927, 1929, 1931), and Rigau Pérez (2000).
188.
The collection of vital statistics in Puerto Rico in the early twentieth century was the responsibility of municipio clerks under direct supervision from the mayor of each municipality. While law required that daily statistics be kept which contained information determined by the Director of Health (Pérez, 1926), the Department of Health did not have direct oversight into the local registers and how data were collected until the early 1930s. In fact, it is dubious whether municipal authorities inspected the civil registers in the early 1920s. However, Puerto Rican laws established during this period clearly outlined fines for not reporting deaths and required that a physician sign the death certificate. Thus the Department of Health viewed the numbers of deaths collected by each municipio as fairly accurate and believed that almost all deaths were reported. According to the Department of Health, over 90 % of births were reported (Bureau of Vital Statistics, 1926). The 90 % estimate agrees with official estimates of underreporting in later annual reports to the governor. The problem of underreporting births appears to be related to missing birth reports for infants who died before they were a year old. In the Fiscal Year 1930 report, an examination of December 1929 deaths of children under 1 year with matching birth reports found that about 45 % of associated births were not reported (Fernós Isern, 1932, page 8): “According to law death reports are 100 % complete as no burial permits are issued without a certificate of death from the physician, but on the other hand, birth reports, taking the month of December, 1929, as a basis are only about 55 % complete… The infant mortality rate…would be 125 per 1,000 live births after proper checking 118 per 1,000 live births.” Thus, in this example, there was about a 6 percentage point difference between the higher calculated and lower corrected infant mortality rate for December 1929. It is not clear from the annual reports to the governor the degree to which underreporting of births may have occurred when the infant did not die before 1 year of age. An important weakness of the system was also the classification of births and deaths by race, domicile, age, and occupation and the reporting of the cause of death and morbidity because there were no uniform standards across municipios. In the 1920s, the Department of Health actively classified deaths according to international standards of disease classification, but many Puerto Rican physicians did not conform or did not report communicable (transmissible) diseases as required by law.
189.
Fernós Isern and Rodríguez Pastor (1930)
190.
The first public health unit was created in 1926 in Río Piedrasand was partially funded by the Rockefeller Foundation (Ortiz, 1929). By 1938, each municipality had its own public health unit. Annual reports throughout the 1930s refer to the gradual coverage of the entire island with public health units staffed by a medical team of a doctor and nurses.
191.
Author’s calculations from the late 1920s to 1943 using municipio-specific IMR obtained from the annual reports of the health commissioner of Puerto Rico.
192.
Garrido Morales (1941) and Vázquez Calzada (1988).
193.
Fernós Isern (1933), Garrido Morales (1935, 1936, 1937, 1939, 1941).
194.
Fogel (2004).
195.
Godoy et al. (2007), Health and Retirement Study, Public Use Dataset (2000–2006), and PREHCO (2007).
196.
See for example López-Alonso and Porras Condey (2003) and Meisel and Vega (2007).
197.
See the series of reports by the health commissioner of Puerto Rico throughout the 1930s. For example Fernós Isern (1932, 1933, n.d.), Garrido Morales (1935, 1936, 1937, 1939), and Ortiz (1931). Also see Morales Otero and Pérez (1939), Morales Otero et al. (1939), and Morales Otero et al. (1937).
198.
Clark (1930).

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Inter-university Consortium for Political and Social Research Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
Mary McEniry

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Mary McEniry
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McEniry, M. (2014). Aging Populations and the Determinants of Older Adult Health. In: Early Life Conditions and Rapid Demographic Changes in the Developing World. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-6979-3_1

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DOI: https://doi.org/10.1007/978-94-007-6979-3_1
Published: 24 July 2013
Publisher Name: Springer, Dordrecht
Print ISBN: 978-94-007-6978-6
Online ISBN: 978-94-007-6979-3
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