Hidden heroes of the health revolution Sanitation and personal hygiene

Transcription

1 Hien heroes of the health revolution Sanitation an personal hygiene Allison E. Aiello, PhD, MS, a Elaine L. Larson, RN, PhD, FAAN, CIC, b an Richar Selak, MSE c Since the mi-1800s, there has been a significant improvement in the public health of people living in the U.S. an Europe. ItÕs propose that changes in personal an omestic hygiene practices playe an essential, but unerstate role in achieving this improvement. A corollary of this hypothesis is that sanitation an personal an househol hygiene practices are responsible for much of the goo health we enjoy toay; an any significant ecline in hygiene stanars will result in increase health problems. This hypothesis will be critically analyze in this chapter. Before examining the evience, itõ s worthwhile to unerstan the challenges an technologies that apply in such an examination, as well as the recognize criteria for juging the relevance an aequacy of the evience. Health can be measure using inices for goo health (e.g., lives save, illness avoie) or, on the other han, the antithesis of goo health (e.g., eath, isease). Here we ll measure community health by three commonly use guies: 1. General population mortality rates; 2. Infant an chil mortality rates; 3. Life expectancy an eath statistics. Assistant Professor of Epiemiology, University of Michigan School of Public Health, Ann Arbor, Michigan a, Professor of Pharmaceutical an Therapeutic Research, Associate Dean of Research, School of Nursing, Professor of Epiemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, New York b, The Soap an Detergent Association, Senior Vice Presient, Technical & International Affairs, Washington, DC c. Allison E. Aiello, PhD, MS, has no financial arrangement or affiliation with a corporate organization or a manufacturer of a prouct iscusse in this supplement. Elaine L. Larson, RN, PhD, FAAN, CIC, has no financial arrangement or affiliation with a corporate organization or a manufacturer of a prouct iscusse in this supplement. Richar Selak, MSE, has no financial arrangement or affiliation with a corporate organization or a manufacturer of a prouct iscusse in this supplement. Am J Infect Control 2008;36:S /$34.00 Copyright SDA. All Rights Reserve. oi: /j.ajic ItÕs suggeste that uring the 19th century, sanitarians in Europe an the U.S. awakene a sanitary consciousness among the common people an popularize cleanliness. This, in turn, le in whole or in part to the ecline of such serious enemic iseases as infant iarrhea (a leaing cause of eath among chilren), typhus, trachoma, an certain skin iseases. If the hypothesis is true, this contribution cannot be ismisse as trivial. If it can be shown that such things as soap an water lowere the incience of infant iarrhea, the irect contribution of personal hygiene to infant survival will become self-evient. Furthermore, if it can be shown that cleanliness interacts with other health eterminates, such as nutrition an overcrowing, then changes in personal cleanliness must also have ha an inirect impact on many other iseases, such as trachoma an typhus. If the logic ens up being so compelling an the contribution so potentially important, how coul the role of personal hygiene in improving health have been unerstate an ignore? The answers to this question illustrate the perceptions an scientific challenges that must be overcome in this type of analysis. This lack of unerstaning coul be partly ue to ignorance of health revolution itself. If one oesn t know it occurre, then one oesn t really care about its unerlying causes. An, most people just on t have the instinct to istinguish between health then an health now. For example, in 1952 polio was viewe as a national emergency when there were 14 cases of paralytic polio per 100,000 people. In comparison, those living in the era aroun 1900 witnesse 4,429 babies per 100,000 ying from infant iarrhea per year, which at the time might not have been consiere exceptional! If polio was a scourge whose elimination brought honors to those responsible, how much more creit shoul be given to those who controlle a isease that was 300 times more tragic? Yet, we have forgotten the latter an on t even remember what they i. It coul be partly ue to the low profile of the sanitary era itself. Toay, we are so well attune to the almost S128

2 Aiello, Larson, an Selak December 2008 S129 aily miracles of meical, surgical, an pharmacological interventions, anything one a century ago is a curiosity at best an primitive as a general rule. Only meical historians an emographers truly appreciate the health revolutions of the 19th century an pre- Worl War I sanitation. Further, such enterprises as water treatment an sewage isposal seem munane. Toay, they pale besie the real avances like kiney transplants an computer-assiste tomography. How can anyone get excite about soap, launry etergents, an garbage collection when open-heart surgery is practically routine? Despite the perio s hien or ignore ientity, the sanitary era was a significant contributor to the health revolution. Let s explore this era in more epth. ADVANCES IN SANITATION One of the more important contributors to the health revolution was the technological-sociologicalenvironmental phenomenon known toay as the sanitary era or the public health campaign. However, getting past the filth took great efforts since sanitary practices weren t given nearly the same value or importance as they are toay. Toay, clean people an surrounings are so much the norm that it is ifficult to imagine an era when they weren t. Clean air an water are assume to be a civic right. Litter-free streets an garbage isposal are traitional responsibilities of local government. Showers, toilets, baths, soaps, etergents, launries, ishwashers, an vacuum cleaners are common features in our homes. All are associate with goo health, goo manners, goo rearing, goo housekeeping, an civilization itself! But toay s accepte stanars of environmental an personal hygiene are very recent concepts. In the mile 1800s, a wave of isgust against environmental filth swept through Western civilization. The sanitarians of those years believe, quite mistakenly, that isease was cause by miasmas, foul smelling emissions from ecaying organic matter. For example, swamps an poorly raine farmlans smelle ba in thesummer, just when people living near them became sick. Therefore, the sanitarians reasone that the ba air, or mal-aria, must have been responsible for the illness. They took heroic steps to clean up the miasma sources water, sewage, factories,an homes. Sanitarians of the mi-1800s believe, quite mistakenly, that isease was cause by miasmas, smelly emissions from ecaying organic matter. The sanitarians ha experimental proof that controlling ba smells woul control isease. Although their reasoning was wrong, their efforts pai off in health benefits. For example, they raine the swamps coincientally eliminating the breeing groun of the mosquito carriers. They installe sewage isposal systems, thus breaking the relentless cycle of cholera epiemics. Proper isposal of garbage helpe control insects an roents, which are reservoirs an carriers of isease. It has been claime that the major ecline in mortality observe uring the late 1800s an the early 1900s was ue to innovations in environmental sanitation. 1 Avancements in sanitation worke han-in-han with science an social an political activism to move this cause forwar. Science an Social/Political Activism The tria filth, poverty, isease appears so frequently in the writings of the 1800s that it s easy to see how they became associate as a cause-effect relationship. Chawick was particularly intereste in this association since he was the secretary to Great Britain s Poor Law Commission. It was his job to eal with the causes an consequences of poverty. In 1840 Englan, socially sensitive citizens believe that isease was cause by poverty. Thus, they avocate control of illness among the poor by proviing grants of money to control poverty. Chawick isagree with the sequence of events an consequently with the remeial strategy. In 1842, he claime that filth leas to isease an that isease, in turn, leas to loss of income an poverty. 2 What was his remey for poverty? The government taking action to improve the sanitary status of the laboring class, which woul improve their health an protect their earning power. Whether or not Chawick s socioeconomic arguments ha merit, his epiemiological arguments came exactly when the country was reay to receive them. Knowlege about the cause of isease was still in its infancy, but Chawick live an wrote at a time when the branches of several streams of scientific an social/political activism were cresting. Together, these streams were sufficient to result in the establishment of public health as a governmental responsibility in Great Britain an the U.S. Vital Statistics. One of the streams that contribute to the acceptance of Chawick s avocacy was the evelopment of vital statistics as a science. This permitte the objective measurement of the consequences of sanitary reform. What coul be a more convincing argument regaring the success of a governmental health program than the measurement of lives save an years ae to life? In Englan the establishment of vital statistics is creite to Chawick an William Farr. In the U.S.,

3 S130 Vol. 36 No. 10 Supplement 3 Aiello, Larson, an Selak Lemuel Shattuck is given creit. However, an intriguing piece of historical etective work by Davi an Abraham Lilienfel traces the work of all three (an most statistician-sanitarian epiemiologists in the 19th century) to Pierre-Charles Louis, a French physician. 3 Some claim that the French sanitary movement of the early 1800s was inspiration for the rest of the worl. Inee, the first public health journal, The Annales Hygiene, originate in France in Origins of Disease. Another stream was the attempt to ientify specific agents of origin for iseases. Coincientally, uring Chawick s active perio in sanitary reform, the following three classic stuies on the epiemiology an control of infectious isease were publishe: John Snow showe that cholera was transmitte by a contaminate water supply. 4 He effectively terminate a Lonon epiemic by persuaing the local boar of Guarians to remove the hanle of the water pump in question. William Bu emonstrate that typhoi fever was not cause by ba oors, but rather by a isease agent carrie via sewage to water an milk. 5 Ignaz Semmelweis showe in an 1861 publication that puerperal fever was transmitte by physicians who i not sanitize their hans between patients. 6 Social an Political Activism. Another stream was the liberal-humanitarian zeal that characterize early- 19th-century Englan an was exemplifie in writer Charles Dickens s crusae against chil labor. Prison reform (incluing bathing facilities, whitewashe walls, ventilation, an separate rooms for the sick) is associate with John Howar consiere by Charles Ewar Amory Winslow to be the first of the pioneer English sanitarians. The social-sanitary campaign to protect inustrial workers resulte in a series of 19th-century legislative acts the early forerunners of toay s labor an occupational health laws. There s no oubt that the sanitary revolution was, in part, a response to humanitarian concern for the lack of resources for proper hygiene. Sanitary Pioneers an Theories The pioneers of the sanitary era were all active prior to 1850 Ewin Chawick, John Snow, William Bu, an John Simon in Englan; Ignaz Semmelweis in Austria; an Lemuel Shattuck in Boston. They maintaine that illness an eath were associate with unsanitary conitions or practices, an they all avocate sanitary reform. Among the sanitary reformers, some supporte the miasma theory of transmission an some were contagionists. Arguments among the avocates of these epiemiologic theories continue for ecaes even after the germ theory of isease ha been well-accepte. From a practical point of view, all of the sanitarians recognize the relationship between filth an isease. The evolution of epiemiological reasoning from 1849 to 1878 is well escribe by Winslow. 7 The sanitary reformers were joine in the next ecae by Florence Nightingale an Joseph Lister, who reforme meical an surgical care. Louis Pasteur an Robert Koch subsequently provie scientific evience that the sanitarians aims though not always their reasoning were realistic. Legislation The payoff for the sanitarians efforts was legislation. Six years after Chawick s report was publishe, a General Boar of Health was establishe in Englan in In 1855, Sir John Simon became the Central Meical Officer of this boar. He was instrumental in the passage of a series of laws proviing the basic taxation an regulatory powers necessary to implement the aims of the sanitarians (see below). The Meical Act was passe to regulate creentials an qualifications of meical practitioners. In the same year, the Public Health Act was passe, establishing the Ministry of Health. Establishment of Health Laws The all-encompassing Sanitary Act was passe. The act obligate local authorities to eal with environmental nuisances, chillabor abuses, factory conitions, poison control, foo aulteration, sewage, water supply, housing, an hospital accommoations. The Merchant The Pharmacy Shipping Act Act restricte was passe the practice of to protect pharmacy by merchant seamen unqualifie against sanitary persons. neglects. In the same perio across the ocean, Shattuck s report of 1850 became the basis of American public health. 8 Winslow calle Shattuck s report for breath an clarity of prophetic vision. the most remarkable ocument in the history of Public Health. 9 In aition to recommening the establishment of state an local boars of health, Shattuck outline the following: vital-statistics gathering tuberculosis control alcoholism control air pollution control mental-health care

4 Aiello, Larson, an Selak December 2008 S131 Deaths per 100,000 Population Filter plant put in operation, Figure 3-1. Reuction in Death Rate for Typhoi Fever, Pittsburgh E. Syenstricker, Health an Environment (New York: McGraw-Hill 1933). Deaths per 100,000 Population Figure 3-2. Death Rates for Typhoi Fever, U.S. U.S. Bureau of the Census, Historical Statistics of the Unite States, Colonial Times to 1970, Bicentennial Eition, Part 1, Washington, D.C., ADVANCES IN PERSONAL HYGIENE An 1840s proposal of Chawick was the collection an conveyance of sewage away from cities. Similar to Asian practices, he envisione that sewage coul be processe for sale to farmers for use as fertilizer. Unfortunately, the availability of more convenient forms of fertilizers, such as guano from South America an synthetic fertilizers, le to the sewage being ischarge into water boies, which le to a history of problems until sewage treatment became effective. 10 eucation reform housing evelopment public bathhouse availability routine physical examinations By 1869, Massachusetts establishe the first State Boar of Health, an within nine years 16 other states followe. 8 OTHER DEVELOPMENTS During the sanitary era, the worl was also introuce to milk pasteurization, autoclave sterilizers for hospitals, chemical germicies, an municipal water treatment systems. For example, Figures 3-1 to 3-3 illustrate avances in water treatmant an istribution in the U.S. The bacteriological iscoveries of Louis Pasteur an Robert Koch provie a scientific rationale for the experimental programs of the sanitarians. Western civilization became convince that infectious isease was not inevitable. The health revolution was in full swing by the turn of the 20th century. 7 In the years leaing up to the health revolution, the custom of bathing wasn t a part of Western civilization. Inee, except for the social relaxation of the aristocracy, religious rites, or miraculous healing, bathing was not reaily accepte in most countries where the temperature was less than tropical. While we might occasionally experience such scenes as above toay in the U.S., they woul really be public health curiosities, not common occurrences. Personal cleanliness is now an accepte value of society. But when an how i the personal hygiene transformation come about? This section will examine the transformation an show how personal hygiene habits change before health improvements arrive. This meical officer s report to Chawick aroun 1840 wasn t at all unusual: 2 I attene a man, woman an five chilren, all lying ill in one beroom, an having only two bes amongst them. The walls of the cottage were black, the sheets were black, an the patients themselves were blacker still. It was inee a gloomy scene. The Reformers The beginning of the personal hygiene transformation was brought about by the sanitary reformers, an again by legislation. The pioneers of the sanitary era weren t only avocates for improving environmental hygiene an public health infrastructures, they were also fervent avocates of personal hygiene. John Simon, for example, was always concerne with organic ecomposition especially human excrement as well as the less riotous forms of uncleanliness (istinguishe

5 S132 Vol. 36 No. 10 Supplement 3 Aiello, Larson, an Selak Year Availability of Filtere Water to Urban Populations Municipally Distribute Filtere Water (Population Serve) * , , ,860, ,805, ,000,000** * Approximately ** Minimum importance of clean skin, an tracing the large amount of isease an misery to uncleanliness, he recommene that public baths be provie for the laboring classes in Englan. These baths were similar to those available in Scotlan an some cities on the continent. 15 An 1867 lecture by Dr. Ewar Dillon Mapother to the Royal College of Surgeons in Dublin states: I believe that health woul be preserve an life prolonge if we ourselves were as assiuously ÔgroomeÕ as our horses. 16 Figure 3-3. Availability of Filtere Water to Urban Populations M. P. Ravenel, e., A Half Century of Public Health: Jubilee Historical Volume of the American Public Health Association (New York American Public Health Association, 1921). Ewin Chawick use the practical argument that: Skin cleanliness augments the nutritive effects of foo. It shoul be preache to the poor, as an aitional inucement to skin cleanliness, that the same foo which is require to make four irty chilren thrive, will serve to make five thrive whose skins are aily washe an kept clean. 16 from accumulate obvious masses of filth ). He was also concerne that the average Englishman han t reache any high stanar of sensibility to irt. Even more important than his legislative enactments was the nee for Eucation. the one far-reaching reformer, an hygiene rules, not less important to mankin than the rules which constitute local authorities. 11 In 1833, the reformers convince the British government to reuce the soap tax, which was three pence per poun. In 1853, William E. Glastone repeale the soap tax altogether, an British an Scottish soap prouction increase from 25,000 tons in 1801 to 83,000 tons in 1851 an 100,000 tons in ,13 Domestic use of soap in Englan was equivalent to 3.6 lbs. per person in 1801, increase to 8 lbs. in 1861, an almost ouble again by In 1846, John Coventry, a British surgeon, publishe an article entitle, The Mischiefs of Uncleanliness an The Public Importance of Ablution. 15 He complaine that the meical publications of the perio mae very meager contributions to the subject of hygiene. After proviing a scientific explanation of the Chil being bathe by New York City Department of Health Little Mother s League. (Reprinte with permission of NYC municipal Archives.) These historical anecotes, such as the one from Chawick, are plentiful an sometimes even amusing, but the sanitary reformers were quite serious. For whatever reasons that motivate them health, esthetics, fear of irt, or scientific insight they extene their sanitary obsession beyon water, sewage, swamps, an ventilation to irty people an vermin-infeste clothing. They use the same weapons for this personal hygiene battle as they i for cleaning up the physical environment, namely legislation, preaching, an teaching. Their successes, however, were harer to measure an longer elaye. It s easier to terminate an epiemic by ismantling a pump than it is to control enemic isease by changing a lifestyle. Still, they persevere, an uring the next 150 years, the sanitary consciousness an habits of Europe, the U.S., an elsewhere were graually but funamentally altere. The Introuction of Baths an Bathing Europe. In George Ryley Scott s history of baths an bathing, he explaine that Victorian citizens really

6 Aiello, Larson, an Selak December 2008 S133 couln t bathe, even if they wante to, unless they enjoye col streams an pollute rivers. 17 In aition, there wasn t running water, heating fuel was expensive, soap was har to get (or make), an there weren t facilities for personal hygiene. Bathing coul be one in wash basins with some effort, but it wasn t part of the folk culture. Few private houses, even of the aristocracy, possesse bathrooms. The rich an title gathere at Turkish baths or spas, but i more socializing than bathing. Some British employers i make sporaic attempts to protect the health as well as the morals of their workers by influencing their personal cleanliness habits. 10 In some factories an mines, hot wastewater from steam engines an smelters was poure into large basins so workers coul take warm baths. In fact, some of these wastewater baths became so popular that factory owners opene them to the public an profite from the amission fees. In 1844, a movement was starte in Lonon to provie bathing an launering accommoations for the working classes, who ha very limite access to hot water, bathtubs, sinks, or a place to bathe. A bathhouse an launry was built, an became an immeiate success! Chawick escribes two such enterprises: Some families subscribe a shilling each month, which entitles them to five baths weekly. Men an women bathe on alternate ays an a bath keeper for each attens for an hour an a half in the evening. 2 In Westminster. the establishment. (was reporte)... of similar tepi swimming baths where only three pence is charge to persons of the working class. As many as 2,000 an 3,000 of this class have resorte to these baths in one ay... 2 English Regency shower (circa 1810). Until the mile 1800s, the great unwashe remaine that way for two reasons: lack of esire an lack of opportunity to o anything about it. During the same time in Paris an Brussels, people coul hire a warm bath in their own homes. Entrepreneurs provie portable bathtubs an hot water, with the tubs carrie in a cart from the bathing establishment to the home, an then carte away again after use. In 1840, the cost of this service was equivalent to three English shillings. 17 With a British laborer earning 10 to 18 shillings a week, clearly only the wealthy coul affor this service. In 1846, the English government passe the Public Baths an Wash-Houses Act for the health, comfort an welfare of the population. This was the forerunner of a series of statutes an amenments that sanctione builing loans to local governmental units for bathing facilities. The maximum charge for a seconclass col bath was one penny; a hot bath cost two pence. 18 By 1890, the prices ha increase a col bath coul be purchase for two pence an a warm bath for six pence. A clean towel came with the amission price, but a small bar of soap cost one penny more. 19 The movement sprea to other countries in Europe, with France passing similar public bath legislation in Then Germany, Switzerlan, Austria, Italy, an Belgium followe suit. The glorious breakthrough in personal hygiene that shoul have come soon after 1846 took much longer than expecte. An 1879 meical officer complaine: A healthy esire for bathing, not having yet been awakene in the wage-earning class, what guarantee has anyone for concluing that the baths, when provie, woul be use? Just as one man can bring a horse to water, but a own cannot make it rink, it woul be a comparatively simple feat to erect baths, but an exceeingly aruous one to get the uncleanly to use them... 20

7 S134 Vol. 36 No. 10 Supplement 3 Aiello, Larson, an Selak Use of Lonon Bathhouses In the 1860s, among the 10 baths in Lonon, there were 1,001,041 baths taken in a given year, an 321,474 women use the launry facilities. 16 Between 1896 an 1897, two million people in Englan use the facilities. 18 Between 1904 an 1905, this number grew to 6,347,158. ItÕ s not known how many of these millions were repeaters, i.e., whether six million bathe once that year or 120,000 bathe every week. But it is known that only 18% were females. 18 Why wouln t more of the public take avantage of the baths? First, public baths were only built in towns an boroughs that requeste them. For nearly 50 years, most towns an boroughs ignore this opportunity. It wasn t until the 1890s that there was anything close to a spurt of enthusiasm for the program on a countrywie scale in Englan. Secon, the bathing facilities were usually locate in the slums of town. The majority of people equate public baths (not the recreational swimming pools) with public workhouses. Accoring to contemporary critics, public baths were as far from one s conception of a haunt of pleasure as it was humanly possible to make them. They were rab an reary. Furthermore, they stank of officialom an patronage. 17 Unite States. The history of baths an bathing in the U.S. up through the mi-1800s was not much ifferent than in Western Europe at that time. With no running water in homes, bathing was largely left to occasional ips in pons or streams. 21 Washing parts of the boy an bathing starte to come into the home uring the mi-1800s via the kitchen an then rooms off the bechamber, though inoor plumbing in any builing was still extremely rare. 22 From a story of American public baths publishe in 1896, the sanitary hero in the U.S. was Dr. Simon Baruch. 23 He avocate rain baths or showers as early as 1889, an he recommene they be establishe in schools, asylums, an in the poorer istricts of large cities. His purpose was to popularize bathing an protect the community against many iseases, without a large outlay of the people s money. By 1890, the public bath movement gaine a foothol in the U.S. The following is a quote from the Journal of the American Meical Association, October 1892: If prevention be better than cure, then, to fun a great public bath woul confer a graner blessing than to erect a hospital. To provie an institution which shoul bring refreshment an vigor to the overworke, healing to the sufferer, warmth, comfort, an self-respect to the victim of squalor, poverty an neglect, woul be to raise a cenotaph more glorious than ever from Attic or Etruscan hans arose. 24 Japan Hygiene in Japan from the mi-1600s to mi-1800s contraste sharply with that in the U.S. an Europe, which woul have playe an important role in reucing isease. A visitor s account from the late 1600s to early 1700s reports:... it is an invariable custom of both nobles an commoners to wash their hans every time after using the privy... Other customs resulting from a strong avoiance of anything irty, such as boiling water for tea, cooking foo, separate eating utensils for everyone in the househol, an removal of footwear when entering homes an builings reuce viral an bacterial contamination, impeing the sprea of isease. Public baths, which began to appear in the 1500s, also woul have reuce the sprea of isease. 25 China Commercial baths were reporte in Hangchow, China, as far back as During a stay in Hangchow in the 1260s, Marco Polo note as many as three thousan commercial bathing establishments. Use by mile an lower classes, resients frequente them almost aily. Upper classes ha a custom of taking a bath every ten ays in the privacy of their own homes. 26 The Big Transformation. Unfortunately, the public baths an launries in the U.S. an Englan in t have much impact on personal hygiene an health. However, they i influence, to some extent, the personal hygiene practices of hunres of thousans, perhaps millions, who wouln t otherwise have bathe. But the largest part of the population remaine unaffecte. Any moification of community mortality an morbiity rates by public baths woul, necessarily, be slow an very ifficult to ascertain. The big transformation in personal hygiene in t occur until running water coul be provie to homes from municipal treatment an istribution systems. Along with water-heating evices, plumbing, baths an sinks, builing improvements, an rainage systems, running water permitte the installation of true bathrooms in mile-class homes an the prospering labor class. In Englan, home bathing an launering became a social norm in the years immeiately before an after Worl War II; in the U.S., it might have

8 Aiello, Larson, an Selak December 2008 S135 happene slightly earlier. Although these occurrences cannot be pinpointe, we wouln t be too far off in ientifying the years from 1890 to 1910 as the perio of significant personal hygiene transformation in the English-speaking countries of Europe an North America. Jean LemMon escribes the little-known history of home launering. Accoring to him, prior to the availability of hot running water, commercial launry soap, an mechanical washers, the task of keeping a househol s linens clean was grim an laborious. 28 The following changes that occurre in the U.S. in the 1800s eventually mae the launering task much easier. Launry Developments in the U.S The first motoroperate washing machine was built. 2,000 patents for mechanical washers ha been issue. A patent was issue for the swinging, reversible wringer. This provie a moel for wringer washing machines that has enure for many years. Late Victorian bathtub (circa ). The Growth in Availability of Hygiene an Cleaning Proucts Events in the U.S. illustrate the availability of hygiene-relate proucts to the masses. Avertisements, as well as washing machines an soap ata, all point to the high level of interest in hygiene in pre Worl War I America. The best pictures of the late 1800s an its hygienic maturation are foun in the pages of the early Sears catalogues. The company was foune in 1895, an by 1897, the Sears catalogue liste three columns of avertising for soaps (both launry an toilet), bluing, ammonia, an borax. From the 1897 Sears Catalog: Procter an Gamble s Ivory soap sol for $0.07 per bar or $6.75 for a case of 100. China Soap s avertisement state: China Soap. Far excees any soap on the market. Best in the worl for the launry. Is bought by thousans an preferre to any other for the toilet. Better than Ivory; 100 eight oz. cakes to a box, $ Again, the Sears catalogues present reasonable evience that personal hygiene playe a sufficiently important role in pre-worl War I America (Figures 3-4 to 3-6). The purpose was to attract serious commercial attention. In Depression America, hygiene was eviently one of the big consumer interests (Figures 3-7 to 3-8). Soap prouction also increase ramatically uring this time. In the late 1800s, the U.S. government began collecting information on the combine value of soap an canle prouction (Figure 3-9). Soap prouction began to be split out in From 1904 to 1916, the value of soap prouction in the U.S. increase more than 500% (Figure 3-9). Soap sales continue to increase until aroun From 1940 to 1970, synthetic soap (etergent) sales rose steaily as launry proucts converte from soap to etergents. 29 The evelopment of etergents (synthetic soaps) was riven by the shortage of fat an oil supplies for making soaps uring WWI an WWII. Another river was the military s nee for a cleaning agent that woul work in mineral-rich seawater an col water. In aition, there were ramatic increases in the growth of launry appliances. Annual home launry appliance shipment rates increase more than eight times between 1916 an 1920 (Figure 3-10). After 1945, newly built houses use to accommoate the huge waves of immigrants were almost universally supplie with inoor plumbing, flush toilets, sinks, launry facilities, an bathtubs or showers. Figure 3-11 shows the ramatic increase in shipments of both home launry appliances an ishwashers in the U.S. in the post-worl War II era. Aitional evience of avancement at the personal hygiene level in the U.S. is inicate by figures on toilet soap prouction from 1909 to 1987 (Figure 3-12), which show increasing per capita prouction. Other countries show similar trens in the use of toilet an bath soaps. Figure 3-12 shows per capita toilet an bar soap consumption for Inia an Japan. Toilet an bath soap use in Inia has been steaily increasing. The same is true for Japan, though bar soap use per capita has been ecreasing from aroun 1990, when liqui soap was introuce.

9 S136 Vol. 36 No. 10 Supplement 3 Aiello, Larson, an Selak Avertisements for Soap an Bathroom Fixtures in Sears 1902 Catalogue Figure 3-4. Sears, Roebuck an Co. catalogues, Chicago, 1902, Avertisements for Bathtubs, Lavatories, an Toilets in Sears 1902 Catalogue Figure 3-5. Sears, Roebuck an Co. catalogues, Chicago, 1902, LINKING PERSONAL AND HOUSEHOLD CLEANLINESS WITH HEALTH Valiations an Methoologies Even those who know about the sanitary era an its revolutionary impact on eath an isease over a century ago in the U.S. an Western Europe virtually ignore its personal hygiene aspect. This is probably because improvements in personal hygiene are not ramatic an are ifficult to ocument. For example, it is relatively easy to pinpoint the installation of a sewer system, the establishment of a milk pasteurization program, or the completion of a swamp rainage operation. On the other han, it is almost impossible to pinpoint behavioral changes, like personal hygiene habits. Bathing an launering practices are sociocultural activities that were aopte at uneven rates among iverse populations over long perios of time. In evaluating the contributions of personal hygiene to historical health changes an current health status,

10 Aiello, Larson, an Selak December 2008 S137 Avertisements for Home Launering Devices in Sears 1902 Catalogue Figure 3-6. Sears, Roebuck an Co. catalogues, Chicago, 1902, it is important to consier that many other social, behavioral, environmental, an meical changes have taken place concurrently. All of these other changes coul reasonably be expecte to moify the incience of the same iseases whose control we are attributing to hygiene. An irrevocable fact of health history is that the use of any of the following vaccines, soap, pasteurization, plumbing, autoclaves, showers may interact with the introuction an use of the others, which makes their specific iniviual contributions har to unravel. Interventional an Observational Stuy Designs Stuies employing either interventional or observational esigns provie other means of investigating hygiene an health relationships. An interventional stuy is one in which a stuy investigator imposes an intervention an observes changes in isease incience. Intervention stuies can be conucte on the same group of people, where isease incience is compare before an after the intervention. Or it can be compare among groups of people who are ranomize to either the intervention metho or no change in practices. The strengths an limitations of intervention stuies shoul be assesse by consiering the methos use to esign an conuct them. Such methos can inclue ranomization, assessment an control of confouning factors, blining, an other pertinent valiity issues. In an observational stuy, groups of people are observe or questione concerning practices or exposures (i.e., without an impose intervention) an assesse for subsequent changes in isease incience. Observational stuies report isease inciences in populations following certain hygiene practices. To resolve our contention that cleanliness an personal hygiene changes actually contribute to the ramatic changes in the health status of populations, four separate but converging lines of evience are employe: Plausibility of the hypothesis from an epiemiological point of view. Historical evience that specific an ocumentable changes in personal hygiene practices uring the last century an a half ha an impact on several major components of mortality an morbiity. Evience from multiple populations, which shows that the health status of ifferent geographic regions can be closely relate to certain inices of personal hygiene an cleanliness. Evience from interventional an observational stuies.

11 S138 Vol. 36 No. 10 Supplement 3 Aiello, Larson, an Selak Avertisements for Soaps an Washing Machines in Sears 1930 Catalogue Figure 3-7. Sears, Roebuck an Co. catalogues, Chicago, 1902, Plausibility of the Hypothesis The most that can be expecte from historical information, stuies of populations in ifferent geographic regions, or interventional an observational stuies are associations. Perhaps it is an association between soap consumption an iarrhea ecline, or between launering frequency an typhus control. To many people, association between two variables is the same as causality. To the scientist an in particular to the epiemiologist who stuies the istribution an eterminants of health in populations association between two factors is just a first step. Before the epiemiologist can say, with any egree of confience, that a given factor cause a given isease (or in our case, that a given factor was responsible for the control of a isease), she or he must climb a laer of logic an reinforcement. This isn t intene to be a short course in epiemiology, but the point is so important, we really cannot procee to a critical analysis of our basic hypothesis without making this point clear: Observe associations between personal hygiene practices an improve health are not enough to prove that one causes the other. The other rungs of the logic laer are the following set of criteria (not prioritize) that have been suggeste as an ai for istinguishing between noncausal an causal associations: 30 Strength of the Association What is the magnitue of association between the two variables? How often coul such an association occur by chance alone (statistical significance)? Consistency of the Association Has the same association between a hygiene practice an health impact been shown among ifferent populations? At ifferent times? In ifferent geographic regions? Using ifferent research esigns? Specificity of the Association Is this a unique association or is the same effect attributable to ifferent causes? Does the cause prouce one effect? Time Depenence Di the outcome occur after the cause was introuce? Was there enough elay between cause an outcome to suggest true association? How can we be sure, when two factors are associate, that one is the cause an the other the effect? Can they both be effects of a thir, unsuspecte cause? If the cause is remove or reverse, oes the outcome also change? Biological Plausibility Are the two associate factors logical caniates for a biological cause an effect association? Is there a biological mechanism consistent with the hypothesis? Biological Graient Is there evience of a oseresponse relationship between the number of infectious organisms an transmission or occurrence of isease? Experimental Evience Do the stuies escribe changes in health when hygienic measures are introuce?

12 Aiello, Larson, an Selak December 2008 S139 Avertisements for Bathroom Sets in Sears 1930 Catalogue Figure 3-8. Sears, Roebuck an Co. catalogues, Chicago, 1902, A fuller iscussion of tools to characterize epiemiological relationships between two or more factors, an the occurrence of an effect is presente elsewhere, incluing examples of the application of these criteria. 31 These criteria are not meant to be use as haran-fast rules for either accepting or rejecting causal relationships. 30 One of the implications of holing steafast to these criteria an ignoring other basic scientific principles woul be the pitfall of basing causality on finings from stuies that are methoologically flawe. Hence, the criteria shoul not be applie in the absence of rigorous evaluation of the scientific quality of each stuy. IMPACT OF THE HEALTH REVOLUTION ON INFANT MORTALITY The most ramatic impact of the health revolution was its influence on the mortality of infants an chilren. We examine infantsõ an chilren s morbiity an mortality rates because chilren are more susceptible to many iseases than aults. Prior to 1915, the most important cause of infant eath in the U.S. was iarrhea the most common cases being cholera infantum an teething isease. Causespecific mortality ata prior to 1900 are har to come by for several reasons. The causes of infant eath, as recore in 19th-century eath certificates, are ifficult to interpret, an iarrhea is often reporte in iverse terms. Chilren near an apartment builing. (Reprinte with permission of NYC municipal Archives.) Infant mortality begins a sharp ecline in the U.S. aroun 1890 (Figure 3-13). To further illustrate this fact, iarrhea mortality in Baltimore among chilren less than two years ol consistently roppe every ecae from 1870 (265/100,000) to 1920 (90/ 100,000). 32 This tren of eclining infant mortality rates has continue in more moern times (see Figure 2-5 in the previous article, The Health Revolution: Meical an Socioeconomic Avances ).

13 S140 Vol. 36 No. 10 Supplement 3 Aiello, Larson, an Selak Value ($ million) Soap an Canles Soap Figure 3-9. Soap an Canle Prouction, U.S. Manufactures of the Unite States: 1860 (Washington, D.C.: Government Printing Office, 1865). Compenium of Eleventh Census: 1890, Part III (Washington, D.C.: Government Printing Office, 1897). Census of Manufactures: 1914, The Soap an Detergent Inustry (Washington, D.C.: Government Printing Office, 1917). Biennial Census of Manufactures: 1921, The Soap an Detergent Inustry (Washington, D.C.: Government Printing Office, 1924). eath (which inclue iarrhea) were of an infectious nature, whereas by 1998 mortalities ue to infectious iseases were only two of the top-ten causes (in aition to having much lower rates compare to 1916 an 1940). Nutrition, pasteurization, an personal hygiene all playe important roles in improving the health of infants an chilren. In fact, the ramatic ecrease in infant mortality in the U.S. from about per 1,000 live births prior to 1890 to about 70 per 1,000 live births in 1930 can be attribute mainly to the ecline of iarrheal iseases that are prevente by proper nutrition, milk pasteurization, an personal hygiene. However, iscussion is neee about the egree of impact that nutrition an pasteurization ha on infant mortality an health improvement in general. Factory Shipments (Units per million Capita) 6,000 5,000 4,000 3,000 2,000 1, Figure Home Launry Appliance Shipments Association of Home Appliance Manufacturers, Total Home Launry Appliances, Washington, D.C., Figures 3-14 a, b, an c illustrate the trens for the leaing causes of infant mortality by comparing 1916, 1940, an Diarrhea an relate iseases were the number-one killer in Six of the top causes of infant eaths were infectious iseases. Even as late as the 1940s, six of the top-ten causes of infant Chilren at lunch. (Reprinte with permission of NYC municipal Archives.) Nutrition, pasteurization, an personal hygiene all playe important roles in improving the health of infants an chilren. TheRoleofNutrition Nutritional improvements have been cite by Thomas McKeown as major factors contributing to the ecline of infant mortality. However, he reache this conclusion by euctive reasoning rather than irect evience. 33 His hypothesis might account for the general ecline of infant mortality through the 1800s, but he in t provie ata to account for the sharp ecline in infant mortality between 1890 to 1915.

14 Aiello, Larson, an Selak December 2008 S141 16,000 Factory Shipment (in thousans) 14,000 12,000 10,000 8,000 6,000 4,000 Total Home Launry Appliances Automatic Launry Washers Automatic Dishwashers 2, Figure Home Launry an Dishwashing Appliances Association of Home Appliance Manufacturers, Total Home Launry Appliances, Automatic Washers, Dishwashers, Washington, D.C., TheRoleofPasteurization The role of pasteurization, on the other han, is a public health classic. Mazÿck Ravenel escribes its role. Pasteurization benefits are much more plausible than nutrition. Also, pasteurization was introuce closer in time to the ecline in mortality at the turn of the century. However, pasteurization wasn t generally introuce into the U.S. until the early 1900s, an it wasn t really accepte until a few years later. 33,34 The few available ata on milk consumption suggest that 1910 to 1920 was the earliest time perio with sufficient consumption of pasteurize milk to have a noticeable impact on the infant mortality rate. 35 Thus, pasteurization an nutrition cannot account entirely for the marke infant mortality ecline between 1890 to TheRoleofPersonalHygiene As mentione earlier, the steep ecline in infant mortality began in 1890, a perio in which neither nutrition or pasteurization woul be expecte to account for it. Consiering ata from the states of Massachusetts an Illinois, as well as areas within the City of Newark, New Jersey, eclines of about 20 to 60% occurre by 1910 (Figure 3-13). Personal hygiene changes are a reasonable explanation, as inicate by the rapi growth in soap prouction in this time perio (Figure 3-9). Hanwashing an bathing ecrease the potential transmission to infants of iarrhea agents, which can liberally contaminate the skin of people who on t wash their hans after efecation. These eclines have continue, as illustrate by infant mortality rates in Massachusetts prior to 1890 compare to toay in the U.S. as a whole (see Figure 2-5 in the previous article). In the mi-1800s, 130 to 170 babies out of every 1,000 ie in the first year of life. Toay, that loss has been reuce more than 25 fol! These ata are an inication that hygiene may have playe a role in the ecline in eath rates an isease prevention uring this time perio. The Interrelationship Between Health an HygieneArountheWorl:TheCaseofInfant Mortality Another way to analyze the relationship between personal hygiene an health is to examine geographical ata. If we can show a correlation between hygiene practice an health status among populations in ifferent countries an climates, who have ifferent social systems an iets, an even o so over time, we can help strengthen the link between hygiene an health. Moreover, we will further support this eneavor by showing that the same personal hygiene habits are associate with the same isease problems in all of these areas. In each country, health eterminants genetics, environment, iet, lifestyle, an politics are unique an

15 S142 Vol. 36 No. 10 Supplement 3 Aiello, Larson, an Selak Kg/Capita/Yr Unite States Prouction Inia Consumption Japan Consumption (Bar soap) Figure Toilet Bath Soap Prouction/Consumption. U.S. ata: Census of Manufactures: 1914, The Soap an Detergent Inustry (Washington, D.C.: Government Printing Office, 1917). Biennial Census of Manufactures: 1921, The Soap an Detergent Inustry (Washington, D.C.: Government Printing Office, 1924). Census of Manufactures: 1923, Soap (Washington, D.C.: Government Printing Office, 1925). Census of Manufactures: 1925, Soap (Washington, D.C.: Government Printing Office, 1927). Census of Manufactures: 1927, Soap (Washington, D.C.: Government Printing Office, 1929). Census of Manufactures: 1931, Soap (Washington, D.C.: Government Printing Office, 1933). Census of Manufactures: 1939, Drugs, Meicines, Toilet Preparations, Insecticies, an Relate Proucts, Soap an Glycerin (Washington, D.C.: Government Printing Office, 1941). Census of Manufactures: 1947, Volume II: Statistics by Inustry (Washington, D.C.: Government Printing Office, 1949). U.S. Bureau of the Census, U.S. Census of Manufactures: 1954, Volume II: Statistics by Inustry, Part 1: General Summary of Major Groups 20 to 28 (Washington, D.C.: Government Printing Office, 1957). U.S. Bureau of the Census, Census of Manufactures: 1963, Volume II: Statistics by Inustry, Part 1: Major Groups 20 to 28 (Washington, D.C.: Government Printing Office, 1966). U.S. Bureau of the Census, Census of Manufactures: 1967, Volume II: Inustry Statistics, Part 2: Major Groups 25 to 33 (Washington, D.C.: Government Printing Office, 1971). U.S. Bureau of the Census, Census of Manufactures: 1972, Volume II: Inustry Statistics, Part 2, SIC Major Groups 27 to 34 (Washington, D.C.: Government Printing Office, 1976). U.S. Bureau of the Census, Census of Manufactures: 1977, Volume II: Inustry Statistics, Part 2, SIC Major Groups 27 to 34 (Washington, D.C.: Government Printing Office, 1981). U.S. Bureau of the Census, Census of Manufactures: 1987, Inustry Series, Soaps, Cleaners, an Toilet Goos, Inustries 2841, 2842, 2843, an 2844 (Washington, D.C.: Government Printing Office, 1988). U.S. Census Bureau, Soap an Other Detergent Manufacturing, 1997 Economic Census, Manufacturing, Inustry Series, Washington, D.C., Population numbers: U.S. Census Bureau, Japan ata: Japan Soap an Detergent Association, Ministry of Health, Labour, an Welfare (Japan) populate/popl.html, accesse on February 18, Inia ata: Inian Soap an Toiletries Makers Association, accesse on February 18, combine to show various health outcomes. Thus, any common threa (e.g., soap an etergent use) if measure in each country, woul require controlling for the various baseline risk factors specific to each country. At the very least, itõ s possible to stuy areas where the infant mortality is either lower, higher, or equal to that experience in 19th-century America. Then the hypothesis that soap use an personal hygiene are associate with beneficial health outcomes can be teste. Examples relating soap an washing power consumption aroun the worl to infant mortality rates are presente in Figures 3-15 a an b, which emonstrate a relationship between increase consumption of these proucts an lower infant mortality rates. Figure 3-15a represents an attempt to correlate soap an washing power consumption in an infant mortality rates in 1970 for 36 countries for which these ata are available. Figure 3-15b shows the same