History of Public Health and Sanitation in the West since 1700

The nature and role of public health are constantly changing, and its definition has been a major preoccupation of public health leaders in the twentieth century. Essentially, public health is and always has been community action undertaken to avoid disease and other threats to the health and welfare of individuals and the community at large. The precise form that this action takes depends on what the community perceives as dangers to health, the structure of government, the existing medical knowledge, and a variety of social and cultural factors. From the beginning, communities, consciously or not, have recognized a correlation between filth and sickness, and a measure of personal and community hygiene characterized even the earliest societies.

By the eighteenth century, personal and community hygiene were becoming institutionalized. A wide variety of local regulations governed the food markets, the baking of bread, the slaughtering of animals, and the sale of meat and fish. These regulations were motivated by a concern for the poor, a desire for food of a reasonable quality, and commercial considerations. Bread was always a staple of the poor, and regulations in the Western world invariably set the weight, price, and quality of loaves. For economic reasons, merchants shipping food abroad promoted regulations on meat and grains in order to protect their markets and save themselves from dishonest competition.

The American colonial laws and regulations, which were patterned after those of English towns and cities, illustrate the ways in which communities protected their food. Most of the regulations were enacted in the first century of colonization and strengthened in the second. For example, when New York City received a new charter in 1731, the old bread laws were promptly reenacted. Bakers were required to stamp their initials on loaves, the mayor and aldermen determined the price and quality of bread every three months, and bread inspectors were appointed to enforce the regulations. Butchers could be penalized for selling putrid or "blowne" meat, and a series of regulations governed the town markets, with special attention to the sale of fish and meat.

Slaughterhouses, which could be both public nuisances and potential sources of bad meat, were among the earliest businesses brought under town control. The term public nuisance in the eighteenth and nineteenth centuries embraced a great many sources of filth and vile odors. Wastes, rubbish, and garbage were simply dumped into the nearest stream or body of water, except in major cities, which generally had one or more covered sewers. Some foul-smelling open sewers characterized all cities and towns. The water closet was rare until the late nineteenth century, and the vast majority of residents relied on privies. In the poorer areas they were rarely emptied, with the result that their contents overflowed into the gutters. The work of emptying privies was handled by scavengers, sometimes employees of the municipality, but more often private contractors. They slopped human wastes in open, leaking carts through the streets to the nearest dock, wharf, or empty piece of land.

Street cleaning and garbage collection were left largely to private enterprise and were haphazard at best. The malodorous mounds of manure in the dairies and stables and the equally foul-smelling entrails, hides, and other materials processed by the so-called nuisance industries attracted myriad flies in addition to offending the nostrils of neighboring residents. The putrefying odors from these accumulations of entrails and hides, particularly in summer, must have been almost overwhelming.

Early U.S. towns were spared the worst of these problems because they were smaller and their residents more affluent. The small size of communities and the cheapness of land made it easier for the town fathers to order the slaughterers and other nuisance industries to move to the outskirts. By 1800, however, the growing U.S. cities were beginning to experience the major sanitary problems faced by their British and European counterparts. The great bubonic plagues beginning in the fourteenth century had taught Europeans the value of quarantine and isolation, but by the eighteenth century, the major killer diseases had become endemic. Smallpox, one of the most deadly, was largely a children's disease by the second half of the eighteenth century, and no longer aroused alarm. On the Continent, occasional resurgences of bubonic plague led governments to establish quarantines on their eastern borders, but even this threat diminished toward the close of the century.

The one area where quarantines were applied with some consistency was the North American colonies. Because of the colonies' sparse population and geographic separation from Europe and one another, great epidemic diseases could not establish themselves permanently until late in the colonial period. The two most feared disorders were smallpox, brought from Europe or by slaves from Africa, and yellow fever, usually introduced from the West Indies. Smallpox appeared only occasionally in the seventeenth century, but it struck the colonials with devastating effect. By 1700 all of the colonies had enacted quarantine laws of various degrees of effectiveness and most of the port towns had established "pesthouses" in which to isolate smallpox patients.

Yellow fever did not enter the colonies until the end of the seventeenth century. Unlike smallpox, which was obviously spread from one individual to another, yellow fever was a strange and unaccountable pestilence that brought death in a horrible fashion to its victims. It struck the colonies only occasionally, but news of its presence in the West Indies led authorities in every coastal town to institute quarantines against vessels from that area. A series of epidemics, which struck the entire eastern coast beginning in 1793, led to the establishment of permanent quarantine officers and temporary health boards in nearly every major port. The limited sanitary and quarantine laws of the eighteenth century, many of which dated back several hundred years, were to prove inadequate under the impact of rapid urbanism and industrialism after 1750. Fortunately, that eighteenth-century period of intellectual ferment, the Age of Enlightenment, created a new awareness of the need for a healthy population. The earlier theory of mercantilism had argued that popu lation represented wealth, and the emergence of political arithmetic or population statistics in the seventeenth century provided a crude means of measuring the health of a given population. John Locke's Essay on Human Understanding, emphasizing the role of environment, encouraged intellectuals, particularly in France, to advocate improving the lot of human beings through social reform. In his Encyclopedia, Denis Diderot discussed medical care, hospitals, and a wide range of topics related to health.

Economic changes led to a population explosion in Europe beginning in the mid-eighteenth century, and one result was an enormous infant mortality rate in the crowded cities and towns. A second result was the emergence of a socially conscious middle class out of which grew the British humanitarian movement. An important aspect of the movement was a concern for infant welfare, a concern that stimulated the rise of voluntary hospitals in Great Britain and ultimately led to an awareness of the deplorable health conditions of all workers. The eighteenth century, too, saw the publication of Bernardino Ramazzini's classic study on the diseases of workers, De Morbus Artificum Diatriba.

Even more significant than the writings of Ramazzini, the French philosophers, and other intellectuals in bringing government action was the work of Johann Peter Frank. In 1779 he published the first volume of a comprehensive nine-volume study instructing government officials on how to maintain the health of the people. Stimulated by the prevailing intellectual ferment, the enlightened despots of Prussia, Austria, Russia, and other states made tentative attempts to impose health regulations on their subjects. At that time, however, the governing structures were inadequate for the task, and the upheavals of the French Revolution and Napoleonic Wars temporarily ended efforts at health reform.

In Great Britain the seventeenth century had seen the execution of one king and the deposing of a second in the course of the Glorious Revolution of 1688. The resulting distrust of the central government meant that, for the next century and a half, a high degree of authority remained at the local level. Hence, until the mid-nineteenth century, efforts to improve public health were the work of voluntary groups or of local governments. Although some progress was made at the local level - most notably in terms of infant care, the mentally ill, and the construction of hospitals — public health was of little concern to the national government. Probably the most significant development was the rapid increase in hospitals and asylums and the appearance of dispensaries or outpatient clinics. In England the majority of these were funded by private charity, whereas on the Continent they were largely municipal or state-supported.

It was no accident that England, which was in the vanguard of the Industrial Revolution, took the first effective steps toward establishing a national public health program. The original charters of most English towns and cities gave the municipal government only limited powers, and these proved totally inadequate to meet the needs of their increasing populations. The first local health board in Great Britain came into existence in Manchester in 1796. A series of typhus epidemics among the overworked cotton mill employees, who lived and worked in crowded, filthy conditions, led Thomas Percival, John Ferriar, and other physicians to organize a voluntary board of health. In Liverpool, James Currie and a small group of other physicians assumed the same responsibility. Owing to the haphazard structure of English local government and the prevailing laissez-faire sentiment, little was accomplished in the following half-century.

Atrocious factory conditions, particularly as they affected child and female workers, provided the next stimulus to public health. Through the agitation of socially minded physicians, and in particular the work of Sir Robert Peel, a socially responsible textile manufacturer, the first English factory law, the Pauper Apprentice Act of 1802, was pushed through Parliament. Changing circumstances made the law meaningless, and it took years of agitation by Peel, Robert Owen, and numerous others before a relatively effective factory act in 1833 limited the working hours of children in textile mills. The most significant feature of the act was a provision for four officers to inspect, report on, and enforce the law. This measure marked the first time that the central government broke away from a laissez-faire policy and assumed a limited responsibility for health and welfare. Equally important, the reports of the factory inspectors proved invaluable to Edwin Chad-wick, Southwood Smith, Lord Ashley, and other reformers seeking to make the public aware of the brutal and degrading conditions in which workers labored and lived.

At least as important as the horrible factory conditions in promoting government action on behalf of health was the first of the three great pandemics of Asiatic cholera to strike the Western world in the nineteenth century. This disease, which devastated the poor, who were crowded in filthy, miserable slums, convinced public health pioneers that sanitary programs were the solution to the problems of disease and ill health. Consequently, in the prevailing argument over the value of quarantine versus sanitation, the sanitationists, represented by Chad-wick in England, won out. The panic and disruption in Great Britain caused by the first epidemic in 1831 undoubtedly contributed to the general unrest in England and, indirectly, was responsible for a number of major reforms. Among the significant legislative measures enacted in these years were the Parliamentary Reform Bill of 1832, the Factory Act of 1833, the Poor Law Amendment of 1834, and the Municipal Corporations Act of 1835. The last act was particularly important because it strengthened the authority of town officials and gave them wider powers in the areas of health and social services.

In 1834 Chadwick was made secretary of the new Poor Law Board, and the board's investigations under his direction laid the basis for his great Report on the Sanitary Condition of the Labouring Classes. Its publication in 1842 led to the appointment of a Royal Commission on the Health of Towns, and the grim reports of this commission eventually forced Parliament to enact the first major national health law, the Public Health Act of 1848, which created the General Board of Health. This board ran into immediate difficulties, since the medical profession was strongly opposed to it, and local officials were still reluctant to surrender any of their authority to a central board. In 1858 the board was dismissed, and its public health responsibilities were transferred to the Privy Council. Despite its weakness, the board was successful in spreading the gospel of cleanliness and sanitation.

During these years a series of sanitary laws, such as the Nuisances Removal Act, Common Lodging House Act, and the Adulteration of Food Act, were shepherded through Parliament. In addition, beginning in 1847, medical officers were appointed in a number of cities. The culmination of almost half a century of health education was the passage (helped along by the third cholera pandemic) of the Sanitary Act of 1866. This measure broadened the health and sanitary areas under the jurisdiction of the national government and authorized its officials to compel municipalities and counties to meet minimum sanitary standards. Within the next nine years successive legislative action gradually strengthened the 1866 law. In 1875 a comprehensive health law consolidated the many pieces of legislation relating to health and sanitation and gave Great Britain the best national health program of any country in the world.

The Industrial Revolution was much slower in coming to France and other countries, and the energy devoted to improving social conditions in England was dissipated on the Continent in wars and struggles for political freedom and national independence. Yet the French Revolution and the Napoleonic Wars gave France leadership in medicine and public health by destroying much of the old order and releasing the energy of the lower classes. Among its contributions in these years was the publication of the first public health journal, the Annales d'hygiène publique et médecine legale, which appeared in 1829. The outstanding public health figure in France during these years was René Louis Villermé, whose studies in the 1820s clearly demonstrated the relationship between poverty and disease. His major report in 1840 on the health conditions of textile workers led to the enactment the following year of a limited child labor law.

Continued appeals for reform by Villermé and health reformers achieved a measure of success following the Revolution of 1848. The new French government under the Second Republic established a system of local health councils (conseils de salubrité). Despite the hopes of public health leaders, these councils, which met every three months, were purely advisory and exercised no real authority. Any further chance of immediate health reform was dashed in 1851 when Napoleon III overturned the Second Republic. The system of weak advisory health councils remained in effect until the end of the nineteenth century, and public health in France continued to lag far behind that of Britain.

On paper, the public health regulations of the Russian imperial government seemed quite advanced, and because the government was autocratic, it had the power to enforce its laws. Unfortunately, as the successive Asiatic cholera epidemics revealed, these regulations were seldom exercised with any degree of effectiveness. Quarantine measures against cholera were belated, haphazard, and applied too ruthlessly. The widespread poverty and ignorance of the Russian people made many of them resent even the most well intentioned government actions. Whereas the cholera outbreaks in the West aroused demands for health reform, particularly in Britain and the United States, the autocratic government in Russia and the lack of a socially conscious middle class prevented any meaningful reform before the twentieth century. The development of public health in the United States closely followed that of Great Britain, although the sheer expanse of the nation reinforced the belief in local control and delayed action by the federal government. Spurred on by epidemics of Asiatic cholera and yellow fever, U.S. cities began appointing permanent quarantine officers at the beginning of the nineteenth century. New York City, which tended to assume leaderhsip in public health, created the Office of City Inspector in 1804. The office was designed to gather statistics and other information relating to the city, but under the leadership of such men as John Pintard and John H. Griscom, it became a significant force for social change. Their annual reports as city inspectors were damning indictments of the poverty, misery, and squalor that characterized the life of so many New Yorkers.

Nonetheless, the prevailing spirit in the nineteenth century was laissez-faire, and except when epidemics threatened, government officials felt little responsibility for health. The threat of an epidemic or its presence usually aroused the quarantine officials from their lethargy and stimulated the city council to appoint a health board, open temporary hospitals, and initiate a campaign to clean up the worst sanitary abuses. Once the epidemic was over, the quarantine was relaxed and city hall returned to politics as usual. When a particular abuse, such as an unusual number of putrefying dead animals in the streets or a particularly odorous canal or sewer down the main street, became an outrage, public opinion would demand action, but the relief was usually temporary.

While the public worried about the two great epidemic diseases of the nineteenth century, yellow fever and Asiatic cholera, and to a lesser extent about smallpox, the major causes of morbidity and mortality in both Europe and the United States were pulmonary tuberculosis and other respiratory infections, enteric disorders, malaria, typhoid, typhus, and such perennials as measles, diphtheria, scarlet fever, and whooping cough. These were familiar disorders that killed young and old alike, and in an age when almost half of the children died before the age of 5 and sickness and death were omnipresent, the public attitude was one of quiet resignation.

One explanation of this passive acceptance of endemic disorders was that before the bacteriological revolution little could be done about them. Another is that, until the accumulation of reasonably accurate statistics, it was impossible to gauge the significance of these diseases. Beginning in the 1830s, individuals in Great Britain, on the Continent, and in the United States began collecting a wide range of statistical information. The studies of William Fan-in England and Villerme and Pierre Laplace in

France were duplicated in the United States by Lemuel Shattuck, Edward Jarvis, and others. These early statistics, however, brought few immediate results in the United States. The same can be said of three classic public health studies published in the years before the Civil War — Griscom's Sanitary Condition of the Laboring Population of New York City, Shattuck's Report of a general plan for the promotion of public and personal health (1850), and McCready's essay (1837) on occupational diseases. Nonetheless, these men laid the basis for substantial progress in the post-Civil War years.

Their work also contributed to arousing an interest in public health and sanitation in the United States during the 1850s. Devastating yellow fever outbreaks from 1853 to 1855 raised fears throughout the country and led to a series of National Quarantine and Sanitary Conventions from 1856 to 1860. The major issue at these meetings was whether yellow fever could be kept at bay by quarantine or by sanitation. The sanitationists won the day. By 1860 they were preparing to turn the conventions into a national organization of health officers and sanitary reformers, but the outbreak of civil war brought the project to a sharp halt.

All was not lost, however, because the hygienic problems engendered by crowding thousands of men into army camps and the movements of troops throughout the country stimulated the public health movement. As evidence of this, in 1866 the Metropolitan Board of Health was established in New York City, the first permanent municipal health department. It was followed in 1869 by the first effective state board of health in Massachusetts. By the end of the nineteenth century, most major cities had established some type of health agency. Many of them, particularly the state boards, were only nominal, but the principle of governmental responsibility for public health was firmly established.

In the meantime the work of Joseph Lister, Robert Koch, Louis Pastern-, and a host of scientists working in microbiology was changing the whole basis for public health. Sanitation and drainage, the chief preoccupation of health officials in the nineteenth century, were replaced in the twentieth century by specific methods of diagnosis, prevention, and cure. Yet the sanitary movement had brought remarkable advances in life expectancy and general health. A higher standard of living, the introduction of ample and better city water, and large-scale drainage and sanitary programs all contributed to a sharp reduction in the incidence of urban disorders. Although the basis for the sanitary movement, the miasmic theory, was invalid, the movement itself achieved notable success in improving the public's health.

The major drive in all Western countries during the early twentieth century was to reduce or eliminate the major contagious diseases. With the aid of new diagnostic techniques, antitoxins, and vaccines, the major killer diseases of former times gradually were brought under control. Tuberculosis, probably the most fatal disease in the West during the nineteenth century, was greatly reduced, in part by improved living conditions and in part through concerted action by voluntary associations and governments to identify, isolate, and cure all cases. In addition, large-scale educational campaigns informed the public about the disease, and visiting nurses and social workers helped families of victims. As was true of drives against other contagious disorders, large-scale screening programs were used for the early identification of cases. Recognition of the role of vectors made it possible to drive malaria and yellow fever virtually from the Western world through antimosquito campaigns. The greatest success against disease has been with smallpox. With the help of the World Health Organization and massive vaccination programs, the disorder literally has been eliminated from the world.

Even as the fight against contagious diseases was getting underway, health officials began moving into other health areas. Among the more obvious social problems in the late nineteenth century was the enormous infant death toll. In western Europe, where nationalism was the real religion and the military power to defend that religion was equated with population, the birthrate was falling, increasing pressure to improve maternal and child care. The movement to do so began in England and France, where voluntary organizations began promoting dispensaries for child care. In the United States a New York philanthropist, Nathan Straus, opened a pure-milk station in 1893 to provide free or low-cost milk to the poor. The idea was picked up in other U.S. cities and soon spread to western Europe. Over the years, these stations gradually evolved into well-baby clinics and maternal and child health centers.

A major step forward in the movement for child care was taken in 1908 when New York City, in response to the urging of Sara Josephine Baker, became the first municipality to establish a Division of Child Hygiene. The success of Baker's program in New York encouraged Lillian Wald and Florence Kelley, who had long been advocating a children's bureau at the national level, to redouble their efforts. Four years later, in 1912, President Theodore Roosevelt signed a bill establishing the Federal Chil dren's Bureau. The next action at the national level was the passage of the Sheppard-Towner Act of 1921, a measure that provided matching federal grants for states to encourage maternal and child health programs. Although this act was allowed to lapse in 1929, the New Deal Program of Franklin Roosevelt in the 1930s firmly established a role for the national government, not only in maternal and child care, but in all aspects of public health.

Another important health area that had its origins in Europe in the late nineteenth century was school health. Smallpox vaccination appears to have been the entering wedge, because compulsory vaccination of school children was relatively easy to enforce. The discovery of so many other contagious disorders among children led to the introduction of school inspectors and school nurses around the turn of the century. The early twentieth century saw the beginning of physical examinations for school children, and these in turn created a need for school clinics and other remedial measures. As living standards were raised, particularly after World War II, school health programs declined in importance.

The discovery of vitamins (so named by Casimir Funk in 1912) opened up the field of nutrition, and a substantial effort has been made by health officials to educate the public on matters of diet. Commercial firms, capitalizing on public ignorance of scientific matters and the popularity of food fads, have managed to confuse the issue of what constitutes a well-balanced diet, thus negating much of the educational work. Despite this, however, food and drug regulations have generally improved the quality of the food supply.

An effective autocracy can mandate public health, but health officials in the Western democracies have been forced to rely largely on health education. The United States, which has the oldest tradition of mass education, was the first to recognize the value of information and persuasion in changing people's way of life. By the 1890s, a number of state and municipal health boards were publishing weekly or monthly reports and bulletins. Originally, these publications were intended for physicians and other professionals serving as health officers, but by the early twentieth century a variety of pamphlets and bulletins were being distributed to the general public. By this time, too, health education was given a formal status in the organization of health departments. Lacking the U.S. penchant for public relations, European health departments have not given as much emphasis to health education, relying much more on private groups to perform this task.

The education of public health workers originated in Great Britain in the second half of the nineteenth century. It was essentially a practical course to train food and sanitary inspectors. Early in the twentieth century, courses in public health were offered by the University of Michigan, Columbia, Harvard, and the Massachusetts Institute of Technology, and in 1913 Tulane University established a School of Hygiene and Tropical Medicine. The latter survived only briefly, and the first permanent school of public health was opened by Johns Hopkins University in 1918. Rather than an institution designed to train general health workers, it was essentially a research organization intended to educate the highest echelon of public health professionals. This pattern has been followed by all subsequent U.S. public health schools.

Although the term public health implies government action on behalf of the community, from the beginning voluntary work by individuals, groups of citizens, and philanthropic foundations has played a major role in promoting the general health. Citizens' sanitary organizations were very active in the late nineteenth century, and their counterparts in the twentieth have been voluntary groups fighting against particular disease and medical problems. These associations are found in nearly all Western countries, but they are most active in the United States. One of the best examples is the National Tuberculosis Association, founded in 1904, which had an active part in reducing the incidence of this disorder in the United States. Of the many foundations working in the health area, the Rockefeller Foundation is the best known. Along with the Carnegie Foundation, it has given major support to medical education. It is equally well known for its contributions to public health, particularly with respect to the drive against hookworm in the southern United States, the Caribbean, and Brazil and yellow fever in Latin America and Africa. The efforts of the Rockefeller Foundation also helped lay the basis for the Pan American Health Organization and the World Health Organization.

Since World War II, public health agencies, having won control over most of the contagious infections that formerly plagued the Western world, have turned their attention to chronic and degenerative disorders and to the problems of aging. Veneral diseases appeared to have been relegated to a position of minor significance with the success of antibiotics in the 1950s, but resistant strains and the appearance of genital herpes and AIDS have drastically changed the picture. An area where some success has been achieved is that of community mental health, but progress has been slow.

With the success of the sanitary movement and the emergence of bacteriology in the early twentieth century, health departments tended to assume that care for the environment was largely an administrative matter. Since the 1950s, they have come to recognize many subtle, and not so subtle, forms of air and water pollution and dangers from pesticides, harmful factory wastes, and radiation. They have also sought to deal with problems of alcoholism, drug addiction, occupational hazards and diseases, and a major source of death and disability, automobile accidents.

The twentieth century has seen public health shift from an emphasis on the control of contagious diseases to the broader view that public health should concern itself with all factors affecting health and well-being. Whereas an original aim was to increase life expectancy, today public health also seeks to improve the quality of life. The current view of public health is that it should actively promote health rather than simply maintain it. Achieving a longer life expectancy is still a major aim, but it is equally important to improve the quality of life.

John Duffy

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