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Water, Race, and Disease

Author(s):Troesken, Werner
Reviewer(s):Brown, John C.

Published by EH.NET (June 2005)

Werner Troesken, Water, Race, and Disease. Cambridge, MA: MIT Press, 2004. xvii + 251 pp. $35 (cloth), ISBN: 0-262-20148-8.

Reviewed for EH.NET by John C. Brown, Department of Economics, Clark University.

Werner Troesken’s Water, Race and Disease challenges a key element of the standard historical view of the Jim Crow era, which lasted from about 1900 to the 1960s. Historians of this era have documented the pervasive legal discrimination that African-Americans faced in those aspects of their lives that were touched by public policy and government-provided services, most notably education. Historians generally concur that state-sponsored discrimination also harmed the health of African-Americans. Assuming that water and sewer service were key influences on improvements in health during the first forty years of the twentieth century, many historians go on to infer that African-Americans also faced discrimination in the provision of these key elements of urban infrastructure. This book offers an overdue corrective to this perspective. It argues that in the clash between the ideology of separate but equal and the reality of disease externalities and scale economies, the interest of public health won out. African-Americans may have benefited more than white residents from the massive investments in water supply and waste removal that transformed American cities. The book’s approach offers an exemplary contribution to the economic history of American cities.

Water, Race and Disease focuses primarily on the period from 1900 to the early 1920s. By the end of this period, most American cities had completed the task of installing sanitary infrastructure. Troesken lays out the argument in three steps. First, he develops both qualitative and quantitative evidence that the net costs of discrimination were high, particularly for the relatively integrated cities of pre-1920s America. Spatial integration and the presence of large numbers of African-American (domestic) workers in white homes created the potential for disease spillovers from underserved (poor) African-American neighborhoods to the (non-poor?) white community. For that reason, sanitary reform everywhere in the city had significant external benefits. The cost savings from discriminating in the provision of infrastructure were modest. Second, Troesken marshals the available evidence on black-white differentials in overall mortality, typhoid mortality and “water-borne” disease mortality to test for the impact of various innovations, such as the installation of water filtration systems, on differences in black and white mortality. He concludes that blacks disproportionately benefited from such investments. Finally, based upon some admittedly fragile evidence for a rapid decline in black mortality in urban areas during the 1900 to 1940 period, he argues that water supply measures and the provision of sewers played a key role in the decline.

The most effective arguments concern the high implicit price that (white and southern) urban areas would have incurred had cities attempted to discriminate in the provision of sanitary services. The first part of the argument (presented in chapters 4 through 6) focuses on the external benefits of better sanitation. The discussion examines primarily the transmission of typhoid fever, which could be spread through ingestion of water or food contaminated with fecal matter that contained the typhoid bacillus. A fascinating account of the case of Jacksonville, Florida suggests that flies from unscreened privies could also serve as indirect sources of contamination. Unequal provision of sanitary services in an urban area could lead to spillovers from (black) areas with inadequate provision for disposing of human waste (and high rates of endemic typhoid) to areas with a lower-risk environment. The spillovers would be strongest where blacks and whites lived closely together or where blacks worked in close proximity to whites, perhaps as domestic help. Appeals to spillovers couched in racial terms were an essential part of the rhetorical arsenal of proponents of sanitary reform in southern U.S. cities, just as the rhetoric of reform appealed to fears about the sanitary and moral habits of immigrant hordes in northern U.S. cities and of the lower classes in western European cities. Black mortality rates from typhoid were also 40 to 70 percent higher than white rates. Evidence from the success of the Jacksonville campaign to screen privies provides the strongest evidence for spillovers. After the campaign, typhoid rates fell substantially for both groups, but the strongest decline was for African-American residents. Regression evidence for the spillover hypothesis is patchier, primarily because of the lack of controls for other variables (in- and out-migration) that are known to be correlated with typhoid rates and may have also been more strongly correlated with typhoid among African-Americans than among whites. Some specification issues also arise when using lagged dependent variables.

The other part of the argument notes that the economics of constructing sanitary infrastructure raised the cost of discrimination. By the standard of 1970, neighborhoods in1900 were racially integrated. There would be few savings from restricting water mains and trunk sewer lines to white neighborhoods. The low marginal cost of attaching any one home (including the home of an African-American) also meant that excluding African-Americans saved cities very little Troesken develops direct evidence for the absence of discrimination by laboriously matching known information on sewer and water provision and comparing served areas with the racial patterns of residence in Memphis and Savannah (in chapter 4). He also draws on data from the 1896 “Negro mortality project” for evidence subject to statistical verification. The argument is weaker in discussing the economics of constructing and paying for these systems. They clearly offered substantial scale economies. Discriminating against a large number of potential (black) users would shift fixed and quasi-fixed costs onto a smaller number of white users. An explicit comparison with the cost consequences of maintaining separate school systems — with constant returns to scale and substantial scope for differentials in quality — would be helpful. The other issue at the core of community decision-making about infrastructure is finance. Water supply systems resulted from a mix of public and private provision. They could be self-financing private or public utilities or they could be subsidized by other tax sources. Sewers could be financed by one-time hook-up fees, the general property tax (much more common in the South), assessments on the increase in property value (betterment) or ongoing sewer connection charges. Cities also varied on whether they would require mandatory connection to the sewer or water supply system. The choices cities made on these questions bear directly on the implicit cost of discrimination. Tracing out these details for a few selected cities would help to firm up this part of Troesken’s argument. Establishing causality between integration and sanitary reform is also challenging. One would expect the most integrated cities to have the highest amount of potential benefits (highest spillovers), but also the strongest incentives on the cost side to invest in advanced infrastructure early one.

The second part of the argument concerns the significance of the separate and equal provision of sanitary services and is presented in chapters 6 through 8. To understand this part of the argument, it is important to recall that centrally-supplied water and sewer systems were not synonymous with sanitary health in the United States. With per capita incomes at least fifty percent higher than in Europe, American cities were generally well ahead of cities in Europe in providing piped water to residences, more often than not from surface water sources that were plentiful and relatively inexpensive to tap into. Inexpensive piped water eased a key constraint on the installation of flush toilets, which were installed at a faster clip than in Europe. Various systems of private and public sewers were installed to serve the flow of wastewater generated by flush toilets. These often emptied into the same surface waters that served as the source for piped water. Although American cities were ahead of European cities in providing the most modern of conveniences, many were behind in the battle against typhoid.

Troesken makes the plausible argument that once informed of the potential lethality of piped tap water, higher-income (and white) residents of cities would have been more likely to engage in averting behavior, including boiling tap water, filtering it, or purchasing it from alternative sources. Ocular regressions of trends in black and white typhoid rates before and after installation of filtration systems or chlorination in several cities lead to the conclusion that racial differences declined substantially after interventions. Regressions of typhoid mortality rates or mortality rates from typhoid and diarrheal disease (“water-born disease”) confirm the importance of filtration in reducing mortality; more often than not, the impact was stronger on African-American mortality rates.

This result forms the basis for Troesken’s strongest claim about the significance of sanitary reform, which is presented in the first three chapters of the book. It goes something like this. The gap between urban and rural black mortality was significant at the beginning of the twentieth century and fell rapidly by 1920-1940, so that while inter-racial differences remained large, urban versus rural differences among African-Americans had disappeared. Drawing upon the claims by turn-of-the-century reformers and subsequent studies that one life saved from a premature death from typhoid resulted in many times that number in reduced overall mortality, Troesken presents an argument that reductions in typhoid and other “water-born diseases” may have been primarily responsible for the overall convergence of urban black mortality with rural black mortality. That would be a significant finding. Economics and externalities trumped the ideology and practice of Jim Crow.

This conclusion is open to a critical appraisal. Data problems make the task of understanding trends in race-specific mortality rates very challenging even for the first third of the twentieth century. Many U.S. cities were well in advance of the Europeans in installing the most modern of conveniences, but they were woefully behind them in developing an adequate statistical understanding of mortality trends. Britain established unified civil registration of births and deaths in 1837. Consistent registration of mortality only began in the early 1900s in a small number of American states known as the registration area. Registration of births only began in 1915 in the birth registration area, which was also confined to a limited number of states. Unfortunately the southern states, which were the home of most of the nation’s urban and rural African-American population, became part of the registration area relatively late (in the 1920s). Only with the entry of Texas into both systems in 1933 did the United States finally achieve a unified system of registration

Based upon the data that are available (from registration and the 1900 and 1910 censuses), Haines (2001) and others have been able to piece together a long term view of black and white mortality. The evidence suggests that life expectancy at birth for African Americans in 1900 was ten years shorter than the life expectancy for whites. Although it showed some improvement, the black-white gap increased so that it peaked at twelve years in 1930. Then it began its historic decline. Immense differentials in infant and child mortality drove much of this gap. The difference was highest in urban areas, and was closed by 1939 only for blacks living in cities with a population over 100,000. Paradoxically, the most dramatic differentials ca. 1900 were in middle to large northern cities, which may have been more segregated than cities in the south (Preston and Haines, 1991), but which also included a tiny share of the urban African-American population.

As Troesken notes, high infant mortality stemmed primarily from diarrheal disease, which we now know is transmitted primarily through direct contact with fecal matter. Investigations of the conditions that led to high rates of infestation of southern residents with hookworm in the ‘teens revealed sanitary conditions on par with some very poor developing countries today; under such conditions, installation of any kind of latrine can mark a dramatic improvement in the treatment of human waste. Sanitary conditions were very poor in rural areas of the south, but apparently just as inadequate in some urban areas. In the face of such conditions, untainted tap water would have helped, but would not have eliminated the exceptional risk of infant death. As Troesken’s regression evidence suggests, flush toilets would have also helped, but only if they also ensured adequate disposal of waste from infected infants and children. Breastfeeding, campaigns for clean milk, and other efforts may have also played a role.

Water, Race and Disease offers an invaluable example of high-quality urban economic history. The recent surge of interest in this field of is long overdue; it has suffered from neglect despite the critical importance of urbanization for the economic history of developed countries. One reason is that writing urban economic history faces a unique challenge. Urban history is fundamentally the history of localities, and urban historians have uncovered most of their insights with detailed case studies of rich veins of documentation available for individual cities. At the same time, urban places share common histories because of the common economic forces — economies of localization, migration, and allocating scarce urban land among competing users — that shape them. Troesken’s able use of case study evidence and his statistical analysis of myriad cross-city datasets highlights the gains from integrating both approaches. It sets a standard for writing the economic history of urban areas.


Michael Haines (2001), “The Urban Mortality Transition in the United States: 1890-1940,” NBER Working Paper H0134.

Samuel Preston and Michael Haines (1991), Fatal Years: Child Mortality in Late Nineteenth-century America. Princeton: Princeton University Press.

John C. Brown’s recent publications include “Estimating the Comparative Advantage Gains from Trade: Evidence from Japan” (with Daniel Bernhofen), American Economic Review (March, 2005); “A Direct Test of the Theory of Comparative Advantage: The Case of Japan” (with Daniel Bernhofen), Journal of Political Economy (February, 2004);”Working Class Careers: On-the-Job Experience and Career Formation in Munich, 1895-1910″ (with Gerhard Neumeier), in John C. Brown, David Mitch, and Marco Van Leeuwen, editors, Origins of the Modern Career: Career Paths and Job Stability in Europe and North America, 1850-1950 (Ashgate, 2004); and the entries “Public Health,” “Sanitation,” and “Water Supply,” in Joel Mokyr, editor, Oxford Encyclopedia of Economic History (2003).

Subject(s):Urban and Regional History
Geographic Area(s):North America
Time Period(s):20th Century: Pre WWII