Decline in Chinese Mortality

Why then did mortality decline? Ho Ping-ti's (1959, 1978) findings on the introduction of new crops from the Americas during the sixteenth century provide us with one of the more persuasive answers. These easy-to-grow crops-for example, sweet and white potatoes and maize-may well have substantially stabilized food supplies for the poor in less fertile and mountainous regions. D. H. Perkins (1969), however, suggests that changing cropping patterns and rising traditional capital inputs increased crop yields per acre. Either way an improved food supply was certain to have reduced the chances of starvation for the people and consequently their susceptibility to various diseases.

Some would argue that long-term climatological evolution was the main factor: the post-fifteenth-century population growth, its decline in the mid-seventeenth century, as well as the explosion in the eighteenth century, all corresponded to climate changes of the time (Eastman 1988). Here even the changes in food production and the disease factor can be considered as affected by the climate.

Another important factor that should be considered is that in its earliest stages, a mortality decline is the result of lowered mortality rates for the young. This was the case in modern Europe and in Japanese-occupied Taiwan (Chen 1982; Riley 1986).

The health of the mother is an important variable in infant mortality, whereas better resistance to childhood diseases typically explains a reduced mortality in children over one year of age. Surely mother's education and infant mortality are directly related; however, the relationship is impossible to verify in this period. In addition, the lowering of mortality in children in modern Europe and early twentieth-century Taiwan was closely linked to the improvement in general hygiene (Chen 1982; Riley 1986). Unfortunately, it would be mere speculation to say anything about the improvement in the hygienic conditions (especially the provision of clean water for drinking, washing, and bathing) in premodern China at this stage, and in any event, there must have been enormous regional differences.

However, the early practice of variolation against smallpox is a possible factor in explaining the decline in Chinese mortality. An eighteenth-century smallpox specialist, for example, claimed that over 80 percent of the children of wealthy families in China had been inoculated (Leung 1987b). On the other hand, the majority of children were not inoculated, and clearly, no single factor is likely to serve as an explanation. Avenues of research that may prove fruitful in examining the question of reduced infant and child mortality include changing concepts of pregnancy, childbirth, and infancy (Leung 1984; Furth 1987); the attitudes behind the nationwide establishment of foundling homes; improved hygiene and immunization; and traditional diet therapy based on the humoral dimensions, and the whole folk nutritional science built largely on empirical observation (Anderson 1988).

If we are uncertain of the positive effects of new developments in agriculture, new crops, or variolation on reducing mortality, we can at least be confident that diseases no longer hindered long-term population growth, and that the contribution of disease to the mortality rate was no longer as great as it had been in the past, despite the introduction of some new diseases from the sixteenth century onward. Improved therapy and medication may have played a limited role in reducing the importance of disease, as, for example, the increasing use of herbal-based drugs (before the introduction of quinine in the eighteenth century) to fight malaria instead of the more dangerous arsenicals used in the Ming-Qing period (Miyasita 1979). But like variolation, the effects of herbal-based drugs, probably only used by small sections of the population, are difficult to estimate.

Certain institutional changes may have had some indirect effects on mortality rates. The Song state in the twelfth and thirteenth centuries took responsibility for providing medical help to the poor through public pharmacies. The Mongol dynasty continued this tradition by creating a nationwide system of "medical schools" to train local doctors. Yet, the tradition began to decline in the late fourteenth century, and by the late sixteenth century such institutions had largely disappeared. To some extent, this void was filled by local philanthropists who took responsibility for providing regular medical help to the needy from the seventeenth century on. They organized charitable dispensaries that provided the local people with medical care and medicines, and sometimes decent burials for the dead. These public but nonstate medical organizations could be found in many urban centers in the eighteenth and nineteenth centuries (Leung 1987a), and the free or very cheap medical treatment offered must have provided at least a minimum of necessary care to the urban poor. Moreover, the burying of dead bodies collected from the streets also helped to upgrade the sanitary conditions of these urban centers. According to an 1860 report by the American Presbyterian missionary in Shanghai, John Kerr, the local charitable dispensary, which was staffed by eight or nine Chinese physicians, was visited daily by 300 to 500 individuals "of all classes" (Kerr 1861).

After weighing the many changes that together brought about the mortality decline in China, we find it probable that an improved supply of food, which strengthened the nutritional status of the general population, was the most important factor from the late seventeenth century onward. The spread of variolation and an increasingly denser network of charitable dispensaries in the same period may also have contributed to a reduction in mortality, especially in southern China. Improved hygiene and child care practices were also probably important factors in bringing about what seems to have been a decline in infant mortality rates, but this has yet to be demonstrated.

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