Abstract
This article examines how the epidemiologic transition and the reduction of the urban mortality penalty gave rise to the current mortality regime of the United States and demonstrates how the 1918 influenza pandemic signaled its advent. This article approaches those issues through the analysis of urban-rural mortality differentials from 1890 to 1930. Until 1910, infectious diseases dwarfed degenerative diseases in leading causes of death, and generally, the more urban the location was, the higher infectious disease and overall death rates were-a direct relationship. But by 1930, degenerative diseases had eclipsed infectious diseases, and infectious disease mortality had ceased to differ between cities and rural areas. The 1918 influenza pandemic broke out toward the end of these changes, and the larger the city was, the lower influenza and overall death rates were in that year-an inverse relationship. Such gradations characterized a new mortality regime emerging in the late 1910s and foreshadowed urban-rural mortality differentials in 1930 among persons aged 45 years or older, the group whose high rates of degenerative disease death would symbolize that regime. Thus, intertwined changes in the late 19th and early 20th centuries-a shift in leading causes of death from infectious diseases to degenerative diseases and a concomitant shift from a direct relationship to an inverse relationship between urban environment and mortality-produced the current mortality regime of the United States.