Health Policy

The “Antebellum Paradox”: What is it and why it matters.


I recently made the case that “Health is foundational to a functioning democracy. But health must be shared and be broadly accessible to be an effective enabler of good government.” I also suggested that the pursuit of good health is implied and imbedded in the aspirational and idealistic wording of our U.S. Constitution, and that the active pursuit of health as a nation is essential if we wish to rise to Hamilton’s challenge in Federalist #1 and prove that we are “capable of establishing good government from reflection and choice.” So why are native white males lagging behind in health?

Our progress as a nation toward health was severely hampered from the start. The reality of self-government “of the people, by the people, and for the people” applied only to 6% of inhabitants, all white male land owners at the time. Health was never voiced as a priority, though modern day critics insist it is clearly implied in the promise of “life, liberty, and the pursuit of happiness.” But what was that promise worth in the late 18th century, in a nation that allowed slavery, disenfranchised women, and slaughtered and dislocated its indigenous brothers and sisters?

In those earliest years of the birth of this nation, in the first half of the 19th century, what was the state of health for enfranchised native born white citizens of this nation? Most may presume (as I did) that the general health and standard of living over the next two hundred years, as reflected in lifespan, was a straight (if gradual) upward slope. But what I learned from a bit of digging is that uncovering the facts on mortality, fertility, migration, and population growth during those early years of our nation is a complex venture at best.

Our federal government did conduct a census every ten years, but one hundred years passed before we reliably collected vital statistics including comprehensive birth and death registration. Beginning in 1850, age, sex, race, marital status, occupation and cause of death were supposed to be collected. But an audit in those years disclosed that mortality (for example) was 40% underreported.

This was not too surprising when one considers what can go wrong with a census even on a blunt entry like death. Solitary household death left no one to report. Loss of a household lead in a large family often meant dissolution of family members. Deaths of infants or elders within 6 months tended to be reported, but after 12 months they were often forgotten. And all of this was made worse by westward migration.

The earliest life tables date back to 1790 in Massachusetts. These can not be extrapolated as representative of the colonies, or growing nation as a whole, because this small northeastern state was largely urbanized, industrialized, filled with immigrants and had lower levels of nuptiality and fertility (1/3 lower than the nation) compared to their neighbors.

To fill in the gaps over the years, academic experts have turned to alternate data sources including family genealogies, biographical data from schools and local legislators, and height as a reflection of nutritional status and general health. By using these sources, and integrating different databases, modern day historians and economists now agree that there was “a significant increase in (native white male) mortality in the antebellum era, especially in the three decades between 1830 and 1860.” 

Termed the “antebellum paradox”, life expectancy at age 20 was six years lower in 1850 than in 1800. In fact, the nation didn’t catch up with 1800 survival rates until 1880. And the question is “why?” What happened to early American health? On average white males between 1830 and 1890 lost 1 1/2 inches in height which experts suggest may have been from a combination of deteriorating diets, early industrialization and urbanization resulting in spread of infectious diseases and traumatic injuries, rising inequality and mass populations on the move westward with the “transportation revolution” utilizing canals, steamboats, and railways.

Other factors that experts have pointed to include the congregation of young children in new public schools aiding the spread of whooping cough, diphtheria, and scarlet fever, and food shortages and elevated food prices in the 1830’s.

The United States of 1860 bore little resemblance geographically to the 1790 version of our nation. Its size had increased from 891,364 square miles to 3,021,295 square miles. Our 16 states had grown to 33 states. And the average center location of our population had now shifted 135 miles west of where it had been.

If it is difficult to quantify life expectancy for white males in the 19th century in America, it is even harder to gauge white female survival. In general, women were often ignored in public records. Their names changed with marriage, and they routinely disappear from observation during these years. What has been pieced together is that white women’s life expectancy in the mid 1880’s at age 20 trailed white males of the same age by about 2 years. This male advantage disappeared by age 35 if a woman survived to that point. 

With up to 10 material deaths per 1000 live births at the time, marital fertility tracked with maternal mortality. But experts believe that tuberculosis was an equal or greater contributor to death in child-bearing women, especially in rural settings. Where food was limited, men and boys were favored with meat and calories. Pregnancy and lactation were nutritional drains, weakening women’s health status and ability to withstand infectious diseases, especially tuberculosis. As for the children, 1 in 5 born alive in 1850 didn’t survive to age 1.

By 1880, the gender gap began to disappear with increased industrialization, urbanization, imposition of public health measures to create clean water and pasteurized milk as the germ theory and sanitation took hold. Women now entered the work force. In addition, fertility in 1900 was about half that in 1840.

The “antebellum paradox” suggests that the health of a nation, as reflected in life expectancy, is fungible. It also can be argued that health status is a reasonable measure of whether a society of humans is “capable of establishing good government from reflection and choice.”

Ohio State University’s Emeritus economic historian, Richard Steckel,  used to ask his students to imagine they were reborn and had to chose their place of birth based on only three of following characteristics: “access to material goods and services; health; socio-economic fluidity; education; inequality; the extent of political and religious freedom; and climate.” It is notable that health and income always scored at the top.

As for human stature in modern times, America’s native white men have stagnated, with average height essentially flat over the past 50 years. This is in contrast to European nations like Norway, Sweden and Denmark with similar genetic stock.  They are two inches taller. All of these nations have national health care systems. Specifically, all are “known for regular pre-and post-natal checkups, which are important for early childhood health.” 

As Steckel reminds us, “We know that on average, stunted growth has functional implications for longevity, cognitive development, and work capacity….it is important to know why Americans are falling behind.”

Mike Magee MD is a Medical Historian and author of “CODE BLUE: Inside the Medical-Industrial Complex.”