Despite the acknowledged importance of a comparative perspective to “sharpen our understanding” of the development of public health policy, research on the evolution and impact of European health delivery systems in the nineteenth century remains constrained by the continuing absence of national case studies (Hollingsworth, 1986; Mechanic, 1975, 57). This is a particular problem in the case of countries such as Germany and Switzerland where executive power was largely retained by constituent states or cantons throughout most of the nineteenth century, because federalism was associated with a high degree of variation in administrative structures and legislative enactments (Rapmund, 1901, 29). In the former case some authors simply ignore this issue and assume, incorrectly, that increased public health provision after 1871 took place “under the aegis of the new national government” (Mitchell, 1991, 58), despite the fact that there were extensive differences between individual German states both in terms of administrative personnel and practices. Moreover, recent research has focused exclusively on Prussia either because it had a “more elaborate administrative machinery with highly developed routines”, or because “generalizations across the numerous German states prior to 1871 are precluded by the diversity of their policies” (Weindling, 1994,120; Hennock, 1998, 49-50). The result from a comparative perspective is a rather distorted and incomplete picture of the development of health policy in Germany. Throughout the nineteenth century political power in Germany remained fragmented: a great deal of government administration was federal, not national, and federalism continued to define the nature and objectives of health policy. Even after political unification in 1871, new Reich institutions, such as the Imperial Health Office, were denied executive powersand the development of a uniform health delivery system proved difficult to achieve.

There were extensive and persistent differences in the medical infrastructure of individual states and the specific nature of public health provision reflected the interaction between local associations and societies as well as urban and states authorities (Weindling, 1984, 1989, 1994; Labisch and Spree, 1982, 1986; Labisch and Tennsdedt, 1991). Although a disaggregated approach has been applied effectively to some aspects of German medical history, in particular medicalization and professionalization, the administrative structures and policy objectives of state public health systems have seldom been the focus of comparative research (Weindling, 1994, 120; Drees, 1988; Huerkamp, 1985a; Loetz, 1993; Tamm, 1992). The German federal states therefore provide a useful framework for examining the impact of selective public health policies on mortality trends and for assessing within an historical context some of the criteria developed by Caldwell (1986) as preconditions for achieving unusually low mortality in poor modern countries. This paper represents an initial attempt to analyse the comparative structure of medical administration in the German Länder in terms of the allocation of executive responsibility between the different levels of government. It will assess the extent to which policy-making was determined by civil servants of directly influenced by medical practitioners and professional advisory agencies. Attention will be focused on a number of policy areas, in particular smallpox vaccination, water supply, and infant welfare programmes, in order to establish the extent to which health outcomes were affected by differences in government strategies and the relative efficiency of state administrative systems.

The federative theme remained dominant in the Constitution of 1848/49 as well as at the foundation of the North German Confederation in 1867: with few exceptions, there was no support for the centralization of political power, particularly as federalism reinforced the “monarchical principle” (Boldt, 1990). Furthermore, the 1871 constitution was superimposed on a collection of previously independent states: it acknowledged their continued territorial existence; granted them their own constitutions and state parliaments; and confirmed their extensive legislative and executive powers. In reality, only Alsace-Lorraine was administered directly from Berlin (Roesler, 1996). Although there were significant unitarist elements in the 1871 constitution, the maintenance of a federal system was viewed as a bulwark against the threat of increased parliamentary power. As a result, different types of state government persisted: Prussian centralism offered a marked contrast to the laissez-faire amateurism of the city-states of Bremen and Hamburg; state administrative structures, as well as civil service laws, remained diverse; and new Reich institutions were denied executive powers. Despite an increasing emphasis on imperial symbolism, the Second Empire revealed little evidence of a national consensus: there was no generally accepted national monument; a number of states, including Baden, Bavaria, Saxony and Württemberg, retained their separate note-issuing banks; and Germany only adopted a national anthem after the First World War (Lee, 2002).

The retention of a federal constitutional framework in Germany throughout the nineteenth century had important implications as far as the development of public health was concerned in relation to both administration and policy. Substantive arguments in favour of a central coordination of public health administration were advanced at the time of the North German Confederation and the creation of the Reich: imperial agencies, for example, would be able to develop more effective solutions to public health issues than individual states, and medical policing measures could only be applied effectively by a central authority. However, it was quickly apparent that the Reich would be unable to assume responsibility for the administration of public health, as it was simply “not feasible to proceed against state legislation or local administration or the rights of individuals by federal decree” (Virchow, 1985, 77, 85). As a result, the Imperial Health Office established in 1876 only exercised a “passive monitoring role” and the individual states remained responsible for the enactment and implementation of health legislation (Weindling, 1991, 205; Rapmund, 1901, 64). Although the imperial government undertook important initiatives, promulgating the Vaccination Law of 1874 and introducing compulsory health insurance in 1883, other legislation, such as the Foodstuffs Law of 1879 and the Law on Contagious Diseases of 1900, simply sought to standardize existing state regulations (Witzler, 1995, 96). In reality, the IHO was denied executive powers and even the introduction of a uniform cause-of-death classification system proved difficult to achieve (Leidinger, Lee and Marschalck, 1997). There was no consolidated public health legislation in Germany before 1914 and health administration in the individual states, such as Prussia, continued to reflect an operational structure which frequently had its origins in the eighteenth century (Sachs, 1879, 506). Indeed, it was not until 1934 that a uniform health service was legally established for the country as a whole (Labisch and Tennstedt, 1985).

Tab. 1 -
The Structure of State Medical Administration in individual German States, 1913

Source: A.Guttstadt, Deutschlands Gesundheitswesen. Organisation und Gesetzgebung des Deutschen Reichs und seiner Einzelstaaten. Leipzig, 1890; W. Prausnitz, Grundzüge der Hygiene. Munich, 1916 (10^th edition)

The overall system of medical administration in Germany was accurately described by a contemporary observer as a “chaos without form or life” (Stoll, 1842). In reality, the approach of individual states to the management of medical affairs and the development of “national” health care systems varied substantially. If Prussia had four levels of administration (central; provincial; administrative district; and local), other states were far less bureaucratic and local medical officers in both Baden and Hessen were directly responsible to the central government ministry. By contrast, in some of the smaller states, such as Schaumburg-Lippe or Schwarzburg-Rudolstadt, there was simply no legislative framework for regulating medical affairs, or medical officers were only appointed if they enjoyed the full confidence of the government (Guttstadt, 1890, 256, 263). Considerable differences were also apparent in relation to the role and renumeration of local medical officers. In the Grand Duchy of Oldenburg, the Amtsarzt was responsible for carrying out smallpox vaccinations, whereas in other states, such a Sachsen-Weimar and Sachsen-Meiningen, additional vaccination duties were renumerated on a capitation basis. Salary levels for equivalent responsibilities in the early 1870s varied from 200 to 4,200 Marks (Table 2). Employment conditions in Prussia were particularly poor even after the salary increase in 1873 and attracted stringent criticism from medical practitioners who argued that the position of the Kreisphysikus was the “greatest anomaly” within the state administrative system, given the considerable population size of many districts and the requirement to carry out post-mortem examinations and to supply forensic reports (Ploss, 1882, 30). By the end of the nineteenth century, the rate of renumeration for local medical officers in Prussia (per 1,000 inhabitants) stood at 33.60 Mk, in comparison with 114 Mk in Bavaria and 129 Mk in Hamburg (Rapmund, 1901, 37). The resourcing of this key post was interpreted as a clear reflection of the relative status of medical officers and a reliable indicator of the extent and efficiency of public health administration in the individual German states. Whereas Bavaria had introduced full-time medical officers as early as 1808, responsibility for the local implementation of medical policy in Prussia continued to depend on officials whose poor level of pay necessitated the maintenance of an extensive private practice. Although it was recognized for some time that an adequate salary was essential in order to guarantee objectivity and independence, this problem was not rectified until the Kreisarztgesetz (Medical Officer of Health Law) of 1901. In Alsace-Lorraine the position of medical officer health (Kreisarzt) was often filled by appointing applicants who had no special training in hygiene or statistics (Wassefuhr, 1875, 361).

Tab. 2 -
Salary Levels of Local Medical Officers in Different German States, c.1870/80

Source: A.Guttstadt, Deutschlands Gesundheitswesen. Organisation und Gesetzgebung des Deutschen Reichs und seiner Einzelstaatet. Leipzig, 1890: H.Ploss, Über das Gesundheitswesen und seine Regelung im Deutschen Reiche. Leipzig, 1882

In most German states, public health administration and the management of the health care system was dominated by civil servants, invariably with a traditional legal training, and medical personnel were assigned an advisory role with only limited opportunies to influence the implantation of their recommendations (Sachs, 1879, 507; Table 1). In Baden, Braunschweig, Oldenburg and Prussia, the key advisory agency was also headed by a civil servant. As a result, specific proposals from medi-cally-trained experts were either not taken up or their implementation was significantly delayed. However, even in this area there were important differences between the practices of individual states, in terms of the actual composition of advisory bodies and their ability to influence medical policy. In Saxony, the Landesmedicinalcollegium began to play an initiatory role in medical affairs from 1865 onwards, and the Urban Health Board in Frankfurt-am-Main (which had replaced the so-called Provisional Health Counsel in 1883) was actually empowered to initiate business (Sachs, 1879, 523; Guttstadt, 1890, 49). There were also appreciable differences in the response by individual states to medical professionalization and the incorporation of representative bodies into the policy-making process. Both in Bavaria and Württemberg the Ärztekammer were able to deal directly with the relevant ministry and the Medical Committee, elected by the State Medical Association, was accorded an increasingly important role.

There can be little doubt that structural differences in the system of public health administration in the individual German states directly affected the efficiency of the health care system. Firstly, prior to the outbreak of the First World War medical certification of cause-of-death was only required in 14 German states, and this was only undertaken exclusively by trained doctors in three cases (Bremen, Hamburg and Lübeck). In most other states, certification of cause of death was generally carried out by medical practitioners in urban centres, but by lay individuals in rural areas, and the Prussian system, in particular, suffered from serious deficiencies (Wasserfuhr, 1872, 190). Secondly, despite a general emphasis in state policy on the need to remove dangerous agents, such as epidemics, from contemporary society, the approach of individual states to the compulsory notification of specific diseases varied considerably. The Prussian regulation of August 1835 specified a wide range of diseases, including cholera, typhus, smallpox, dysentery, measles and scarlet fever, and laid down a series of sanitary measures which were to be adopted following their notification (Lion, 1862, 117-118). By contrast, in many smaller states, such as Sachsen-Weimar, Sachsen-Meiningen and Schwarzburg-Rudolstadt, the extent of compulsory notification remained limited throughout the nineteenth century. The reaction of individual states to specific diseases was also very uneven: Baden, Bavaria, Hessen and Württemberg merely required a limited notification of measles; whereas medical officers in Prussia only registered tuberculosis deaths, other states (including Baden, Lübeck, Oldenburg and Saxony) insisted on the notification of any change in the address of individuals with advanced symptoms of the disease (Kirchner, 1907; Rapmund, 1901, 465). There were also differences in the registration system: in Saxony notifiable diseases were initially registered with the Bezirksarzt who was then responsible for forwarding the information to the Lades-Medizinal Kollegium, whereas in Prussia they were registered directly with the local authorities. Even within individual states there no consensus on what constituted the most effective notification system and considerable concern over the cost implications to the Post Office of allowing all epidemic diseases to be notified on unfranked forms following the recommendation of the Imperial Ministry of the Interior in 1902 (Sächsisches Hauptstaatsarchiv Dresden, Ministerium des Innern, 15155). Thirdly, even within individual states differences persisted in the regulatory framework of the public health system. Despite the Prussian legislation of 1835 which required all urban communities with over 5,000 inhabitants to establish Sanitary Commissions, they were only established in a few larger cities which had an appropriate range of medical expertise. At a provincial level there were even extensive differences in official regulations relating to outbreaks of cholera (Lion, 1862).

In a number of policy areas, including protective employment legislation, the federal states tended to follow a common strategy. This reflected the need to respond to general processes of economic and social change and a degree of competitive rivalry which encouraged the adoption of policy initiatives developed in other parts of Germany. Particularly in the late-nineteenth century, no German state wanted to be criticised for ignoring contemporary developments in public health, but the fragmentation of state power also encouraged the maintenance of traditional administrative structures and ensured the longevity of well-established medical practices. In reality, the public health administration of a number of states was increasingly characterized by relative “backwardness” (Wasserfuhr, 1870, 134), particularly in the case of Prussia where the health care system continued to be based on the operational principles laid down in the Medical Edict of 1725. The implementation of medical policy remained essentially a police responsibility; technical agencies had no real influence on policy recommendations; the administrative system was too bureaucratic; there were no effective building regulations; and an insufficient concern for school hygiene (Sachs, 1879; Weindling, 1994). Despite its earlier pioneering role in the development of medical administration, Prussia had been overtaken by the mid-nineteenth century by states such as Baden, Bavaria and Saxony which had implemented administrative reforms, successfully introduced better reporting systems and strengthened the role of expert advisers. The sanitary affairs of Frankfurt-am-Main and the city states of Bremen and Hamburg, were also “in good order” (Lion, 1862; Sachs, 1879).

The policy response of individual German states to smallpox vaccination varied considerably, although the initial reaction was generally cautious reflecting a concern, as in Prussia, not to pressurize unduly the indigenous population (Lentz, 1927). Compulsory vaccination for infants was introduced in Bavaria and Hessen in 1807, in Waldeck-Pyrmont in 1811, and in Baden (1815), Nassau (1818), Württemberg (1818) and Hannover (1821) (Rupp, 1975; Huerkamp, 1985b, 623). Prussia, by contrast, only adopted a policy of “partial” or “indirect” compulsion, with vaccination only enforced in workhouses, boarding schools and other institutions under direct state control (Horn, 1863; Lion, 1870). Although there was a recognition of the need to adopt more coercive measures, stricter legislation was not enacted in 1825 because of ministerial reservations. The successful implementation of vaccination policy, therefore, continued to depend on active encouragement, the need to produce vaccination certificates for specific purposes (for example, by applicants for state grants), and “an appropriate administrative framework” which made an official recourse to compulsion unnecessary (Hennock, 1998, 53-54). Ironically, those areas of Swedish Pomerania which were incorporated into Prussia in 1815 had already been subject to more stringent legislation, including a requirement to produce a vaccination certificate for both school admission and employment (1810), compulsory vaccination (1812), and a rigorous imposition of fines for non-compliance (1815) in a manner that foreshadowed the Imperial Vaccination Law of 1874 (Wellner, 1977; Stadtarchiv Stralsund, Rep.14). In the city-state of Bremen, parents were only recommended to vaccinate their children, although a vaccination certificate was required for admission to both public and private schools, as well as for confirmation (Staatsarchiv Bremen, 2-S 7a. 13.c.1).

Differences also existed in relation to revaccination policy. Revaccination was not carried out initially for therapeutic purposes, but primarily as a means of assessing the effectiveness of the initial vaccination. By the early 1820s it was generally recognised that revaccination was only successful after a period of approximately ten years had elapsed following initial vaccination. The case for state intervention in this area was reinforced by the growing evidence of smallpox deaths amongst adults who had been vaccinated as children (Gerstenacker, 1888). In reality, revaccination was only enforced in a selective manner, primarily for military personnel and, as in the case of Prussia, for children in state institutions. Württemberg introduced compulsory revaccination for soldiers as early as 1825 (with a poor success rate), and this policy was adopted by a number of other states during the following decades, including Prussia (1834), Baden (1840), Bavaria (1843) and Saxony (1868) (Fröhlich, 1885). Although those states which had introduced universal compulsory vaccination almost certainly found it difficult to convince the general public of the need for revaccination in the light of earlier claims, revaccination policies for the civilian population were implemented in a number of cases, either on a comprehensive basis (as in Sachsen-Meiningen for all 13-year-olds in 1859), or in a more limited manner (as in Höchstädt, Bavaria in the mid-1830s, the Jagstkreis of Württemberg from the early 1850s, and the Duchy of Nassau) (Gerstenacker, 1888; Taddey,1983, 322).

Despite significant differences in vaccination policy, all German states registered a marked fall in smallpox mortality during the first half of the nineteenth century. In Baden, for example, mortality rates per 100,000 population fell dramatically from 284 (1800-09) to 9 (1820-29) and 8 (1840-49) (Prinzing, 1930-1931, 494). However, smallpox mortality rates remained noticeably lower in those states which adopted compulsory vaccination, as a comparison between Bavaria and Prussia indicates (Table 3). Within a European context, there is evidence of a correlation between the relative decline in smallpox mortality and the extent of compulsory vaccination (Reichsgesundheitsamt, 1925), and policy differences between the individual German states affected significantly the registered trends in smallpox deaths. Indeed, the disease-specific morbidity and mortality of German troops during the Franco-Prussian War (1870-71) also reflected different “national” strategies in relation to revaccination: military recruits from Hessen, which only adopted revaccination in 1869, registered smallpox morbidity and mortality rates five and almost ten-times higher than equivalent rates for Prussian soldiers (Gerstacker, 1888, 101).

Tab. 3 -
Crude Death Rates from Smallpox per 100,000 Population

Year	Prussia	Bavaria	Württemberg
	M	F
1812			2.6 [+]
1814			3.0 [+]
1816	46	46
1817	29	28	4.9 [+]
1818	31	29	5.0 [+]
1819	21	21	2.4 [+]
1820	11	10	0.5 [+]
1840	17	16	11.2
1841	15	14	13.2
1842	23	22	12.1
1843	31	28	10.3
1844	29	26	10.9
1845	17	15	5.5
1846	16	15	3.2
1847	9	9	2.7
1848	14	14	5.0
1849	11	11	13.1
1850	17	14	23.8	8.8
1851	14	12	10.5
1852	20	18	13.1
1853	41	38	10.3
1854	45	43	12.8
1855	9.7		6.5
1856	7.3		10.6
1857	13.3		3.4	8.3
1858	26.4		6.8
1859	19.6		3.2
1860	19.0		2.8
1861	30.2		1.5
1862	27.1		2.5

+ Isarkreis (Upper Bavaria) only Sources: A.Frhr.von Fircks, Rückblick auf die Bewegung der Bevölkerung im preussischen Staate während des Zeitraumes vom Jahre 1816 bis zum Jahre 1874 (Preussische Statistik, XLVIII,A). Berlin, 1879, p. 101; Bayerisches Statistisches Landesamt (ed.), Bayern im Lichte seiner hundertjähringen Statistik (Beiträge zur Statistik Bayerns, Heft 122)(Munich, 1933); H.Losch, Die Bewegung der Bevölkerung Württembergs im 19.Jahrhundert und im Jahre 1899 (Württembergische Jahrbücher für Statistik und Landeskunde, Vol.4). Stuttgart, 1901, p. 153; St. A. ObB. Regierungsakten

At a federal level smallpox mortality rates in Germany reflected the impact of a broad range of factors, including the extent of urbanisation, the impact of annual fluctuations in in-migration on native-born susceptibles, and geographical proximity to other territories, such as the Polish areas of Russia or the Austrian Crown lands, where vaccination policy remained generally deficient (Duncan et al.,1994). Within Prussia, for example, the highest smallpox mortality rates were consistently registered in the eastern provinces where the risk of infection was compounded by poor housing conditions (particularly important during the long winters), lower levels of personal hygiene and low “cultural standing” (Fircks, 1879). However, the impact of different vaccination strategies can be explored by comparing the city-state of Bremen with its permissive, laissez-faire ideology, and Bavaria which was one of the first European states to adopt compulsory vaccination in 1807. Despite the establishment of a public Vaccination Institute in Bremen, the appointment of vaccination doctors, and the provision of free vacci-nation for children of the poor, only a small proportion of infants (0-1) were vaccinated with a gradual improvement in the success rate from a fairly low base line of 65 per cent in 1818-19 (Table 4). Although parents were admonished in 1818 and 1821 not to neglect the vaccination of their children, the response rate remained disappointing, despite the “great benefits and blessings” of medical intervention. By contrast, the mandatory system of smallpox vaccination in Bavaria was implemented efficiently, despite some initial difficulties (Lee, 1977). Although there was considerable annual variation in the proportion of infants vaccinated, the overall rate in the post-1815 period was relatively high even in predominal rural districts (Table 4). In addition, over 90 per cent of vaccinations were registered as successful and the failure rate had fallen to below one per cent by the 1840s (Bayerisches Statistisches Landesamt, 1933). Substantial resources—approximately one eighth of Bavaria's health budget—were allocated between 1807 and 1817 in order to facilitate the introduction of free vaccination (Wolff, 1995, 170; Stollberg, 1986). As a result, official vaccination policy reduced significantly the general risk of infection and contributed to low levels of smallpox mortality.

Tab. 4 -
Smallpox Vaccination Success Rates and Proportion of Infants Vaccinated
a) Upper Bavaria and Landkreis Freising, 1809-1829-30

Year	Upper Bavaria	Landkreis Freising
	% Vaccinated	Success Rate	% Vaccinated	Success Rate
1809-10	63.5	77.5	39.8	83.2
1810-11		88.2
1811-12	65.7	81.3	53.0	94.0
1812-13
1813-14				99.8
1814-15			51.4	94.3
1815-16	100.0	92.5
1816-17	76.4	95.1	68.8	93.0
1817-18	95.4	95.2	98.9	96.0
1818-19	36.3	93.8	41.6	95.7
1819-20	61.6	95.5	29.3	92.2
1820-21	52.4	95.4	76.8	92.4
1827-28			90.7	75.0
1828-29			82.5	79.5
1829-30			56.3	87.8

Source: Staatsarchiv für Oberbayern, Regierungs-Akten 1042, 1046

b) Bremen (Stadt)

Period	Total Vaccinated	Success Rate (in %)	% Under 1	% Infants Vaccinated
1818-19	530	65.0	24.9	5.4
1820-24	742	70.7	36.5	5.3
1825-29	966	79.2	34.4	5.6
1830-34	1251	77.5	33.4	5.7
1835-39	1362	79.2	37.2	7.6
1840-43	1359	83.3	36.2	8.8

Source: Staatsarchiv Bremen 2.S.7.a.13.c.3. Berichte der Schutzblatternimpfungskommission

The effectiveness of state strategy was dependent not only on the degree of compulsion, but also on the operational efficiency of the respective administrative system and the enforcement of associated preventive practices (Sköld, 1996). Most German states by the early nineteenth century had developed an extensive disease control system which was also implemented whenever smallpox cases were reported. In the city-state of Bremen, for example, this involved the mandatory isolation of individual patients, the cordoning off of infected houses, and the posting of official warning notices: in Bavaria financial payments were made to peasants who reported any outbreak of the disease to the relevant authorities. It is nevertheless problematic to assume that the formal existence of well-established administrative structures or the adoption of increasingly “thorough” procedures removed the need for compulsory vaccination or guaranteed an effective implementation of “national” disease control systems (Hennock, 1998). In fact, there were significant differences in state administrative practices. The Prussian system, in particular, revealed serious deficiencies: vaccination certificates were provided by doctors without requiring proof of successful vaccination; “duplicate” certificates could be easily acquired; control mechanisms in urban areas were inadequate; and the association of smallpox vaccination with sanitary policing measures was counter-productive (Lion, 1870). By contrast, the Bavarian system of smallpox vaccination served as a model for other German states and in terms of operational efficiency even Mecklenburg-Schwerin, where local medical officers played a key role in vaccination, had a better organisational system than Prussia (Lee, 1977, 98; Pappenheim, 1864; Wildberg, 1835).

Tab. 5 -
The Expansion of the Health-Related Infrastructure in the ten Largest German Cities, 1888-1912

Source: Statistisches Jahrbuch Deutscher Städte, Vol.1, 1890 (and subsequent volumes)

For many contemporaries there was a clear link between sanitary reform, specifically improvements in water supply, and mortality trends. The disproportionate reduction in crude mortality in many of Germany's larger cities in the late-nineteenth century was interpreted as a direct result of infrastructural investment (Büsing, 1897; Kruse, 1897, 160). More recent research has tended to confirm this assumption: typhoid mortality in Prussia reacted “particularly sensitively to the purification of water”, and for a broad sample of German cities approximately one half of the registered fall in typhoid mortality between 1888 and 1912 was due to sanitary reform measures (Spree, 1988, 140; Brown, 1999). At the same time, there is evidence that typhoid mortality in such cities as Berlin, Frankfurt-am-Main, and Munich, had already begun to decline before the widespread availability of improved water supplies, and by the 1890s urban death rates in general had fallen to an almost uniform level, despite a persistent disparity in the quality of the health-related infrastructure between large cities and smaller towns. Nevertheless, the provision of a central water supply contributed to the reduction in typhoid mortality and also had a positive impact on death rates from other diseases of the digestive system and therefore on infant mortality (Vögele, 1998, 179). Particularly in areas of Germany where breastfeeding was seldom practised, the supply of clean water was particularly important, given that artificial food was frequently prepared with water and animal milk was often diluted. To this extent, improvements in water supply (together with other measures, such as the removal of privies) contributed to the decline in infant mortality and intestinal disease in urban communities (Brown, 1999).

It is commonly assumed that responsibility for health-related infrastructural improvements was completely in the hands of “traditionally self-governing and powerful local communities” and that the role of the state in facilitating the implementation of a central water supply, whether in urban or rural areas, was highly circumscribed (Vögele, 1998, 152; Reulecke, 1985; Brown, 1989; Ladd, 1990; Münch, 1993; Wiztler, 1995; Bauer, 1998). In reality, a number of South German states played a highly proactive role in securing improved water supplies for small towns and rural communities. In Baden, where a Landesculturdienst had been established in 1823, state officials responsible for road construction and hydraulic engineering were required to provide extensive advice to local authorities in drawing up plans for improved water supplies from 1878 onwards (Grahn, 1900, 198). In every case, the cost of preparatory work was carried by the state and considerable grants were made available by the Ministry to assist impoverished local authorities (Generallandesarchiv Karlsruhe, Ober-Direction des Waser-und Strassen-Baues, 770). By 1896, 479 communities with a combined population of 390,250 (or 23 per cent of Baden's total population) had benefited from infrastructural improvements as a direct result of state assistance. In Württemberg a different approach was adopted by the state in order to encourage water supply improvements. Following the appointment of a state hydraulic engineer in the early 1860s, a special construction office was established in 1869 to provide free advice to local authorities and to ensure that future projects were adequately designed. Between 1864 and 1878 technical advice had been provided to 199 urban and 376 rural communities: by the mid-1890s over 863,000 individuals (or 41 per cent of the country's population) had benefited from the assistance of state engineers (Staatstechniker): 15 “;;;;;;;group” water-supply systems had been built for 190 local authorities; a number of state construction projects had been initiated; and 23.3 per cent of the total construction costs had been provided from state funds (Varrentrapp, 1879, 490; Ehmann, 1879; Grahn, 1900, 190). As a result, the overall situation in Württemberg was “excellent” with a high proportion of rural communities taking advantage of natural gradients to secure an adequate supply of water (Roth, 1989, 45). The Bavarian authorities followed a similar path: in 1875 funds to support water-supply improvements were generated by a levy on fire insurance premiums; a specialist engineer was appointed to provide advice to local authorities; and a separate Royal Bureau for Water Supply was established in 1878. Although the local authorities remained legally responsible for water supply (as a result of the Local Authority Regulation of 1869), by 1898 300 projects had been carried out with the assistance of the Bureau and 29 per cent of the total construction costs for all water-supply improvements in Bavaria had been met by the state. Prior to the outbreak of the First World War, the Bureau played an increasingly important role in drawing up construction plans and in implementing specific projects (Table 6).

Tab. 6 -
The Activities of the Royal Water-Supply Bureau in Bavaria, 1883-1913
a) Design and Construction

Year	Projects	Installations	Total Cost (MK)	State Contribution (in %)
	Prov	Compl
1883	20	6	2	96600
1890	34	31	14	1338555	19.1
1900	238	81	16	1210622	16.9
1910	256	93	69	4881838	22.6
1911	238	120	79	4496335	28.2
1912	277	130	92	5484248	20.9
1913	219	139	95	3438509	13.9

b) Installations carried out with the partial assistance of the Bureau

Year	Installations	Total Cost (MK)	State Contribution (in %)
1883	1	56260	8.9
1890	17	1983346	6.0
1900	25	1666800	4.8
1910	13	782756	6.5
1911	22	1612869	4.6
1912	24	904880	5.0
1913	18	422810	5.4

Source: Königliches Statistisches Landesamt (ed.), Bayerns Entwicklung nach den Ergebnissen der amtlichen Statistik seit 1840. Munich, 1915, p. 29

Differences in state policy had a considerable impact on the extent of water-supply improvements, particularly in the case of smaller towns and rural areas. In Prussia, where the state only established a central agency for water supply and canalisation in 1901 in response to public demand, there was a persistent east-west differential in terms of access to a central water-supply system and over 60 per cent of the total population remained dependent on wells, water tanks or natural supplies (Münch, 1993, 59; Spree, 1988, 133-34). At the end of the nineteenth century improved water supply in Prussia was invariably a function of urban size and small towns (of less than 25,000 inhabitants) as well as rural areas remained disadvantaged. By contrast, official policy in the South German states of Bavaria, Baden and Württemberg ensured a more rapid provision of good quality water for small towns and rural communities. Whereas 67 per cent of small towns in Prussia had no access to a central water supply, the comparative figure for all other German states was 35 per cent (Table 7): 14 per cent of small towns in Württemberg were still without an improved water supply, in contrast to 93 and 96 per cent respectively in the administrative districts of West and East Prussia (Grahn, 1904, 309). Similar differences were evident in the inspection and control of water quality: whereas many towns and cities in Prussia were obliged to establish their own hygiene or bacteriological institutes (in most cases at a comparatively late date), in other states technical control agencies were set up by the central government, as in Saxony (1871) and Bavaria (1878), and all local authorities in Baden were encouraged to use the Karlsruhe University Institute free of charge (Witzler, 1995, 127; Grahn, 1900). Improvements in the health infrastructure undoubtedly contributed to the registered mortality decline in typhoid and intestinal diseases in large urban areas, and the policies pursued by some of the South German states meant that the inhabitants of small towns and rural areas benefited from access to a central water supply at an earlier date than was the case in Prussia. As a result, typhoid fever mortality was considerably lower in Bavaria and Württemberg when compared to Prussia (Table 8). Whereas in Prussia typhoid fever mortality was inversely proportional to town size, the situation in Bavaria was more complex with a number of rural areas registering lower morbidity and mortality rates (Vögele, 1998, 167; Prinzing, 1906, 460-3). The overall decline in mortality rates in many rural communities in southern Germany during the last quarter of the nineteenth century was more pronounced than in Prussia, where life expectancy in the agrarian eastern provinces remained particularly low prior to 1914 (Finkelnburg, 1882; Ballod, 1899; Prinzing, 1912; 1931, 579; Kearns, Lee and Rogers, 1989, 12).

Tab. 7 -
The Provision of a Central Water Supply in Urban Communities in Germany

Note: small towns with fewer than 25,000 inhabitants: large towns with more than 25,000 inhabitants Source: E.Grahn, 'Die städtischen Wasserwerke', in R. Wuttke (ed.), Die deutschen Städte. Geschildert nach den Ergebnissen der ersten deutschen Städteausstellung zu Dresden 1903. Leipzig, 1904, Band 1, p. 309

Tab. 8
Typhoid Fever Mortality in Prussia, Bavaria and Württemberg per 100,000 population

Year	Prussia	Bavaria	Württemberg
1873 – 1880	60,4	35,3	27,6
1881 - 1890	35,2	18,1	16,0
1891 – 1900	15,3	7,5	8,7
1901 – 1902	10,5	4,5	4,8

Source: F.Prinzing, Handbuch der medizinischen Statistik. Jena, 1906, p. 377

The creation of an infant welfare centre in the administrative district of Düsseldorf in 1907 (by the Verein für Säuglingsfürsorge im Regierungsbezirk Düsseldorf e.V.) is indicative of the new role of state authorities in this important area of medical policy. All rural districts (Landkreise) and towns (kreisfreie Städte) were expected to participate in the Infant Welfare Association with a total annual contribution of 20,000 Marks (Schlossmann, 1908). By the end of the first financial year the Association had 350 members, including various business companies and high-ranking individuals with important roles in politics, the economy and society (Bericht, 1907). Although the Association was thereby able to operate on a sound financial footing, there were continuous quarrels over the level of financial contributions and some cities threatened to terminate their membership.

A key focus of concern for the infant welfare associations was the low level of breastfeeding in Germany which had an averse effect on infant survival. As a result, breastfeeding campaigns were launched which combined various elements of propaganda, instruction, education and social control (Frevert, 1984). In a number of states, such as Bavaria (1904) and Baden (1906), payments were introduced for breastfeeding particularly in urban areas (Behrens and Schiller, 1907). Nursing mothers in families with an annual income of less than 1,200 Marks were offered support for three to six months, either in the form of goods or monetary payments (Rott, 1914, 13, 27). However, the premium levels varied considerably, ranging in Germany's ten largest cities from 25 Pfennigs per week in Frankfurt-am-Main to 5 Marks in Düsseldorf. Many contemporaries, as well as some modern historians, have been convinced of the success of these campaigns (Brüchert-Schunk, 1994; Castell, 1981). In reality, the available surveys of the work of the infant welfare centres (in Berlin, Breslau, Cologne, Karlsruhe, Leipzig and Munich), suggest that they were ineffective because they failed to raise substantially either the frequency or duration of breastfeeding (Rott, 1914, 46-51; Uffenheimer, 1911). Married mothers could only be persuaded to visit the welfare centres on a regular basis through the payment of breastfeeding premiums, and new legislation requiring formal state guardianship of illegitimate children meant that unmarried mothers had a deep mistrust of female welfare workers and deliberately avoided the infant welfare centres. In fact, there were a number of reasons for the failure of state-directed policy on infant welfare care. Firstly, some contemporaries opposed an interventionist role in infant care, as it contradicted their social-darwinian belief in natural selection (Dietrich, 1907). Secondly, many infant care centres were poorly resourced in terms of funding and personnel: in Frankfurt-am-Main, for example, the monetary allocation in 1910 for breastfeeding premiums amounted to only 2,000 Marks (Rosenhaupt, 1912). Thirdly, local medical practitioners often opposed the infant welfare centres: they feared that their income would be reduced by the availability of free advice and often failed to inform mothers of the available facilities (Uffenheimer, 1911, 311). Fourthly, regulations relating to the payment of breastfeeding premiums were very strict and mothers had to face long bureaucratic procedures and intimidatory investigations. They had to agree to home visits by lady visitors, which implied a significant degree of supervision, and were required to present themselves at the welfare centre on a weekly or fortnightly basis. In some cities eligibility for financial support had to be proven by a demonstration of breastfeeding in front of a male doctor, or by presenting the baby's nappies for inspection (Risel and Schmitz, 1913; Zahn, 1912; Steinhardt, 1909).

More importantly, the strategy of the welfare centres was based on a serious misjudgment of working-class attitudes and living conditions. In most cases, payments for breastfeeding did not provide compensation for lost earnings, and the requirement of regular attendance at an infant welfare centre often involved lengthy journeys and the use of expensive public transport (Proskauer, 1912). Some mothers only partly breastfed their children or were physically incapable of breastfeeding. They were therefore dependent on the specially treated milk available at the centres, but the continued absence of adequate domestic facilities frequently negated the potential benefits of this policy (Heubner, 1897, 30-31). In any case, most mothers, particularly those from the target-group of single or married mothers from the poorest urban districts, were overburdened with a multitude of tasks and had to cope with a limited family budget: they remained, by definition, beyond the reach of official policy. In the long-run, selective state intervention undoubtedly led to the professionalization of infant welfare care and the formulation of systematic strategies to combat high rates of infant mortality. However, state support for breastfeeding campaigns was arguably misplaced. The latter decades of the nineteenth century witnessed a significant decline in infant mortality rates in all towns of over 15,000 inhabitants (Prinzing, 1906; Kintner, 1985). This trend was accompanied by a reduction in the extent of breastfeeding, as a result of labour-market changes, in-migration from non-breastfeeding areas, and the development of an urban-industrial life style (Vögele, 1994; Brown, 1999; Lee and Marschalck, 2000). In larger towns and cities, health-related infrastructural improvements increasingly reduced the importance of breastfeeding for infant survival, particularly as the availability of clean water and extensive controls on the quality of animal milk meant that artificial feeding became a safer alternative. Moreover, infant welfare programmes before 1914 were exclusively an urban phenomenon. Although the mortality differential between breast-fed and artificially-fed infants was increasingly eroded in the highly industrialized areas of Germany, infant mortality rates in rural areas remained negatively correlated with the absence of breastfeeding. In eastern Prussia extensive female labour force participation in the primary sector meant that many mothers were unable to breastfeed and infant mortality rates remained disproportionately high: breastfeeding was also comparatively rare in many rural areas in South Germany, particularly in Bavaria, Württemberg and Baden, with similar consequences in terms of infant survival (Lee, 1979; 1984). To this extent, infant welfare policy was not directed at those areas of Germany which might have benefited substantially from breastfeeding campaigns.

The continued fragmentation of political power in Germany meant that many aspects of public health policy continued to be formulated and implemented at the federal level, even after the creation of the Reich. However, the extent to which the persistence of a federal system of medical administration affected health outcome has never been fully addressed. On the one hand, inter-state competition sometimes acted as a stimulus for government intervention in public health issues and policy initiatives often reflected a close awareness of developments in other states. Indeed, the localized framework of policy-making may have facilitated a more focused approach to contemporary issues and provided a means of testing the appropriateness of specific policies at the federal level. On the other hand, the continued autonomy of the federal states in many areas of public health policy also meant that more effective solutions to “national” problems were often ignored. Despite the proven efficacy of compulsory vaccination in reducing smallpox mortality, the Bavarian legislation of 1807 was only replicated for Germany as a whole in 1874; and almost 40 years were to elapse between the development of state support for water-supply improvements in Württemberg in the early 1860s and the belated adoption of a similar approach in Prussia in 1901.

Public health policy in the federal states, as was the case in other areas of government legislation, was determined by a variety of factors which have seldom been analysed comparatively. Firstly, the constitutional basis of federal state power was far from uniform: whereas a number of states adopted a two-Chamber representative system in the early nineteenth century with varying rights and responsibilities, prior to 1850 Prussia can be classified as a Beamtenstaat (bureaucratic state). Moreover, constitutional differences persisted throughout the second half of the nineteenth century, and determined the extent to which specific institutional arrangements affected the distribution of power and the nature of government policy. The different forms of “pseudo-constitutionalism” in individual German states in the post-Napoleonic period should not be dismissed out of hand, given the historical embeddedness of institutional reform and the dynamic process by which they developed their own political and administrative cultures. Secondly, federal policy was undoubtedly influenced by the role of interest groups or distributional coalitions, but within the German system of “competitive federalism” there was considerable variation in the structure of policy networks and the nature of state-interest group relations which often determined the specific configuration of state policy. Finally, it is generally accepted that the bureaucracy acquired greater powers and influence in all the larger German territories during the course of the nineteenth century. But the state bureaucracy was seldom homogeneous and the rapidity of structural change often engendered divided responses to policy issues. As a result, the nature and direction of official intervention continued to vary from state to state, even after 1871, particularly given the longevity of administrative structures and attitudes (Lee, 2002). In a wider context, any analysis of the role of the state requires the development of an appropriate model of political change which can serve as a basis for analysing both the social context and policy objectives of government action (Tilly, 1988). To a large degree, such a model is still lacking. Few historians have succeeded in locating their analysis of public health policy within the complex framework of contemporary macro-political institutions and the impact of federal legislation has seldom been examined. In relation to both smallpox vaccination and water-supply improvements, policy differences at the federal level had a visible impact on health outcomes, just as different systems of public health administration affected the operational efficiency of disease control legislation and other aspects of health care provision. The German federal states, therefore, provide a useful context for examining the significance of specific public health systems, as they were developed in the nineteenth century, on contemporary mortality trends. The current paper is part of a broader agenda, but we hope that it has given an indication of the direction of future research.