CAIRN-INT.INFO : International Edition

1Which social groups are the first to profit from medical progress? Is the medical profession in the best position to reap the gains of accumulated knowledge and avoid premature death? These questions are relevant today, but even more so for earlier times, when only a minority had access to medical know-how and the benefits it procured. Using extensive historical databases covering the last four centuries in the Netherlands, Frans van Poppel, Govert Bijwaard, Mart van Lieburg, Fred van Lieburg, Rik Hoekstra and Frans Verkade compare the life expectancy of medical practitioners with that of other privileged social groups, including nobles, notable persons, artists and clergymen. Their findings show that direct access to medical knowledge does not guarantee better health, and that difficult living and working conditions may have partially cancelled out the medical practitioners’ advantage.

2In recent debates about the “Rise of the West”, and the start of modern economic growth during the Industrial Revolution, a lot of attention has focused on the role that rising life expectancy may have played in this process by facilitating knowledge accumulation (Bar and Leukhina, 2010) or providing incentives to invest in human capital (De la Croix and Licandro, 2013), for example.

3Most demographers are of the opinion that mortality in European countries did not start decreasing until the late eighteenth century (Caselli, 1991; Floud et al., 2011; Livi Bacci, 1991; Vallin, 1991). Using estimates on adult life expectancy from a variety of sources, Gregory Clark even argued that “the average person in the world of 1800 was no better off than the average person of 100,000 BC. … The lucky denizens of wealthy societies such as eighteenth-century England or the Netherlands managed a material lifestyle equivalent to that of the Stone Age. … Life expectancy was no higher in 1800 than for hunter-gatherers: thirty to thirty-five years.” (Clark, 2007)

4Yet the idea that life expectancy was quite stable until around 1800 has been questioned on the basis of information on the selected population groups that have left the clearest evidence of their lives. Using comprehensive data on the nobility from a variety of countries covering a much longer period than is usually the case, Cummins (2014) was able to show that life expectancy began increasing long before the Industrial Revolution. Using an impressive amount of data on famous people, De la Croix and Licandro (2015) showed that permanent improvements in their life expectancy first became visible in the generations born around 1650 and occurred in almost all (elite) occupations. Information from a very large database of visual artists (a middle-class group) in the Low Countries confirmed this finding (Van Poppel et al., 2013). Yet there is still a lack of data on changes in life expectancy among other population segments.

5An additional reason for seeking data on non-elite groups is that by identifying groups which acted as forerunners in the mortality decline, researchers might find important clues as to why mortality declined. After all, the main causes of the post-1800 increase in life expectancy are still being debated, and those of the possible pre-1800 upturn even more so. A series of factors such as rising incomes, better nutrition, and health measures have been put forward to explain the nineteenth century rise in life expectancy. While the contribution of medical science and the medical profession figured prominently in studies published in the first decades of the twentieth century (Buer, 1926; Griffith, 1926), from the 1970s onward, the role of medical progress was strongly downplayed (Colgrove, 2002; McKeown, 1976a, 1976b; Wootton, 2006). Yet De la Croix and Licandro (2015) hypothesized that medical progress was indeed one of the driving forces of the pre-1800 life expectancy increase. Ryan Johansson (2010) also drew attention to the role of medicine in the long-term pre-1800 mortality decline. In her view, between 1550 and 1750, various forms of useful medical knowledge became available, improving the chances of survival of the wealthy elites with enough money to be treated regularly and frequently by professional physicians. By implication, she argues, the history of the modern rise of life expectancy in the West should begin with the study of elite mortality, i.e. those “exceptional” groups that produced and delivered disease-specific knowledge, and the wealthy elites who were in a position to command their services.

6In line with this suggestion, we study here the development of life expectancy among members of the medical profession in the Netherlands over a long period of time, stretching from the sixteenth to the twentieth centuries. We compare their life expectancy with that of groups which, in some respects, were on equal standing because of their social background and education. The focus on the medical profession allows us also to test the proposition that a growing body of medical knowledge brought a survival advantage to this group. After all, doctors could apply their superior medical knowledge not only to their patients, but to themselves and their families as well, thus producing an earlier and/or faster increase in their life expectancy than observed among other groups.

7We restrict our study to male mortality at adult and older ages. According to Johansson, until the late 1600s when the formal “medicalization” of elite infants and children first began, physicians mostly treated adults. Within this group, the specialized treatment of diseases specific to women was relatively neglected until after 1800. Given that the medical conditions of adult men appear to have been a stronger and earlier focus of treatment than that of children and adult women, and that the number of women in the medical profession and in other professional groups was extremely limited, this narrow focus on adult males is warranted.

I – Medical professions in the Netherlands, sixteenth to twentieth centuries

Medical progress and mortality decline

8Current-day historians of medicine are skeptical about the existence of practical medical progress before the twentieth century. The picture that emerges from studies on the life expectancy of specific groups, such as the aristocracy and the upper bourgeoisie, is that only during the course of the eighteenth century did the most privileged groups acquire an advantage over the rest of the population (Livi Bacci, 1991). Until then, most health risks affected the entire population, without real opportunities for escape. However, Ryan Johansson argues that a substantial body of evidence supports the view that a growing corpus of useful medical knowledge was produced in Europe from the sixteenth century onwards and that it accelerated rapidly by the 1700s. This included contributions to both “public health” (defined as the prevention and containment of epidemics) and “private health”. For example, as early as the 1200s, Europe’s leading physicians began to advise royal and elite patients that they could delay the onset of chronic diseases, and thus live longer, by making healthy lifestyle choices. This included advice to eat simple food in modest amounts, drink alcohol only in moderation, get enough sleep, and avoid emotional excesses. A “cure” for syphilis – a medicinal powder made from the sarsaparilla root – became more common in the 1600s and offered a means to slow the progress of the disease and lengthen the time between diagnosis and death. Knowledge that scurvy could be cured by consuming oranges was acquired by innovative physicians in England in the early 1600s. Malaria was treated with imported cinchona bark. Royal physicians began giving their patients “public health” advice by encouraging them to flee local outbreaks of the plague, and to spend as little time as possible in unhealthy places. They encouraged their patients to bathe frequently, cultivating the belief that cleaner houses were healthier than dirtier ones, and advised them to keep flies off food and bugs out of beds. And, finally, inoculation became available to the rich and later to the poorer sections of the population. Ryan Johansson concluded that innovative medicine in early modern Europe managed to make disease-specific progress, and delivered that progress to elite patients so effectively that by circa 1700 a set of acute diseases that were once prevalent and deadly among adults, could be prevented, managed, or cured. By the late 1600s, “after a surprising amount of useful, health-related knowledge had been produced”, adult royal life expectancy showed signs of increasing. Compared with earlier cohorts, members of Britain’s royal families born during the eighteenth century survived much longer, on average, than their forerunners.

Mortality among the medical profession

9How does the mortality of physicians fit into this picture? Are there any indications that they enjoyed a relatively high life expectancy earlier than other groups?

10The health of physicians has been of interest to health professionals themselves for a long time in many countries (Woods, 2000). [1] A pioneer in this area was Bernardino Ramazzini (1633-1714), who, on the basis of his extensive clinical experience, described the relationship between occupation and illness in his De Morbis Artificium Diatriba (1700), a book that was translated into many languages. One chapter was devoted to the illnesses of the literati, among whom physicians figured prominently. Clear patterns in the mortality of physicians became visible only from the early 1830s (Casper, 1834; Thackrah, 1832), when unordered casuistry was replaced by studies based upon statistical data on mortality and causes of death (Van Lieburg, 1986). Numerous studies on the mortality of the medical profession were then published in many European countries (Westergaard, 1901). Léonard (1978) gave an impressive overview of local studies published in France in the nineteenth century. For the city of Paris, for example, Jacques Bertillon compared age-specific death rates for medical doctors in the age range of 20-60 years for the period 1885-89 with those of several other liberal professions (Bertillon, 1892).

11Most historical studies concluded that physicians had a higher mortality than comparable professions. In explaining this pattern, reference was often made to the study by the famous Berlin professor of forensic medicine Johann Ludwig Casper. In his opinion, there was no profession that made such a strong demand on the physical and mental forces of a person as the medical one; not a single other profession that allowed its members only irregular and incomplete nights of rest. Physical exertion, exposure to all weathers, night-time call-outs, interrupted meals and strong emotions of all kinds worked together to damage physicians’ health. Medical professionals also ran much higher risks of succumbing to epidemics: “their profession brings them directly and repeatedly into contact with all infective agents, and because their assistance is sought again and again and from all sides at the same time, the irregular and excessive efforts exhaust them so that they are fated to be infected more easily than anyone else” (Zeeman, 1856b, p. 65). Casper’s ideas also figured prominently in Dutch studies on the mortality of physicians (Büchner, 1852; Dompeling, 1882; Zeeman, 1856a).

12Generally, these older studies are based on very small numbers, so the results are subject to large random fluctuations. They use rather crude indicators of survival, such as the average age at death of medical professionals in a given period, or the age distribution of the medical profession at a certain point in time. The lack of information on mortality in comparable population groups is also a problem. Physicians in many countries generally had, and still have, a high social status, high levels of education and above-average income. As their membership of higher socioeconomic groups will have affected their mortality, comparing them with the general population does not reveal the beneficial or detrimental effects of their profession, their special knowledge and skills for survival. Several studies have therefore tried to collect information on the survival of groups with comparable levels of education and status, the protestant clergy in particular.

13These studies hardly ever take time trends into account, although there are some exceptions. Hill, for example, studied birth cohorts of physicians included in the Roll of the Royal College of Physicians of London. Between birth cohorts 1570-1689, 1690-1749 and 1750-1799, expectation of life at age 35 increased from 30.3 to 32.1 years and then to 35.3 years. The physicians lived one to two years longer than English peers, an outcome explained by the “simpler life” they lived, their easier pursuit of “the even tenor of their way”, and by selection effects (entering the profession demanded a certain level of health and acquired immunity) (Hill, 1925). For the German city of Esslingen, in the state of Württemberg, Salzmann (Salzmann, 1885) calculated the average duration of life of (a very small number of) physicians over a long period. In the sixteenth century, their average duration of life (at birth) was 36.5 years; in the seventeenth century 45.8; in the eighteenth 49.8, reaching 56.7 years in the nineteenth century. This increase was ascribed to the disappearance of the plague and fewer epidemics of typhus, diseases which formerly decimated medical practitioners.

14Weinberg compared the life expectancy at birth of physicians in the German state of Württemberg in birth cohorts 1785-89 (58.2 years) to 1836-55 (61.1 years), and concluded that only a small improvement of around 2.7-2.9 years could be observed over time. At age 25, physicians had almost the same life expectancy as the state’s population at large but lagged five years behind the Protestant clergy (Weinberg, 1897). Whereas the clergy experienced a clear increase in life expectancy over time, the physicians did not, partly as a result of increased competition among the members of this group and their growing concentration in large cities. The better health of the clergy from the start of their career due to factors inherent to their training period, their comfortable income, their simple and orderly life, and the fact that their work was not physically demanding were among the factors that explained their favourable position. Weinberg also compared his findings on Württemberg with those of studies in Denmark, England, Norway and Switzerland, prompting him to conclude that the increase in life expectancy among physicians in the nineteenth century ran mostly in parallel with that of the general male population.

The social standing of the medical profession in the Netherlands

15The medical profession in the Netherlands is an interesting case to study as the country was long considered to be a forerunner in medical education. Teaching at university level began in the late sixteenth century with a curriculum that was considered relatively advanced (Lindeboom, 1970) and that attracted many students from abroad. Boerhaave was called the “common teacher of Europe” (Lindeboom, 1970). From around 1800, the Netherlands moved towards homogeneity of the medical profession and a fixed level of standards of practice, acquired through education and training. In this way, the profession exercised tight control over entry into its ranks (Schepers, 1991). The country gradually conformed to the model curriculum of medical education that became common to most European countries around 1940 (Luyendijk-Elshout, 2004).

16From the first half of the sixteenth century, alongside academically educated practitioners, the medical profession in the Netherlands included two other groups who differed from the university trained physicians by the legal status of their members, the education and training they had received and the functions they performed. These were the simple barber-surgeons, and an intermediate class of surgical men who had received medical training from a guild in accordance with the regulations of municipal and surgeons’ guilds. Before admission to the guild, apprentices had to take an examination before the masters of the guild (Van Lieburg, 1983a).

17After abolition of the guilds in 1798 (Frijhoff, 1985), a law was introduced in 1818 to regulate the issuing of medical licenses. It created a clear legal boundary separating the unqualified from the qualified practitioners and reinforced an already existing division between academically qualified medical practitioners and those with a non-academic training. The university-educated doctors received extensive theoretical training, and generally earned a higher income and enjoyed a higher status than the non-graduates, who were trained by apprenticeship and/or by attending a private or clinical school to prepare for the examination (Van Lieburg, 1985; 1983b). These categories of medical men performed different functions: the doctors in medicine diagnosed complaints, prescribed treatments and attended and advised, while the surgeons offered craft and manual skills (Van Lieburg, 2014).

18The authority of the medical profession was regulated again in 1865. All medical students would henceforth be required to test their knowledge of theoretical and clinical practice by taking a state examination which conferred the authority to practice in all fields of medicine. The requirements for the examination could be met only by attending the universities (Van Lieburg, 1999).

19In the social stratification system of the Republic (1588-1795) (Groenhuis, 1977), the medical profession ranked highly but the prestige of the various groups of medical practitioners differed widely (Frijhoff, 1983a). The university-trained physicians holding a medical doctor’s degree stood clearly above other practitioners. They predominantly came from the highest layers of the lower middle class and the bourgeoisie. Their prestige was above all determined by the societal consensus on the superiority of intellectual over physical work, of knowledge over skill (Frijhoff, 1983b). In the eighteenth century, medical doctors became part of the more compact and homogeneous middle group of professions, together with clergymen, the upper middle class of merchants, surgeons and army officers (Frijhoff, 1983a). Protestant clergymen are therefore suitable candidates for comparison with the life expectancy of the medical profession. Their social position in the period of the Dutch Republic has been studied extensively (Buisman, 1992; Groenhuis, 1977). From the early seventeenth century, almost all Dutch Reformed ministers were university-trained theologians (Van Lieburg, 2003), and were thus equal to university trained medical professionals in terms of education. They mostly came from families of the bourgeoisie, but many country pastors belonged to, or at least originated from, the lower middle classes (Bots et al., 1979). Their incomes were generally rather modest.

II – Data and method

Information sources

20The life expectancy of medical professionals is estimated from information on dates of birth and death in a database of the medical professions in the Netherlands over the period 1450-1950, developed by Mart van Lieburg. Data are based, among other things, on a variety of local sources about practicing medical professionals, such as lists of medical doctors admitted by the Collegium Medicum; yearbooks of (barber-) surgeons’ guilds; printed and hand-written lists of locally practicing medical practitioners, information on students graduating from the departments of medicine of all universities and those who passed the examination after training in one of the clinical schools. Information was also collected on all persons responsible for the training of students in medicine at the universities, the clinical schools and in the various urban training facilities. As information on medical practitioners who were members of the surgeons’ guilds is missing for the period before 1800, and as information on military health officers is not yet complete, our dataset for the cohorts born before 1750 predominantly consists of university-trained doctors.

21The life expectancy of Protestant ministers is estimated by means of databases that cover practically all clergymen practicing from 1572 until 2004 within the borders of the Dutch Republic and the Kingdom of the Netherlands. One database provides information on all Reformed ministers born in the period 1572-1749 (Ter Braake et al., 2015). The database was compiled on the basis of printed records of ministers kept by the classes, the regional bodies of the Dutch Reformed Church, since 1695, and the primary source publication of the Classical Acts (including lists of ministers) between 1572 and 1621. For the birth cohorts of 1750 and later, we made use of a database called, developed by Frans Verkade, which includes dates of birth and death and dates of entry into the profession for clergymen born between 1 January 1750 and 31 December 1909. It is partly based on the same sources as the aforementioned database, but supplemented with information on dates of death from ecclesiastical and civil registers, family and newspaper announcements, and genealogies covering all Protestant congregations.

22We supplemented our data on life expectancy of medical professionals and protestant clergy with comparable data on three other groups: Dutch visual artists, a group of notable persons, and the nobility and the patriciate (the urban political elite). Life expectancy for visual artists is deduced from a database called RKDartists containing information about Dutch visual artists from around 1200 to the present. As was the case for the non-university trained medical practitioners, it was the guilds that traditionally provided a framework for the training of visual artists, who were generally self-employed and operated much as a craftsman would. Information on their life expectancy thus reflects that of the lower middle classes of their time (Van Poppel et al., 2013). The information on notable persons comes from the Biographical Portal of the Netherlands, [2] which contains biographical information on notable persons in Dutch history from the earliest times up to the present. They come from a variety of mostly high- or medium-ranking status groups, that included people prominent in religious organizations, industry, the armed forces, politics and the administration. Finally, several published small-scale studies contain information on pre-1800 expectation of life at age 20 for the nobility and the patriciate. The data concern the patriciate of Leyden and Zierikzee and the nobility in the former provinces of Friesland, Holland, Guelders, and Utrecht (Van Poppel et al., 2013). Although some members of the nobility and patriciate may have been included among the “notable persons” (unfortunately, this cannot be checked as we do not have the underlying individual records for the nobility and patriciate), the groups as a whole differ from each other.

23For all of these databases, we used the period of birth as the classification principle. Periods of births were constructed without any prior assumptions about factors affecting changes over time in life expectancy at age 20 or 25 and with only the numbers of persons available in each category in mind. Table 1 summarizes the sources used in the study and Table 2 gives the number of cases in the various datasets. It shows that from 1600 on, sufficient numbers are available to estimate life expectancy for the medical profession and for all other social groups.


24Using the previously discussed sources to estimate the life expectancy of the medical profession compared to that of other social groups is not without problems. First of all, selectivity is an issue. For various datasets we do not know at what age exactly the event took place that allowed a person to enter the risk-set. Unlike medical doctors graduating from a university, “famous” artists or “notable” people do not usually have a clear age at which their risk of dying as a “famous” person started. One becomes famous by building a reputation based on a series of activities or a collection of works. By definition, famous people have a zero-mortality risk before they are “famous” and this period must not be included in the risk-set for mortality. For visual artists as well as for notable persons, the inclusion of a person presupposes that some of his work or activities have survived. This inbuilt survival advantage for the best-known persons is an example of what is called “survivor treatment selection bias” (Hanley et al., 2006; Suissa, 2008). This type of bias is not a problem for medical professionals and ministers, as information was collected even on people who worked only briefly in their profession.

25The reliability of the information in the various databases is another issue. Although most people in this selection come from sources of high quality and their life data are well known, dates of birth and death might have been misclassified. Specific years of birth and death are sometimes not given in the database, but simply a range of years. The cases where only the approximate periods within which a person is likely to have been born and/or is assumed to have died are reported, present a problem. By assuming a parametric statistical distribution, such as the Gompertz distribution for the length of life, these approximate birth and death dates are nevertheless sufficient to derive life expectancies.

Table 1

Characteristics of the data used in this study

Table 1
Medical professionals Protestant ministers Notable persons Visual artists Nobility and patriciate Life expectancy estimated on basis of Individual records with dates of birth and death Individual records with dates of birth and death Individual records with dates of birth and death Individual records with dates of birth and death Published studies based on aggregated individual records Sources Local sources about practicing medical professionals: yearbooks of surgeons’ guilds; information on students graduating from university departments of medicine or passing clinical schools’ examination Printed minister records of the regional bodies of the Dutch Reformed Church, Classical Acts, ecclesiastical and civil registers, family and newspaper announcements, and genealogies Biographical Portal of the Netherlands containing biographical information on notable persons in Dutch history, based on ecclesiastical and civil registers, family and newspaper announcements, and genealogies RKDartists, a database with information about Dutch visual artists, based on ecclesiastical and civil registers, family and newspaper announcements, and genealogies Published studies on nobility of provinces of Utrecht, Guelder, Holland and Friesland and patriciate of cities of Zierikzee and Leijden birth cohorts 1550-1910 1550-1910 1500-1910 1550-1910 1500-1899

Characteristics of the data used in this study

Table 2

Number of observations of condensed groups by birth cohort, males, period 1500-1909

Table 2
Period of birth Medical professionals Protestant ministers Notable persons Visual artists Before 1600 80 557 961 1,104 1600-1649 341 1,276 730 1523 1650-1699 346 1,626 794 633 1700-1749 458 1,875 940 655 1750-1799 1,558 2,250 1,424 1,199 1800-1849 4,106 3,026 1,676 2,615 1850-1899 6,147 3,562 1,885 4,756 1900 and after 2,613 1,132 554 1,159 Total 15,649 15,304 8,964 13,644

Number of observations of condensed groups by birth cohort, males, period 1500-1909

Source: See Table 1.

26We used event history analysis to estimate the expected length of life. In event history analysis, the time until an event – in this case from birth to death – is modelled. We assume survival up to at least age 25, as this is the age by which ministers had completed their university training, medical professionals had graduated or taken their exams, and visual artists, in order to become well-known, had lived long enough to produce some noticeable artwork.

27The Gompertz distribution is often assumed in the analysis of lengths of life. This distribution has two parameters, a shape α and a scale parameter β, in which the latter may depend on observed characteristics (such as sex). The density for a duration t in a Gompertz distribution is:

29The life expectancy e at age x in birth cohort T (conditional on reaching age 25) can be approximated by:

31where γ ≈ 0.5772 is Euler’s constant. We use maximum likelihood estimation based on the information on dates of birth and death. [3]

III – Results

32For a first impression of the mortality of medical professionals we calculated non-parametric (Kaplan-Meier) survival curves for ages 25 and higher. Figure 1 illustrates how the survival function varies by birth cohort. The figure includes the first cohort with a sufficient number of cases, which is also the cohort with the lowest life expectancy at age 25 (1600-1649), and six later cohorts. The figure demonstrates the improvement in survival for medical professionals from the eighteenth century on (1700-1749 cohort), that has continued without interruption since then. In the older cohorts, the risk of dying at a relatively young age – say below age 50 – was quite high. This is suggestive of a situation where the role of chronic diseases was limited but where external forces and epidemics played an important role. It is also consistent with several nineteenth-century studies which found that mortality was especially high among medical professionals aged 50 or less (Zeeman, 1856b). Younger doctors “are in contact with the sick; are exposed to zymotic disease, and their night rest is disturbed” (Farr, 1872, cited by Woods, 2000, pp. 232-233).

Figure 1

Survival curves for male medical professionals, by birth cohort

Figure 1

Survival curves for male medical professionals, by birth cohort

Source: See Table 1.

33Figure 2 shows the values for life expectancy at age 25 with 95% confidence intervals.

Figure 2

Expectation of life at age 25, and 95% confidence intervals, male medical professionals, by birth cohort

Figure 2

Expectation of life at age 25, and 95% confidence intervals, male medical professionals, by birth cohort

Source: See Table 1.

34For the period before 1600 where the number of medical professionals was rather small (80), male life expectancy at age 25 would appear to be 33.9 ± 7.3 years. For the first half of the seventeenth century, life expectancy at age 25 of around 29.6 ± 3.2 years is recorded, and for the second half, 32.3 ± 2.8 years. It is plausible that the trough in cohort 1600-1649 is a real one, to a large degree determined by plague epidemics. Noordegraaf and Valk counted a total of 110 plague years in the province of Holland over the period 1450-1668, causing quite high mortality, particularly in the years 1624-1625, 1635-1637, 1652-1657 and 1664-1667 (Noordegraaf and Valk, 1988). The latter three crises could (partly) have affected the 1600-1649 cohort. In addition to that, the effects of adverse economic circumstances and periods of conflict strengthened the impact of the epidemic (Israel, 1995). The drop in life expectancy observed in the cohort born during the first half of the seventeenth century is also consistent with findings from a recent study of ages at death of European nobles (Cummins, 2014).

35Starting with the cohort born in the first half of the eighteenth century, the life expectancy of medical professionals began to increase substantially. This rise was only temporarily interrupted in birth cohort 1800-1849, which was severely affected by the potato blight in the 1840s and by various epidemics of cholera, smallpox and measles in the 1840s, 1850s and 1860s.

36Comparing life expectancies between the various categories within the group of medical professionals is rather complicated. Until around 1780, we only have information on university-trained medical doctors whereas after 1865 all medical practitioners were university-trained. Thus, only for those medical professionals who were licenced between 1780 and 1865 – roughly coinciding with birth cohorts 1750 to 1840 – can we distinguish between medical doctors who graduated from university and practitioners who trained at clinical schools. Table 3 compares the life expectancy of university-trained and non-university trained practitioners for a more refined categorization of birth cohorts. The data suggest that the university trained doctors did slightly less well than the non-university trained practitioners in the first cohort, whereas in cohorts born after 1820 medical doctors had significantly higher life expectancies. The distinction between the two groups not only captures differences in status and training, but also differences in places where people practiced. The university trained physicians, particularly in the first birth cohorts, were overrepresented in towns, where larger numbers of people could afford their advice. Moreover, universities were located in the cities, where ways of thinking corresponded more closely to the cultural and intellectual needs and the social aspirations of the university-trained physicians (Rutten, 1985; Verdoorn, 1965). Urban living was still associated with excess mortality in this cohort. In later birth cohorts, the urban mortality penalty practically disappeared and we observe, in line with earlier studies, that medical practitioners mostly working in the countryside were worse off than those who practiced in towns. As a physician in the 1850s wrote: “To earn a living for themselves and their family, this group had to go out in all weathers, and had often to do without a night’s rest, relaxation and civilized contacts” (Zeeman, 1856b).

Table 3

Expectation of life at age 25 and 95% confidence intervals, male university and non-university trained medical professionals, by birth cohort

Table 3
Birth cohort Non-university trained University trained 1750-1774 43.92 (41.50 – 46.35) 36.85 (33.93 – 39.77) 1775-1799 39.20 (37.63 – 40.78) 36.42 (34.29 – 38.56) 1800-1809 37.27 (35.17 – 39.37) 38.40 (35.88 – 40.93) 1810-1819 34.75 (33.08 – 36.43) 35.95 (33.97 – 37.93) 1820-1829 33.55 (31.24 – 35.85) 37.92 (36.05 – 39.78) 1830-1839 31.84 (28.90 – 34.77) 39.22 (37.66 – 40.77)

Expectation of life at age 25 and 95% confidence intervals, male university and non-university trained medical professionals, by birth cohort

Source: See Table 1.

37To place in perspective the results for the group of medical professionals as a whole, we first of all compare them with estimates of life expectancy for other social groups. Figure 3 shows that trends in life expectancy for the medical profession, visual artists, ministers and notable persons all point in the same direction. There is a drop in the 1600-1649 birth cohort, compared to the group born before the beginning of the seventeenth century, followed by a more or less continuous rise, and a new dip or a flattening of the trend in cohort 1800-1849 followed by a renewed increase. In all groups considered here, we observe that birth cohorts who lived their lives mostly before 1800 had already undergone clear improvements in life expectancy. This was true for medical professionals, ministers and notable persons in particular.

Figure 3

Life expectancy at age 25 by social group, male birth cohorts

Figure 3

Life expectancy at age 25 by social group, male birth cohorts

Source: See Table 1.

38It is noteworthy that medical professionals in the oldest cohorts were worse off than notable persons, and had even lower life expectancies than visual artists. The life expectancy of Protestant ministers was practically the same as that of the medical men for quite some time. After cohort 1800-1849, there was little difference between the various social groups, although the medical profession was still not doing better than any of the others.

39The differences in life expectancy between medical professionals on one hand, and visual artists and notable persons on the other, were statistically significant in each birth cohort except the first one (born before 1600) and, for visual artists, except for the 1750-1799 cohort; compared to ministers, differences in expectation of life were significant in all birth cohorts from 1750-99 on. In the most recent cohorts, there were barely any differences in life expectancy between medical professionals, artists, the clergy and notable Dutch men. When compared with the outcomes of cohort life tables for Dutch males as a whole (unweighted averages for birth cohorts 1810-1849, 1850-1899 and 1900-1910 were respectively 37.57, 45.50 and 47.10 years), the life expectancy of medical professionals evolved more or less in parallel over time, but at a slightly lower level than the Dutch male cohorts. At the end of the observation period, only medical professionals born in 1900-1910 had a higher life expectancy than the general population.

40In Figure 4 we compare the life expectancy of the medical profession with that of the nobility and the patriciate. Data for these two groups come from published aggregated data and mostly relate to very small samples. As data for the patriciate and the nobility were only available for life expectancy at age 20, we calculated life expectancy at age 20 for the medical profession also, applying the same methods as for age 25.

Figure 4

Life expectancy at age 20 of male medical professionals compared to the nobility and the patriciate

Figure 4

Life expectancy at age 20 of male medical professionals compared to the nobility and the patriciate

Note: The dots indicate the 95% confidence interval for life expectancy at age 20 for medical professionals.
Source: See Table 1.

41Although the general trend in life expectancy for the nobility and the patriciate is quite well reflected in the results for medical professionals, the latters’ life expectancy remained much higher than that of these groups throughout the three centuries covered. The trough for the years of birth 1600-1649 is most clearly reflected in the figures for the patriciate of the city of Leyden. The patriciate of Zierikzee had a very low life expectancy throughout the period. This part of the country, where malaria was endemic and flooding was frequent, has long been characterized by its very high mortality (Hofstee, 1978). From the beginning of the eighteenth century onward, the life expectancy of nobles and patricians began to increase fairly steadily, and that of the nobility of Guelders and Friesland moved fairly close to the value calculated for medical professionals.


42From a low point in birth cohort 1600-1649, life expectancy increased modestly, and then more strongly, among a variety of social groups in the Netherlands. The medical profession was no exception to that rule. As was the case in other countries, the life chances of medical professionals improved substantially from the mid-eighteenth century onward, and in particular after the mid-nineteenth century. In the most recent cohort, medical professionals scored better than the general population. A comparable trend was observed in the United States where, since the 1920s, and to an ever-increasing degree, the mortality risks of medical doctors have been below those of the general population (Jütte, 2013). The same tendency has been observed in the United Kingdom (Woods, 1996). During the second half of the nineteenth century, as the status of the medical profession slowly began to rise, and knowledge of the causes of diseases and the means of their prevention improved, physicians were able to take at least elementary measures to protect themselves. This suggests that the occupational hazards of medicine were key factors in the survival of medical professionals before that time. In addition, the improved economic position of physicians in relation to that of the working population between the 1860s and 1960s might be related to this changing health status (Riley, 1996). This was partly due to the fact that non-university trained medical practitioners, who mostly originated from lower social status groups, gradually disappeared.

43The rise in life expectancy in the medical profession lagged behind that in most of the other social groups for which we have data, making it hard to conclude that medical progress was the driving force behind the mortality decline. After all, the increase in life expectancy among medical men was not much different from that of ministers and even below that observed among visual artists and notable Dutch people.

44Our results are in line with the many nineteenth-century studies showing that medical professionals, compared to other “civilized classes”, had a somewhat lower average duration of life. Contemporary observers argued that no other profession had such an intense effect on mental and physical forces, or offered so little opportunity for leisure as the medical one. Inadequate physical exercise, exposure to severe weather, lack of sleep, night-time call-outs, irregularity of meals, emotional strain and exposure to infection risks were the factors undermining the health and survival prospects of medical professionals. Our results therefore do not support the hypothesis that medical men, as a rule, lived longer than non-medically trained or educated individuals from the middle or higher classes. This challenges the idea that the growing body of medical knowledge brought a survival advantage to the medical profession. Although we have indications that university-trained medical doctors – supposedly the most well-informed medical men – had better survival prospects, at least in the cohorts born after 1820, than the less formally educated surgeons, this outcome can also be interpreted as the result of the harsher working and living conditions of the latter, who generally worked in the countryside. It is therefore highly unlikely that medical progress was a driving force of the pre-1800 mortality decline.

45In discussing the reasons for the increase in life expectancy of notable people from the seventeenth century on, De La Croix and Licandro considered two variants of the medical progress hypothesis as potential candidates. First of all, they referred to the increasingly experimental attitude prevalent in the field of medicine in the period 1500-1800, which led to significant advances based on practice and empirical observations rather than on a valid disease theory. A second variant of this medical progress theory, called the Enlightenment hypothesis, suggested that the new approach to the world promoted by the Enlightenment led to a decrease in superstition and “could have led the elite to consider that they indeed had some hold on their length of life”, thereby prompting the upper classes to give up bad medical habits (De la Croix and Licandro, 2015, pp. 300-301). De la Croix and Lisandro did not supply direct evidence on changes in life expectancy of the medical profession as a specific group, and neither do our own findings indicate that this group had a life expectancy advantage over other socio-economic groups. If medical progress had indeed been a factor in the mortality decline before the nineteenth century, the bearers of this new knowledge were not the first or the only group to reap the benefits.

46Compared with other studies of the life expectancy of the medical profession, our database is quite large and is able to bridge a very long period of time. However, it still has shortcomings that need to be remedied before it can provide more precise answers on the long-term increase in life expectancy. Most importantly, more information must be collected on non-university-trained medical men practicing in the seventeenth and eighteenth centuries. This will allows us to focus more closely on the persons who were mainly responsible for the day-to-day health care of the ordinary people. Yet even with these shortcomings, the database is a valuable information source and large enough to draw conclusions about the long-term evolution of life expectancy among the medical profession.


  • [*]
    Netherlands Interdisciplinary Demographic Institute (NIDI/KNAW)/University of Groningen, the Netherlands.
  • [**]
    Medical History, Erasmus University Rotterdam, Groningen and Leyden University, The Netherlands.
  • [***]
    History of Dutch Protestantism, VU University Amsterdam, The Netherlands.
  • [****]
    Huygens ING/KNAW, The Hague, The Netherlands.
  • [*****]
    Independent Researcher, Director Database, Hoogeveen, The Netherlands.
    Correspondence: Frans van Poppel, Netherlands Interdisciplinary Demographic Institute, The Hague, the Netherlands, email:
  • [1]
    The health of medical doctors has remained a popular topic until now (Carpenter et al., 1997; Juel et al., 1999; Rimpelä et al., 1987).
  • [2]
  • [3]
    The computations were carried out using the STREG procedure in STATA (StataCorp, 2009).

Rising life expectancy has been suggested as a determining factor behind the start of modern economic growth. On the basis of information relating to elite groups, economic historians have thus questioned the idea, prevalent among most demographers, that life expectancy remained quite stable until around 1800. There is still a scarcity of data on the long-term evolution of life expectancy able to support this claim. We present data on medical professionals in the Netherlands to study the evolution of life expectancy at age 25 in birth cohorts from the sixteenth to the early twentieth centuries. We compare the medical professions with groups without formal medical knowledge – clergymen, visual artists, notable Dutch people, and members of the nobility and patriciate – thereby providing clues about the role of medicine as a factor behind the mortality decline. We used event history models to estimate the length of life. We observe very strong increases in survival in all selected groups, starting in the cohorts born in the seventeenth century. While medical professionals were no exception to this trend, their life expectancy did not increase faster than that of other groups; for a long time, medical knowledge seems to have provided only limited advantages to those who possessed it.


  • life expectancy
  • historical trends
  • Netherlands
  • medical professionals
  • elite groups

L’espérance de vie des professions médicales aux Pays-Bas du xvie au xxe siècle

L’augmentation de l’espérance de vie est considérée comme l’un des facteurs déterminants du début de la croissance économique moderne. S’appuyant sur des informations concernant les élites, les historiens de l’économie ont remis en question l’idée, très courante chez les démographes, que l’espérance de vie serait restée plutôt stable jusqu’aux environs de 1800. Les informations sur l’évolution à long terme de l’espérance de vie qui pourraient corroborer cette affirmation demeurent rares. Nous présentons des données sur le corps médical aux Pays-Bas pour étudier l’évolution de l’espérance de vie à l’âge de 25 ans de générations nées entre le xvie siècle et le début du xxe. En comparant le corps médical avec des groupes sans formation médicale – ecclésiastiques, artistes visuels, notables néerlandais, nobles et patriciens –, nous obtenons des indications sur le rôle qu’a joué la médecine dans le recul de la mortalité. Nous utilisons des modèles biographiques pour estimer la durée de la vie. Nous avons observé des allongements très importants de la survie dans l’ensemble des groupes retenus à partir des générations nées au xviie siècle. Le corps médical n’a pas fait exception à la règle, mais son espérance de vie n’a pas plus augmenté que celle d’autres catégories. Il semble donc que, pendant longtemps, le savoir médical n’ait procuré que des avantages limités à ses détenteurs.


La esperanza de vida de las profesiones médicas en Holanda del siglo xvi al siglo xx

El aumento de la esperanza de vida es considerado como uno de los factores determinantes del comienzo del crecimiento económico moderno. Apoyándose en informaciones sobre las élites, los historiadores de la economía han puesto en duda la idea, muy común entre los demógrafos, que la esperanza de vida habría permanecido más bien estable hasta alrededor de 1800. Las informaciones sobre la evolución a largo plazo de la esperanza de vida que podrían corroborar esta afirmación son raras. Aquí presentamos datos sobre el cuerpo médico en Holanda para estudiar la evolución de la esperanza de vida a los 25 años en las generaciones nacidas entre el siglo xvi y principios del xx. Comparando el cuerpo médico con otros grupos sin formación médica – eclesiásticos, artistas visuales, notables, nobles y patricios –, obtenemos indicaciones sobre el papel que ha tenido la medicina en la reducción de la mortalidad. Utilizando modelos biográficos para estimar la duración de la vida, hemos observado una prolongación muy importante de la supervivencia en el conjunto de los grupos estudiados a partir de las generaciones nacidas en el siglo xvii. El cuerpo médico ha conocido esta misma evolución, pero su esperanza de vida no ha aumentado más que la de otras categorías. Parece ser pues que los conocimientos médicos solo han procurado ventajas limitadas a sus detentores.


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Frans van Poppel [*]
  • [*]
    Netherlands Interdisciplinary Demographic Institute (NIDI/KNAW)/University of Groningen, the Netherlands.
Govert Bijwaard [*]
  • [*]
    Netherlands Interdisciplinary Demographic Institute (NIDI/KNAW)/University of Groningen, the Netherlands.
Mart van Lieburg [**]
  • [**]
    Medical History, Erasmus University Rotterdam, Groningen and Leyden University, The Netherlands.
Fred van Lieburg [***]
  • [***]
    History of Dutch Protestantism, VU University Amsterdam, The Netherlands.
Rik Hoekstra [****]
  • [****]
    Huygens ING/KNAW, The Hague, The Netherlands.
Frans Verkade [*****]
  • [*****]
    Independent Researcher, Director Database, Hoogeveen, The Netherlands.
    Correspondence: Frans van Poppel, Netherlands Interdisciplinary Demographic Institute, The Hague, the Netherlands, email:
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