Urban mortality in Greece, 1860–1940

Mortality started to decline among some populations in northern Europe as early as the eighteenth century. Mediterranean Europe, on the other hand, still exhibited high mortality levels even until the beginning of the twentieth century, as a result of the very high infant and/or early childhood mortality, as well as the high prevalence of infectious diseases. A main characteristic of the mortality regime in the nineteenth century were the great discrepancies between rural and urban populations. Cities faced an ‘urban penalty’ which reduced survival probabilities for their inhabitants and resulted in a great number of deaths, most significantly among infants. The main conditions responsible for excess urban mortality included the high population density leading to the rapid spread of infectious diseases and the lack of sanitary reforms. This urban-rural mortality gap seems to have narrowed significantly by the early twentieth century in most European populations and was then followed by an urban advantage.

Only little evidence is available about changes in mortality in modern Greece prior to the 1960s. Apart from a few studies which have attempted to estimate national mortality levels (though on the basis of indirect techniques and extensive assumptions) and several studies that refer to non-urban populations, cover short periods of time, or employ rather superficial demographic methods, there remains a significant lack of studies focusing solely on urban mortality patterns in Greece with a long-term perspective.

In this study, I examine the patterns of mortality decline in the Greek urban centre of Hermoupolis on the Greek island of Syros, and, by employing a variety of sources (i.e., death records, census data, local press, public health reports, and oral interviews), I investigate the pathways that facilitated such decline. Hermoupolis is the capital city of the island of Syros and of the Cycladic group of islands. Hermoupolis, in particular, was chosen not only because it was one of the most important nineteenth-century Greek cities experiencing very high mortality, but also because of the unique civil registration sources which it possesses at the individual level. A series of abridged life tables is constructed for the first time for a Greek urban settlement, enabling the calculation of age- and sex-specific mortality rates and life expectancies (see detailed description of methodology, results, and interpretation here).

Mortality patterns

Mortality in Hermoupolis was much higher than the national average and, moreover, the highest rate calculated for Greece in almost every census year from the mid-nineteenth century until 1940; see figure below. Comparisons of Hermoupolis with other semi-urban and rural Greek populations suggest that an ‘urban penalty’ was clearly operating in Greece even during the first decades of the twentieth century, most likely as a result of insufficient sanitary infrastructure, high population density, bad housing, low living standards, unhealthy working conditions, and in-migration. 

Life expectancy at birth in Hermoupolis is significantly lower than any other available rate that has been calculated for Greek populations. When age-specific death rates are plotted, the generally expected U-shaped curve is clearly visible in every census year for which life tables are constructed; see figure below. 

Overall levels of infant mortality remained remarkably stable, but still at relatively high levels, which did not exceed 200 per 1,000, throughout the first 20-year period; see figure 3. Subsequently, infant mortality followed an increasing trend, which lasted up to the turn of the twentieth century. Such an increase is assumed to have been the product of Hermoupolis’ economic decline, the worsening of working conditions and the very low living standards among the lower strata. During the first half of the twentieth century, infant mortality rate (IMR) followed an almost continuous decline (for a detailed analysis of cause-specific mortality during infancy in particular, see here and here).  Early childhood mortality (1-4 years), on the other hand, was initially at greater levels than that of infants, following the typical Mediterranean model but also that of the major nineteenth-century urban populations, then exhibited a significant decline in the late 1880s. Such decline coincided with the timing of mass immunisation practices which started in the late 1880s and possibly contributed to increasing the survival of those in this age group. 

Confirming the assumptions made by others about the timing of the mortality decline, time series for Hermoupolis show that a declining trend was underway by the beginning of the twentieth century or even the late nineteenth century: young children benefited initially, adults and infants followed. Life expectancy at birth had increased from 36 years in 1861 to almost 46 years of age in 1928. The mortality decline was only interrupted in the years around the 1918/19 influenza pandemic and the arrival of the Asia Minor refugees around 1922, which has been associated with increases in mortality throughout the country; see figure 2. During the 1918/19 influenza pandemic, in particular, mortality increased within every age group, however, young adults and adults experienced the largest excess mortality, while short increases occurred among the very young and elderly due to their pre-existing high mortality risk most likely due to the aftermaths of the 1916-17 naval blockade in the country, which has not been properly studied yet (here).

Why did mortality decline?

A combination of factors was found to be responsible for the mortality decline in Hermoupolis, including changes in the registration system; mass immunisation; improvements in living standards and nutrition among lower strata infants; improvements in maternal literacy; the mortality-fertility interaction during the demographic transition; and wider access to water, as an underground water supply system was introduced in the mid-1920s, and although not expanded across the whole city, it may have enabled improvements in personal hygiene among the residents of the city (for a detailed discussion on public health in Hermoupolis, see here). The study, supports the idea that cultural factors may have played a crucial role in the changes in mortality in Hermoupolis during the period under study. This aspect has been under-examined, or at least underestimated, in previous demographic studies, but it seems to be of very special importance in Greece.