The Sanitarians: A History of American Public Health by John Duffy

The Sanitarians: A History of American Public Health Reviews

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  Mark Bowles

  
  The Sanitarians: A History of American Public Health
  by
  Mark D. Bowles
  
  
  The history of American public health is a much neglected topic and one that John Duffy addressed in his book The Sanitarians. Public health is a far-ranging concept, and in this narrative Duffy defined it as "community action to avoid disease and other threats...to the community." This is further clarified with the view that public health policy should be a positive approach to improving health instead of merely maintaining it. The intent of this book is to simply outline the major developments in American public health since the 17th century. Duffy's focus is on the efforts to organize and institutionalize improvements in the overall health of the American community. This paper will overview these main developments and critique Duffy's treatment of his subject.
  There are three main recurring themes throughout this book. The first is the varying periods of attention and apathy to public health. For example, tuberculosis was one of the main killer diseases in the 19th century, yet was viewed with apathy. The diseases which achieved the most attention were the dramatic epidemic disorders. I see a parallel today with the attention the AIDS research receives and the apathy that surrounds the issues of drunk driving. The second major theme was the impact of the rising urban population density and its effect on sanitation. And finally, this book examined the clash between individual liberty and public welfare. Health regulations were passed to control unsanitary behavior (for example, butchers throwing dead animal waste in the street), which curbed some previous freedoms, and was compounded by the general feeling of distrust toward regulatory laws among Americans.
  Only the most basic of sanitary laws were in existence in the 17th and 18th centuries. This included regulations governing ship conditions, littering, construction of outhouses, removal of dead animals, and quality of bread. By the end of the 17th century, these simple laws existed, yet enforcement was only sporadic. In the late 18th century, health boards began to appear in response to the devastating threat of yellow fever. This positive action was spurred on by fear of disease and the belief that cleanliness was not merely for aesthetics. The miasmatic theory was firmly entrenched and would lead to a full sanitary movement in the 19th century.
  The public outcry against yellow fever resulted in a great paternalistic movement to help the victims, but this paternalism was replaced by individualism in the early 19th century. From 1800 to 1830 there was a massive population explosion in the urban areas which created a major sanitation problem. The result was a sharpening of class lines, along with a decline of medical paternalism and concern for the welfare of the poor.
  The next 30 years, from 1830 to 1860, were important for laying the basis of the sanitary movement of the 19th century. There was an increase of concern over sanitary regulations in 1832 and 1849 with the Asiatic cholera outbreaks; however, after the problem was alleviated, the cities became lax with enforcement. The only lasting effect of Asiatic cholera was to stimulate the demand for clean water. Dedicated sanitary reformers also emerged at this time. They included Benjamin McCready, who studied worker health, John Griscom, who advocated tenement reforms and health care for the poor, Edwin Miller Snow, who proposed a sanitary reform program for Rhode Island, and Lemuel Shattuck, who made important statistical contributions to the study of health. The major event in this period was the formation of the National Sanitary Conventions (1857 to 1860), which marked the beginning of the sanitary revolution. The most significant contribution of these conventions was to shift the public health emphasis from quarantine to environmental conditions.
  Duffy claimed that the Civil War was a watershed in public health and the sanitary revolution, but he did not supply convincing facts to support this claim. The war did help educate the people, and a sanitary commission was proposed; but I think that fear of unknown disease was a major factor in forcing health laws and regulation. Massive troop movements caused the spread of disease, and the previously isolated slaves were set free in a society in which they had no immunity to these diseases. Impoverished immigrants further complicated health problems. The result was the appearance of the first municipal health department in a major city (New York). So, while Duffy claims that a sanitary revolution was under way, he stated that by the end of the 1860s most Americans were unaffected by health laws and regulations.
  The last 40 years of the 19th century were a time of increasing institutionalization and professionalization of public health. Scientific advances were made in bacteriology with research performed by Koch, Pasteur, and Lister. Professionalization of public health occurred in 1872 with the appearance of the American Public Health Association and in 1879 with the creation of the National Board of Health. From 1880 to 1900, the full sanitary revolution occurred with the implementation of water and sewer systems, garbage collection, and expanding health departments. Though by 1900 most states had created health boards, the majority of them were ineffective and powerless; and their main job was to license physicians. Once again, I am not convinced of a sanitary revolution.
  By 1930 these health boards were transformed from weak agencies to strong departments staffed by professionals. This was due to the Progressive movement and improved health techniques learned from World War I, but a main factor was the rise of support by the federal government. An example was the Sheppard-Towner Act of 1921 which provided a five-year ($1, 240,000 per year) budget to the advancement of maternity and infant welfare. During this period of increased governmental involvement, private philanthropy also began to play a more important role in public health. In 1916 the Rockefeller Foundation gave $267,000 to Johns Hopkins School for basic research on public health. The result of these transformations was that the field of public health was fully institutionalized by 1930.
  The depression resulted in the retraction of some of this government spending, and health board budgets were cut. However, Roosevelt's jobs through construction did help the New York Health Department. As the war approached more federal expenditures began to be used for defense. During the war, advances were made that had beneficial effects on public health on the home front. Treatment of shock, hemorrhage, and surgical methods improved. Also, the treatment of mental health benefited with the experience gained from treating battle fatigue. Duffy claimed that the result of this was that the public became convinced that "medicine was the queen of sciences."
  In the postwar years, people became overenthusiastic about the medical advances. The belief was that penicillin was a miracle drug; but new problems arose, like alcoholism for which there was no miracle cure. The postwar years were also characterized by Truman's hospital construction bills, the increased immunization of the 1960s, and the rise in interest in environmental concerns. When Duffy peered into his crystal ball, he saw an optimistic future with the reduction of poverty, the rise of medical ethics, and changing personal habits.
  In assessing this book, I would say that Duffy did an excellent job researching his subject; yet I believe he failed in the structuring of his thoughts into a cohesive organization. His chronology was haphazard; for example, his postwar years chapter discussed Roosevelt's urging Congress for National Health in 1939 and a discussion of sulfa drugs of the 1920s. The title of his book was also too broad. This was not a history of American public health, it was a history of public health institutions and regulations. Also, the name "The Sanitarians" emphasizes the human side of the health problem. Duffy discussed some of the sanitarians but focused mainly on impersonal health boards and regulatory laws. Thus, both the title and sub-title are in error.
  Public health has always interested me. I was greatly moved after reading about the poor health conditions of immigrants in Upton Sinclaire's, The Jungle, and hoped that The Sanitarians would expand my on knowledge this subject within a wider historical and chronological framework. I also became fascinated with the history of public health after my study last semester on Akron's health. So, I anticipated reading Duffy's book, but was, unfortunately, disappointed after completing it. I was very surprised that The Jungle was not mentioned for providing the impetus for the 1906 Pure Food and Drug Act. The story I had always heard was that T. Roosevelt was so appalled after reading the book that he demanded that something be done. In my mind, Sinclaire is a sanitarian, and the Pure Food and Drug Act is the result of human effort for reform. This is where I thought Duffy failed most severely. He did not bring the human condition to the study of public health; and, I believe, this is one of the most essential elements to be included.
  I would also like to point out a factual error which, while trite, should not be made by a historian of medicine. Duffy claimed that "Alcoholism...represent[ed] personal choice." This is, unfortunately, a widespread misconception about a disease. During past student employment I worked at the National Alcoholics Anonymous Convention, which is held at the University (AA was founded in Akron). I listened to literally hundreds of testimonials from recovering alcoholics, as well as doctors, who spoke about the disease. This gave me a new understanding that they suffered from a never-ending disease, and could only begin to recover with the combination of intense willpower and the support of a group like AA. Perhaps, I digress too far, yet I feel that Duffy's error is a common one; and a historian of medicine should not be so irresponsible of his facts.
  
  
  
  
  
  
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  Ashvini

  A very informative book but too broad of a view of the history of public health. There are too many neglected perspectives and experiences that aren’t mentioned to give an accurate view of the history. It was a very wordy book and a bit of a bore.
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  Mike

  A quality if somewhat rushed in places history of public health in America. Probably best read in tandem with Health, Civilization and the State: A History of Public Health from Ancient to Modern Time by Dorothy Porter, to get an international viewpoint. This is a book that I feel should be read by every journalist in America as well as students of medicine and public health, because so much of what we deal with in contemporary health care comes from earlier public health approaches and that's crucial for journalists to understand. The roles of churches, government, and even the military in public health have all been at times as pronounced that of hospitals. Duffy does a good job of providing that overview, I feel the book could have been maybe 200 or so pages longer, however, because there are things he glosses over, yet it's a good introduction and well-written, very readable.
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  Ashley

  Duffy provides a broad, though somewhat shallow, account of the history of public health from 1600 to 1980. He covers a range of topics, including public health education/training, efforts to institutionalize public health, and the political will required to move on a health issue. However, the book is dated and the large scope mean that it is useful as an overview or introduction.
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  Rogue Reader

  The true heroes of 20th Century medicine - poop, piss and spit are often overlooked.
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  Molly

  Very informational, very dry. Difficult to get through, but essential if you're studying the history of public health.