The emergence of a suburban penalty during the 1918/19 influenza pandemic in Malta: The role of a marketplace, railway, and measles.

The Malta 1918/19 influenza experience adds to our understanding of the pandemic by illustrating the importance of suburban populations, their vulnerabilities, and elevated mortality rates. Studies on the socio-geographical variation in the 1918/19 influenza mortality has largely overlooked the suburban experience, and thus the often-hidden heterogeneity of the disease experience is missing. A comparison of mortality rates across the three settlement types (urban, suburban, and rural) for the second wave of the pandemic revealed that there were significant differences across the settlement types (x2 = 22.67, 2df, p <0.0001). There was a statistically significant divide between suburban settlement type versus urban and rural communities. Further, the geographical division of the central suburban region had the highest mortality rate at 4.28 per 1000 living of all suburban regions. A closer examination of the central suburban communities revealed that the town of Birchicara was the driving force behind the elevated influenza mortality, with a rate of 5.28 per 1000 living. The exceedingly high rate of influenza mortality in Birchicara was significantly different from the other suburban communities (Z = 2.915, p = 0.004). Birchicara was notable as both a transmission and burden hotspot for influenza infection because of a unique conflation of factors not observed elsewhere on the island. Foremost, was the pitkali market, which was a produce wholesale distributing centre; second, was the fact that the train station was a central hub especially for Maltese labourers; third, was that the measles epidemic in 1916/17 contributed to elevated childhood influenza deaths because the presence of military personnel and their families. We argue that the interaction of the three factors, and in particular, the measles epidemic with childhood influenza, amounted to a syndemic. Factors associated with urbanization and high rates of infectious diseases, such as overcrowding and infant mortality, did not play a primary role in the syndemic.

Situating mortality: quantifying crisis points and periods of stability.

A wide range of stressors can cause a dramatic and sudden rise in the death rate in populations, typically resulting in what is referred to as crisis mortality. Here we present a method to standardize the assessment of identifying moments of crises. A modification of the mortality Z-score methodology which is combined with time series analysis was used to investigate mortality events over the course of nearly two centuries for two populations: Gibraltar and Malta. A benefit of this method is that it situates the yearly death rate within the prevailing mortality pattern, and by doing so allows the researcher to assess the relative impact of that event against the norm for the period under investigation. A series of threshold values were established to develop levels of mortality to distinguish moments of lower mortality than expected, background mortality, a crisis, and a catastrophe. Our findings suggested that within defined periods, a limited number of events constituted moments of excessive mortality in the range of a crisis or higher. These included epidemics (yellow fever and influenza in Gibraltar only, and cholera) and casualties associated with World War II. Episodes of lower than expected mortality were only detected (although not significant) in the 20th century in Malta, and at the micro level, the harvesting effect appears to have occurred following cholera epidemics in both locations and influenza in Gibraltar. The analysis demonstrates clearly that the impact of epidemics can be highly variable across time and populations.

The Jewish advantage and household security: life expectancy among 19th Century Sephardim of Gibraltar.

Using the historical population of Gibraltar to examine the pattern of mortality of Jews and Roman Catholics revealed that: (1) the Jews exhibited a significantly better health status as measured by life expectancy at birth (47.66 and 47.56 for Jewish males and females vs. 38.10 and 40.89 for Catholics males and females, respectively), (2) most of the disparity is found in the very young age categories and (3) the significantly lower rates of deaths could be attributed to the diarrheal and nutritional complex. Stage two of the research involved the linkage of deaths over a 7-year period relative to their household context as of 1878. Being Jewish, having a servant, having access to a water well in the tenement and residing in a tenement only with other Jews, were all factors that contributed to a higher life expectancy. Our explanation for the enhanced survivorship among the Jews is grounded in economics as well as in an established welfare system, in religious precepts and in secular knowledge of health. One of the more notable and hitherto unobserved findings is that Roman Catholics residing in the same tenements with Jews enjoyed a distinct health advantage. This suggests that a positive amplification effect arose from their co-residence with the Jews.

Tuberculosis mortality and recent childbirth: a retrospective case-control study of Gibraltarian women, 1874-1884.

Prior to the introduction of effective treatment for pulmonary tuberculosis, there was little consensus on the potential health risk of pregnancy among infected women. While, intuitively, pregnancy was viewed as a risk for tuberculosis disease and mortality, early studies could not establish such a link with any great certainty. Our case study combines the methods of family reconstitution and a case-control approach to explore the possibility that the physiological and social strains of recent childbirth and the early mothering of infants may have been risk factors in adult female tuberculosis mortality in late 19th-century Gibraltar. The study is based on 244 reproductive age women who died between 1874 and 1884; some 55% of these deaths were attributed to tuberculosis. The record linkage indicates that almost 12% of the women who died had given birth within the year preceding their death. Factoring in the effects of age at death, marital status, and religion, the logistic regression results indicate that recent childbirth did not increase the risk of tuberculosis mortality among these women.

A matter of privilege: infant mortality in the Garrison Town of Gibraltar, 1870-1899.

The British colony of Gibraltar offers an opportunity to compare the infant mortality rates of the civilian and military populations inhabiting a small-scale urban setting from 1870 to 1899. Both groups shared the same poor-quality housing, the same sanitary infrastructure, and the same environmental inseparability. Sufficient water supply, in particular, proved to be a daily struggle for the families living on the Rock. Privilege for the military meant that service families had preferential access to a pure water supply after the installation of a water-condensing plant as well as to a better quality supply of water and milk. The availability of these privileges to one group, and not the other, is associated with a marked decline in infant mortality in the second half of the study period.