Tuberculosis and beyond : Public health campaigns and long‑run effects of neonatal BCG vaccination in Sweden 1916–2016

The extent to which public health interventions and medical innovations have improved population health has long been debated. This thesis addresses this question by examining anti‑tuberculosis (TB) campaigns—often considered the first modern public health campaigns—through the case study of twentieth‑century Sweden.

The thesis begins by documenting the rise and fall of Sweden’s anti‑TB campaigns, providing details on when, where, and to what extent major institutions and interventions—including dispensaries, TB hospitals, Bacillus Calmette–Guérin (BCG) vaccination, bovine TB eradication, and mass X‑ray screening—were implemented. By synthesizing evidence from official reports, historical literature, and archival newspapers, the analysis shows how small, locally organized initiatives gradually evolved into large‑scale national programs with broad population coverage, before receding in the second half of the twentieth century.

Building on this historical context, the thesis then investigates: (1) the short‑term effects of major anti‑TB measures on the decline in TB mortality; (2) the long‑term non-specific effects of neonatal BCG vaccination on women’s mid‑life reproductive health relative to unvaccinated cohorts; and (3) the long-term overall effects of neonatal BCG vaccination on multimorbidity in old age compared with vaccination later in childhood. These analyses draw on newly assembled historical data and modern administrative registers and employ state‑of‑the‑art econometric methods, some of which aim at identifying causal effects. Together, they assess both short‑ and long‑term consequences across multiple dimensions of health.

The results show that TB hospitals and BCG vaccination contributed to declining TB mortality in the first half of the twentieth century. The findings also reveal life‑course benefits: neonatal BCG vaccination yields small but significant improvements in women’s reproductive health in mid‑life and is associated with lower multimorbidity in old age. The findings show that (1) public health measures played a meaningful role in improving population health, both immediately and across the life course; (2) the non‑specific effects of early‑life vaccination warrant closer attention, as neonatal BCG produces lasting health gains even in low‑burden settings; and (3) the postnatal period constitutes a critical window for intervention, with benefits that are larger than those produced by measures introduced later in childhood. Further research is needed to evaluate anti‑TB measures in other contexts, compare early‑life and adulthood interventions, and explore heterogeneity in effects across populations.