Sanitary Conditions in Towns

Sanitary Conditions in Towns

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Towns in the 14th century were unhealthy places. Most houses were small and contained only a couple of rooms. Sanitary arrangements were very primitive and usually involved having a bucket in the corner of the living room. Efforts were made to persuade people to dig garderobe pits' in their gardens. Others used their waste as manure for their crops growing on their portland plots. However, some people emptied the contents of their buckets onto the street outside.

There were no drains or pipes to carry away dirty water and rotting sewage. The main method of drainage were ditches along the sides of the houses. The government passed a law that forbade the throwing of filth and garbage into ditches and rivers. However, this law was usually ignored.

In East Grinstead one of these ditches ran down the side of Hermitage Lane. On the other side of the road there was another ditch that eventually reached a stream behind the church and entered the Medway at Old Mill Bridge. The river was also polluted by local workers. Tanners, for example, often cleaned their animal skins in the local river which resulted in tannic acid, lime, blood and fat entering the water supply.

Shopkeepers also dumped their rubbish onto the streets. Butchers often slaughtered animals outside their shops and then left the entrails and offal in the street. The rotting and germ-infested refuse would stay in the streets until it was eaten by pigs owned by people living in East Grinstead or it was washed away by a violent rainstorm. Most of this rubbish ended up in a foul-smelling pond at the bottom of the High Street.

1. Look at the drawing of East Grinstead. Explain why rich people tended to build their houses on the High Street near the church.

2. Imagine you are visiting East Grinstead in 1360. Describe your walk down the High Street. Include in your account what you see, hear and smell.

3. Consider your life in Yalding. Would you have been tempted to run away and live in East Grinstead? Write down the arguments for and against moving to East Grinstead. If you decide it is a good idea to move to East Grinstead explain what work you would try to do. Where would you live? Why might some people living in East Grinstead be unhappy about your decision to move to their town?

United States Sanitary Commission

The United States Sanitary Commission (USSC) was a private relief agency created by federal legislation on June 18, 1861, to support sick and wounded soldiers of the United States Army (Federal / Northern / Union Army) during the American Civil War. [a] It operated across the North, raised an estimated $25 million in Civil War era revenue (assuming 1865 dollars, $422.66 million in 2021) and in-kind contributions [1] to support the cause, and enlisted thousands of volunteers. The president was Henry Whitney Bellows, and Frederick Law Olmsted acted as executive secretary. It was modeled on the British Sanitary Commission, set up during the Crimean War (1853-1856), and from the British parliamentary report published after the Indian Rebellion of 1857 ("Sepoy Rebellion"). [2] [3] [b]


With the introduction of General Registration from July 1837 it was possible to gather statistics on mortality for the whole of England and Wales. Edwin Chadwick (1800-1890) drew on this information to write his celebrated report. It helped the passage of the Public Health Act (1848) and the establishment of a Board of Health, of which Chadwick served as a commissioner until it was abolished in 1854. Here are the key conclusions:

"After as careful an examination of the evidence collected as I have been enabled to make, I beg leave to recapitulate the chief conclusions which that evidence appears to me to establish.

First, as to the extent and operation of the evils which are the subject of this inquiry:-

That the various forms of epidemic, endemic, and other disease caused, or aggravated, or propagated chiefly amongst the labouring classes by atmospheric impurities produced by decomposing animal and vegetable substances, by damp and filth, and close and overcrowded dwellings prevail amongst the population in every part of the kingdom, whether dwelling in separate houses, in rural villages, in small towns, in the larger towns - as they have been found to prevail in the lowest districts of the metropolis.

That such disease, wherever its attacks are frequent, is always found in connexion with the physical circumstances above specified, and that where those circumstances are removed by drainage, proper cleansing, better ventilation, and other means of diminishing atmospheric impurity, the frequency and intensity of such disease is abated and where the removal of the noxious agencies appears to be complete, such disease almost entirely disappears.

That high prosperity in respect to employment and wages, and various and abundant food, have afforded to the labouring classes no exemptions from attacks of epidemic disease, which have been as frequent and as fatal in periods of commercial and manufacturing prosperity as in any others.

That the formation of all habits of cleanliness is obstructed by defective supplies of water.

That the annual loss of life from filth and bad ventilation are greater than the loss from death or wounds in any wars in which the country has been engaged in modern times.

That of the 43,000 cases of widowhood, and 112,000 cases of destitute orphanage relieved from the poor rates in England and Wales alone, it appears that the greatest proportion of deaths of the heads of families occurred from the above specified and other removable causes that their ages were under 45 years that is to say, 13 years below the natural probabilities of life as shown by the experience of the whole population of Sweden.

That the public loss from the premature deaths of the heads of families is greater than can be represented by any enumeration of the pecuniary burdens consequent upon their sickness and death.

That, measuring the loss of working ability amongst large classes by the instances of gain, even from incomplete arrangements for the removal of noxious influences from places of work or from abodes, that this loss cannot be less than eight or ten years.

That the ravages of epidemics and other diseases do not diminish but tend to increase the pressure of population.

That in the districts where the mortality is greatest the births are not only sufficient to replace the numbers removed by death, but to add to the population.

That the younger population, bred up under noxious physical agencies, is inferior in physical organisation and general health to a population preserved from the presence of such agencies. That the population so exposed is less susceptible of moral influences, and the effects of education are more transient than with a healthy population.

That these adverse circumstances tend to produce an adult population short-lived, improvident, reckless, and intemperate, and with habitual avidity for sensual gratifications.

That these habits lead to the abandonment of all the conveniences and decencies of life, and especially lead to the overcrowding of their homes, which is destructive to the morality as well as the health of large classes of both sexes.

That defective town cleansing fosters habits of the most abject degradation and tends to the demoralisation of large numbers of human beings, who subsist by means of what they find amidst the noxious filth accumulated in neglected streets and bye-places.

That the expenses of local public works are in general unequally and unfairly assessed, oppressively and uneconomically collected, by separate collections, wastefully expended in separate and inefficient operations by unskilled and practically irresponsible officers.

That the existing law for the protection of the public health and the constitutional machinery for reclaiming its execution, such as the Courts Leet, have fallen into desuetude, and are in the state indicated by the prevalence of the evils they were intended to prevent.

Secondly. As to the means by which the present sanitary condition of the labouring classes may be improved: -

The primary and most important measures, and at the same time the most practicable, and within the recognised province of public administration, are drainage, the removal of all refuse of habitations, streets, and roads, and the improvement of the supplies of water. That the chief obstacles to the immediate removal of decomposing refuse of towns and habitations have been the expense and annoyance of the hand labour and cartage requisite for the purpose.

That this expense may be reduced to one-twentieth or to one-thirtieth, or rendered inconsiderable, by the use of water and self-acting means of removal by improved and cheaper sewers and drains.

That refuse when thus held in suspension in water may be most cheaply and innoxiously conveyed to any distance out of towns, and also in the best form for productive use, and that the loss and injury by the pollution of natural streams may be avoided.

That for all these purposes, as well as for domestic use, better supplies of water are absolutely necessary.

That for successful and economical drainage the adoption of geological areas as the basis of operations is requisite.

That appropriate scientific arrangements for public drainage would afford important facilities for private land- drainage, which is important for the health as well as sustenance of the labouring classes.

That the expense of public drainage, of supplies of water laid on in houses, and of means of improved cleansing would be a pecuniary gain, by diminishing the existing charges attendant on sickness and premature mortality.

That for the protection of the labouring classes and of the ratepayers against inefficiency and waste in all new structural arrangements for the protection of the public health, and to ensure public confidence that the expenditure will be beneficial, securities should be taken that all new local public works are devised and conducted by responsible officers qualified by the possession of the science and skill of civil engineers.

That the oppressiveness and injustice of levies for the whole immediate outlay on such works upon persons who have only short interests in the benefits may be avoided by care in spreading the expense over periods coincident with the benefits.

That by appropriate arrangements, 10 or 15 per cent on the ordinary outlay for drainage might be saved, which on an estimate of the expense of the necessary structural alterations of one-third only of the existing tenements would be a saving of one million and a half sterling, besides the reduction of the future expenses of management.

That for the prevention of the disease occasioned by defective ventilation and other causes of impurity in places of work and other places where large numbers are assembled, and for the general promotion of the means necessary to prevent disease, that it would be good economy to appoint a district medical officer independent of private practice, and with the securities of special qualifications and responsibilities to initiate sanitary measures and reclaim the execution of the law.

That by the combinations of all these arrangements, it is probable that the full ensurable period of life indicated by the Swedish tables that is, an increase of 13 years at least, may be extended to the whole of the labouring classes.

That the attainment of these and the other collateral advantages of reducing existing charges and expenditure are within the power of the legislature, and are dependent mainly on the securities taken for the application of practical science, skill, and economy in the direction of local public works.

And that the removal of noxious physical circumstances, and the promotion of civic, household, and personal cleanliness, are necessary to the improvement of the moral condition of the population for that sound morality and refinement in manners and health are not long found co-existent with filthy habits amongst any class of the community."

History of Medicine © Craig Thornber, Cheshire, England, UK. Main Site Address:


A Brief History of Pollution

Pollution is not a new phenomenon. In fact, pollution has been a problem since the appearance of our earliest ancestors. Increasing human populations have opened the door to more bacteria and disease. During the Middle Ages, diseases such as cholera and typhoid fever broke out all across Europe. These epidemics were directly related to unsanitary conditions caused by human and animal wastes, and garbage. In 1347, the bacterium Yersinia pestis, carried by rats and spread by fleas, caused the "Black Death" &mdash an outbreak of bubonic plague. Unsanitary conditions provided the perfect environment for the deadly bacteria to flourish.

This is a magnified image of Xenopsylla cheopis (oriental rat flea) engorged with blood. This flea is the transmitter of plague diseases in Asia, Africa, and South America. Both male and female fleas can transmit the infection.

By the 1800s, people began to understand that unsanitary living conditions and water contamination contributed to disease epidemics. This new awareness prompted major cities to take measures to control waste and garbage. In the mid-1850s, Chicago built the first major sewage system in the United States to treat wastewater. Soon, many other U.S. cities followed Chicago's lead.

Improved sanitary conditions and less disease were important factors in making cities healthier places to live, and helped encourage people to move to urban areas. As cities became more populated towards the end of the 19th century, industrialized cities across Europe and the United States were experiencing a new kind of pollution: waste from industries and factories. In 1897, a report to the Royal Commission on River Pollution detailed the gross industrial contamination of the Tawe River in Wales, noting that it was polluted by "alkali works, copper works, sulfuric acid liquid, sulfate of iron from tin-plate works, and by slag, cinders and small coal."

In the United States, industrial chemicals and wastes, including sulfuric acid, soda ash, muriatic acid, limes, dyes, wood pulp, and animal byproducts from industrial mills contaminated waters in the Northeast.

This map shows the layout of sewers in Chicago at the end of 1857. Chicago built one of the first sewage systems in the United States to treat wastewater.

Water and air pollution in U.S. urban areas continued to increase well into the 20th century. The Cuyahoga River in Cleveland, Ohio, which flows into Lake Erie, became so polluted that the water erupted into flames! The first fire occurred in 1936, when a spark from a blowtorch ignited floating debris and oils. Over the next 30 years, the river caught fire several more times.

In 1969, another major fire erupted. This time, with the help of news and magazine coverage, the fire prompted the nation to take immediate action against water pollution. The public response to this event helped create the Federal Water Pollution Control Act (1972), commonly called the Clean Water Act. This legislation provides money to improve sewage treatment plants and sets limits on the things that industries and treatment plants can discharge into the water. The Cuyahoga River fires also provided the motivation to create the Great Lakes Water Quality Agreement establish federal and state environmental protection agencies and pass the Oil Pollution Act of 1990, which prohibits the discharge of oil into navigable rivers.

Air pollution from automobiles, industrial processes, and the burning of coal in factories and in homes has also been a serious problem. In the 19th century, episodes of "smog" (a combination of smoke and fog) in cities like New York and London resulted in many deaths. Air pollution continued to be a significant problem up through the middle of the 20th century. In late October of 1948, 20 people were asphyxiated and more than 7,000 became seriously ill as the result of severe air pollution over Donora, Pennsylvania.

Like the 1969 Cuyahoga River fire, the 1948 Donora incident led to the creation of the Air Pollution Control Act of 1955. This was the first federal attempt to control air pollution. Since then, clean air legislation has been revised and strengthened. The Clean Air Act of 1990 sets limits on the discharge of air pollutants from industrial facilities and motor vehicles, and addresses acid rain and ozone depletion.

These laws have significantly reduced the amount of pollution released into the environment. Grossly contaminated water and air are much less common today than they were 50 years ago. Nevertheless, some of today's experts are concerned about the possible risks of continuous low-level exposure to pollutants, and particularly to nonpoint source pollutants.

Firefighters battle a fire on Ohio's Cuyahoga River in 1952. The polluted river caught fire on several occasions between 1936 and 1969, when debris and oil had concentrated on the water's surface and ignited. A blaze in 1969 came at a time of increasing environmental awareness and symbolized years of environmental neglect. The Cuyahoga River fires helped spur grassroots activism that resulted in a wave of federal legislation devoted to taking serious action against air and water pollution.

This eerie photograph was taken at noon on Oct. 29, 1948 in Donora, PA as deadly smog enveloped the town. 20 people were asphyxiated and more than 7,000 became seriously ill during this horrible event.


While outhouses are one of the humbler elements of our sanitation systems, they have received a surprising amount of design attention and even public affection. They were actually a considerable advance over many older disposal methods in the United States (open trenches, cesspits), and the U.S. government actively encouraged their use in rural areas in the 1930s and 40s.

Outhouses remaining from older times are the subject of photography books and posters, while new outhouses are constructed for parades and competitions. The outhouse seems to have an enduring place in the public imagination.

Plans for General Israel Putnam's privy, Brooklyn, Windham County, Connecticut. The outhouse was built in 1776 by Israel Putnam. Note on sheet 2: "It was in the field to the west and south of this building that Gen. Putnam was plowing when he was summoned to come to Massachusetts and join the patriot forces in the Revolution." The outhouse was overturned in the hurricane of 1938 (see below). These plans were drawn in 1940 by the Historic American Buildings Survey, U.S. Dept. of the Interior, National Park Service. Sheet 1 of 2.Source: Library of Congress, Prints and Photographs Division, Historic American Buildings Survey or Historic American Engineering Record, Reproduction Number HABS, CONN,8-BROOK,2-.

Plans for General Israel Putnam's privy, Brooklyn, Windham County, Connecticut. The outhouse was built in 1776 by Israel Putnam. Note on the sheet: "It was in the field to the west and south of this building that Gen. Putnam was plowing when he was summoned to come to Massachusetts and join the patriot forces in the Revolution." The outhouse was overturned in the hurricane of 1938 (see below). These plans were drawn in 1940 by the Historic American Buildings Survey, U.S. Dept. of the Interior, National Park Service. Sheet 2 of 2.Source: Library of Congress, Prints and Photographs Division, Historic American Buildings Survey or Historic American Engineering Record, Reproduction Number HABS, CONN,8-BROOK,2-.

Ruin of General Israel Putnam's privy, Brooklyn, Windham County, Connecticut. The outhouse was built in 1776 by Israel Putnam, and was overturned in the hurricane of 1938. Photograph by Stanley P. Mixon. Photo date May 16, 1940.Source: Library of Congress, Prints and Photographs Division, Historic American Buildings Survey or Historic American Engineering Record, Reproduction Number HABS, CONN,8-BROOK,2-.

Plans for outhouse for the June Residence, North Salem, Westchester County, New York. The outhouse was built in 1846. These plans were drawn in 1936 by the Historic American Buildings Survey, U.S. Dept. of the Interior, National Park Service. Cover sheet.Source: Library of Congress, Prints and Photographs Division, Historic American Buildings Survey or Historic American Engineering Record, Reproduction Number HABS, NY,60-SALN,1- & 1A-.

Plans for outhouse for the June Residence, North Salem, Westchester County, New York. The outhouse was built in 1846. These plans were drawn in 1936 by the Historic American Buildings Survey, U.S. Dept. of the Interior, National Park Service. Sheet 1 of 2.Source: Library of Congress, Prints and Photographs Division, Historic American Buildings Survey or Historic American Engineering Record, Reproduction Number HABS, NY,60-SALN,1- & 1A-.

Plans for outhouse for the June Residence, North Salem, Westchester County, New York. The outhouse was built in 1846. These plans were drawn in 1936 by the Historic American Buildings Survey, U.S. Dept. of the Interior, National Park Service. Sheet 2 of 2.Source: Library of Congress, Prints and Photographs Division, Historic American Buildings Survey or Historic American Engineering Record, Reproduction Number HABS, NY,60-SALN,1- & 1A-.

Outhouse for the June Residence, North Salem, Westchester County, New York. The outhouse was built in 1846.Source: Library of Congress, Prints and Photographs Division, Historic American Buildings Survey or Historic American Engineering Record, Reproduction Number HABS, NY,60-SALN,1- & 1A-.

Unusual privy constructed circa 1847 in Monterey, New Castle County, Delaware. Photo date after 1933.Source: Library of Congress, Prints and Photographs Division, Historic American Buildings Survey or Historic American Engineering Record, Reproduction Number HABS, DEL,2-MCDO.V,1-B-.

Plans for renovation of Custis-Maupin Necessary House, 200 Duke of Gloucester St., Williamsburg, Williamsburg County, Virginia. The necessary house was one of the original 88 buildings in colonial Williamsburg. It dates from the late 18th - early 19th century, and was renovated in 1928 and 1980. These plans were drawn in 1980 for the Office of Archeology and Historic Preservation, Heritage Conservation and Recreation Service, U.S. Dept. of the Interior. Sheet 1 of 2.Source: Library of Congress, Prints and Photographs Division, Historic American Buildings Survey or Historic American Engineering Record, Reproduction Number HABS, VA,48-WIL,63-.

Plans for renovation of Custis-Maupin Necessary House, 200 Duke of Gloucester St., Williamsburg, Williamsburg County, Virginia. The necessary house was one of the original 88 buildings in colonial Williamsburg. It dates from the late 18th - early 19th century, and was renovated in 1928 and 1980. These plans were drawn in 1980 for the Office of Archeology and Historic Preservation, Heritage Conservation and Recreation Service, U.S. Dept. of the Interior. Sheet 2 of 2.Source: Library of Congress, Prints and Photographs Division, Historic American Buildings Survey or Historic American Engineering Record, Reproduction Number HABS, VA,48-WIL,63-.

Privy of President Calvin Coolidge, Vermont. Photograph by Samuel H. Gottscho, 1857-1971. Photo date August 2, 1961.Source: Library of Congress, Prints and Photographs Division, Gottscho-Schleisner Collection, Reproduction NumberLC-G613-77177 DLC.

Brick privy at Korner's Folly, 271 S. Main St., Kernersville, Forsyth County, North Carolina. Photo date after 1933.Source: Library of Congress, Prints and Photographs Division, Historic American Buildings Survey or Historic American Engineering Record, Reproduction Number HABS, NC,34-KERN,1A-.

Image published in 1875 in the Scientific American, Volume 10, Issue 9. The image depicts the “Johnson and Nettleton’s Deodorizing Excavator’, which was invented for pumping out cesspools and septic tanks all the while minimizing odors". Source: Jon C. Schladweiler

Cholera Highlights the Need

A cholera epidemic left India in 1817 and reached Sunderland in late 1831 London was affected by February 1832. Fifty percent of all cases proved fatal. Some towns set up quarantine boards, and they promoted whitewashing (cleaning clothing with chloride of lime) and speedy burials, but they were targeting disease under the miasma theory that disease was caused by floating vapors rather than the unrecognized infectious bacterium. Several leading surgeons recognized that cholera prevailed where sanitation and drainage were poor, but their ideas for improvement were temporarily ignored. In 1848 cholera returned to Britain, and the government resolved that something had to be done.

Factors associated with sanitary conditions of food and drinking establishments in Addis Ababa, Ethiopia: cross-sectional study

Introduction: Food borne illness has been a global challenge and it persisted as a major public health problem, which consumes significant amounts of health care resources, particularly in the developing world. Poor sanitary conditions of food and drinking establishments are the major cause for the occurrence of food borne illness. This study assessed sanitary conditions of food and drinking establishments in Arada sub-city, Addis Ababa, Ethiopia.

Methods: A cross-sectional study design with stratified simple random sampling technique was used. Data were collected from 587 licensed food and drinking establishments and their managers, using interviewer administered questionnaire and observation checklist. The data were entered using Epi info version 3.5.3 and analyzed using SPSS version 20. Binary and Multi-variable logistic regression analyses were conducted.

Results: The study showed 58.8% of food and drinking establishments were under poor sanitary conditions only 16.5% of the establishments had a proper liquid waste disposal facility, and only 7.2% had a suitable dish washing facility. Availability of trained managers on hygiene and sanitation (AOR = 2.56, 95% CI: 1.66-3.94) inspection from the respective body (AOR = 4.41, 95% CI: 2.9-6.8) and the distance between kitchen and toilet (AOR = 1.8, 95% CI: 1.1-3.0) were associated factors which affected sanitary conditions.

Conclusion: A majority of the establishments had poor sanitary conditions where an absence of sanitary facilities for waste management was major cause. Regulatory bodies should conduct regular inspection on the establishments to promote and ensure proper hygiene and sanitation practices.

Keywords: Arada sub-city Food and drinking establishments sanitary conditions.

Chapter 1: Housing History and Purpose

&ldquoSafe, affordable housing is a basic necessity for every family. Without a decent place to live, people cannot be productive members of society, children cannot learn and families cannot thrive.&rdquo

Tracy Kaufman, Research Associate
National Low Income Housing Coalition/
Low Income Housing Information Service 2003

The term &ldquoshelter,&rdquo which is often used to define housing, has a strong connection to the ultimate purpose of housing throughout the world. The mental image of a shelter is of a safe, secure place that provides both privacy and protection from the elements and the temperature extremes of the outside world. This vision of shelter, however, is complex. The earthquake in Bam, Iran, before dawn on December 26, 2003, killed in excess of 30,000 people, most of whom were sleeping in their homes. Although the homes were made of the most simple construction materials, many were well over a thousand years old. Living in a home where generation after generation had been raised should provide an enormous sense of security. Nevertheless, the world press has repeatedly implied that the construction of these homes destined this disaster. The homes in Iran were constructed of sun-dried mud-brick and mud.

We should think of our homes as a legacy to future generations and consider the negative environmental effects of building them to serve only one or two generations before razing or reconstructing them. Homes should be built for sustainability and for ease in future modification. We need to learn the lessons of the earthquake in Iran, as well as the 2003 heat wave in France that killed in excess of 15,000 people because of the lack of climate control systems in their homes. We must use our experience, history, and knowledge of both engineering and human health needs to construct housing that meets the need for privacy, comfort, recreation, and health maintenance.

Health, home construction, and home maintenance are inseparable because of their overlapping goals. Many highly trained individuals must work together to achieve quality, safe, and healthy housing. Contractors, builders, code inspectors, housing inspectors, environmental health officers, injury control specialists, and epidemiologists all are indispensable to achieving the goal of the best housing in the world for U.S. citizens. This goal is the basis for the collaboration of the U.S. Department of Housing and Urban Development (HUD) and the Centers for Disease and Control and Prevention (CDC).

Preurban Housing
Early dwelling designs were probably the result of cultural, socioeconomic, and physical forces intrinsic to the environment of their inhabitants. The housing similarities among civilizations separated by vast distances may have been a result of a shared heritage, common influences, or chance.

Caves were accepted as dwellings, perhaps because they were ready made and required little or no construction. However, in areas with no caves, simple shelters were constructed and adapted to the availability of resources and the needs of the population. Classification systems have been developed to demonstrate how dwelling types evolved in preurban indigenous settings [1].

Ephemeral Dwellings
Ephemeral dwellings, also known as transient dwellings, were typical of nomadic peoples. The African bushmen and Australia&rsquos aborigines are examples of societies whose existence depends on an economy of hunting and food gathering in its simple form. Habitation of an ephemeral dwelling is generally a matter of days.

Episodic Dwellings
Episodic housing is exemplified by the Inuit igloo, the tents of the Tungus of eastern Siberia, and the very similar tents of the Lapps of northern Europe. These groups are more sophisticated than those living in ephemeral dwellings, tend to be more skilled in hunting or fishing, inhabit a dwelling for a period of weeks, and have a greater effect on the environment. These groups also construct communal housing and often practice slash-and-burn cultivation, which is the least productive use of cropland and has a greater environmental impact than the hunting and gathering of ephemeral dwellers.

Periodic Dwellings
Periodic dwellings are also defined as regular temporary dwellings used by nomadic tribal societies living in a pastoral economy. This type of housing is reflected in the yurt used by the Mongolian and Kirgizian groups and the Bedouins of North Africa and western Asia. These groups&rsquo dwellings essentially demonstrate the next step in the evolution of housing, which is linked to societal development. Pastoral nomads are distinguished from people living in episodic dwellings by their homogenous cultures and the beginnings of political organization. Their environmental impact increases with their increased dependence on agriculture rather than livestock.

Seasonal Dwellings
Schoenauer [1] describes seasonal dwellings as reflective of societies that are tribal in nature, seminomadic, and based on agricultural pursuits that are both pastoral and marginal. Housing used by seminomads for several months or for a season can be considered semisedentary and reflective of the advancement of the concept of property, which is lacking in the preceding societies. This concept of property is primarily of communal property, as opposed to individual or personal property. This type of housing is found in diverse environmental conditions and is demonstrated in North America by the hogans and armadas of the Navajo Indians. Similar housing can be found in Tanzania (Barabaig) and in Kenya and Tanzania (Masai).

Semipermanent Dwellings
According to Schoenauer [1], sedentary folk societies or hoe peasants practicing subsistence agriculture by cultivating staple crops use semipermanent dwellings. These groups tend to live in their dwellings various amounts of time, usually years, as defined by their crop yields. When land needs to lie fallow, they move to more fertile areas. Groups in the Americas that used semipermanent dwellings included the Mayans with their oval houses and the Hopi, Zuni, and Acoma Indians in the southwestern United States with their pueblos.

Permanent Dwellings
The homes of sedentary agricultural societies, whose political and social organizations are defined as nations and who possess surplus agricultural products, exemplify this type of dwelling. Surplus agricultural products allowed the division of labor and the introduction of other pursuits aside from food production however, agriculture is still the primary occupation for a significant portion of the population. Although they occurred at different points in time, examples of early sedentary agricultural housing can be found in English cottages, such as the Suffolk, Cornwall, and Kent cottages [1].

Permanent dwellings went beyond simply providing shelter and protection and moved to the consideration of comfort. These structures began to find their way into what is now known as the urban setting. The earliest available evidence suggests that towns came into existence around 4000 BC. Thus began the social and public health problems that would increase as the population of cities increased in number and in sophistication. In preurban housing, the sparse concentration of people allowed for movement away from human pollution or allowed the dilution of pollution at its location. The movement of populations into urban settings placed individuals in close proximity, without the benefit of previous linkages and without the ability to relocate away from pollution or other people.

Urbanization was relatively slow to begin, but once started, it accelerated rapidly. In the 1800s, only about 3% of the population of the world could be found in urban settings in excess of 5,000 people. This was soon to change. The year 1900 saw the percentage increase to 13.6% and subsequently to 29.8% in 1950. The world&rsquos urban population has grown since that time. By 1975, more than one in three of the world&rsquos population lived in an urban setting, with almost one out of every two living in urban areas by 1997. Industrialized countries currently find approximately 75% of their population in an urban setting. The United Nations projects that in 2015 the world&rsquos urban population will rise to approximately 55% and that in industrialized nations it will rise to just over 80%.

In the Western world, one of the primary forces driving urbanization was the Industrial Revolution. The basic source of energy in the earliest phase of the Industrial Revolution was water provided by flowing rivers. Therefore, towns and cities grew next to the great waterways. Factory buildings were of wood and stone and matched the houses in which the workers lived, both in construction and in location. Workers&rsquo homes were little different in the urban setting than the agricultural homes from whence they came. However, living close to the workplace was a definite advantage for the worker of the time. When the power source for factories changed from water to coal, steam became the driver and the construction materials became brick and cast iron, which later evolved into steel. Increasing populations in cities and towns increased social problems in overcrowded slums. The lack of inexpensive, rapid public transportation forced many workers to live close to their work. These factory areas were not the pastoral areas with which many were familiar, but were bleak with smoke and other pollutants.

The inhabitants of rural areas migrated to ever-expanding cities looking for work. Between 1861 and 1911 the population of England grew by 80%. The cities and towns of England were woefully unprepared to cope with the resulting environmental problems, such as the lack of potable water and insufficient sewerage.

In this atmosphere, cholera was rampant and death rates resembled those of Third World countries today. Children had a one in six chance of dying before the age of 1 year. Because of urban housing problems, social reformers such as Edwin Chadwick began to appear. Chadwick&rsquos Report on an Enquiry into the Sanitary Condition of the Labouring Population of Great Britain and on the Means of its Improvement [2] sought many reforms, some of which concerned building ventilation and open spaces around the buildings. However, Chadwick&rsquos primary contention was that the health of the working classes could be improved by proper street cleaning, drainage, sewage, ventilation, and water supplies. In the United States, Shattuck et al. [3] wrote the Report of the Sanitary Commission of Massachusetts, which was printed in 1850. In the report, 50 recommendations were made. Among those related to housing and building issues were recommendations for protecting school children by ventilation and sanitation of school buildings, emphasizing town planning and controlling overcrowded tenements and cellar dwellings. Figure 1.1 demonstrates the conditions common in the tenements.

In 1845, Dr. John H. Griscom, the City Inspector of New York, published The Sanitary Condition of the Laboring Population of New York [4]. His document expressed once again the argument for housing reform and sanitation. Griscom is credited with being the first to use the phrase &ldquohow the other half lives.&rdquo During this time, the poor were not only subjected to the physical problems of poor housing, but also were victimized by corrupt landlords and builders.

Trends in Housing
The term &ldquotenement house&rdquo was first used in America and dates from the mid-nineteenth century. It was often intertwined with the term &ldquoslum.&rdquo Wright [5] notes that in English, tenement meant &ldquoan abode for a person or for the soul, when someone else owned the property.&rdquo Slum, on the other hand, initially was used at the beginning of the 19th century as a slang term for a room. By the middle of the century, slum had evolved into a term for a back dwelling occupied by the lowest members of society. Von Hoffman [6] states that this term had, by the end of the century, begun to be used interchangeably with the term tenement. The author noted additionally that in the larger cities of the United States, the apartment house emerged in the 1830s as a housing unit of two to five stories, with each story containing apartments of two to four rooms. It was originally built for the upper group of the working class. The tenement house emerged in the 1830s when landlords converted warehouses into inexpensive housing designed to accommodate Irish and black workers. Additionally, existing large homes were subdivided and new structures were added, creating rear houses and, in the process, eliminating the traditional gardens and yards behind them. These rear houses, although new, were no healthier than the front house, often housing up to 10 families. When this strategy became inadequate to satisfy demand, the epoch period of the tenements began.

Although unpopular, the tenement house grew in numbers, and, by 1850 in New York and Boston, each tenement housed an average of 65 people. During the 1850s, the railroad house or railroad tenement was introduced. This structure was a solid, rectangular block with a narrow alley in the back. The structure was typically 90 feet long and had 12 to 16 rooms, each about 6 feet by 6 feet and holding around four people. The facility allowed no direct light or air into rooms except those facing the street or alley. Further complicating this structure was the lack of privacy for the tenants. A lack of hallways eliminated any semblance of privacy. Open sewers, a single privy in the back of the building, and uncollected garbage resulted in an objectionable and unhygienic place to live. Additionally, the wood construction common at the time, coupled with coal and wood heating, made fire an ever-present danger. As a result of a series of tenement fires in 1860 in New York, such terms as death-trap and fire-trap were coined to describe the poorly constructed living facilities [6].

The two last decades of the 19th century saw the introduction and development of dumbbell tenements, a front and rear tenement connected by a long hall. These tenements were typically five stories, with a basement and no elevator (elevators were not required for any building of less than six stories). Dumbbell tenements, like other tenements, resulted in unaesthetic and unhealthy places to live. Garbage was often thrown down the airshafts, natural light was confined to the first floor hallway and the public hallways only contained one or two toilets and a sink. This apparent lack of sanitary facilities was compounded by the fact that many families took in boarders to help with expenses. In fact, 44,000 families rented space to boarders in New York in 1890, with this increasing to 164,000 families in 1910. In the early 1890s, New York had a population of more than 1 million, of which 70% were residents of multifamily dwellings. Of this group, 80% lived in tenements consisting mostly of dumbbell tenements.

The passage of the New York Tenement House Act of 1901 spelled the end of the dumbbells and acceptance of a new tenement type developed in the 1890s&mdashthe park or central court tenement, which was distinguished by a park or open space in the middle of a group of buildings. This design was implemented to reduce the activity on the front street and to enhance the opportunity for fresh air and recreation in the courtyard. The design often included roof playgrounds, kindergartens, communal laundries, and stairways on the courtyard side.

Although the tenements did not go away, reform groups supported ideas such as suburban cottages to be developed for the working class. These cottages were two-story brick and timber, with a porch and a gabled roof. According to Wright [5], a Brooklyn project called Homewood consisted of 53 acres of homes in a planned neighborhood from which multifamily dwellings, saloons, and factories were banned.

Although there were many large homes for the well-to-do, single homes for the not-so-wealthy were not abundant. The first small house designed for the individual of modest means was the bungalow. According to Schoenauer [1], bungalows originated in India. The bungalow was introduced into the United States in 1880 with the construction of a home in Cape Cod. The bungalow, derived for use in tropical climates, was especially popular in California.

Company towns were another trend in housing in the 19th century. George Pullman, who built railway cars in the 1880s, and John H. Patterson, of the National Cash Register Company, developed notable company towns. Wright [5] notes that in 1917 the U.S. Bureau of Labor Standards estimated that at least 1,000 industrial firms were providing housing for their employees. The provision of housing was not necessarily altruistic. The motivation for providing housing varied from company to company. Such motivations included the use of housing as a recruitment incentive for skilled workers, a method of linking the individual to the company, and a belief that a better home life would make the employees happier and more productive in their jobs. Some companies, such as Firestone and Goodyear, went beyond the company town and allowed their employees to obtain loans for homes from company-established banks. A prime motivator of company town planning was sanitation, because maintaining the worker&rsquos health could potentially lead to fewer workdays lost due to illness. Thus, in the development of the town, significant consideration was given to sanitary issues such as window screens, sewage treatment, drainage, and water supplies.

Before World War I there was a shortage of adequate dwellings. Even after World War I, insufficient funding, a shortage of skilled labor, and a dearth of building materials compounded the problem. However, the design of homes after the war was driven in part by health considerations, such as providing good ventilation, sun orientation and exposure, potable pressurized water, and at least one private toilet. Schoenauer [1] notes that, during the postwar years, the improved mobility of the public led to an increase in the growth of suburban areas, exemplified by the detached and sumptuous communities outside New York, such as Oyster Bay. In the meantime, the conditions of working populations consisting of many immigrants began to improve with the improving economy of the 1920s. The garden apartment became popular. These units were well lighted and ventilated and had a courtyard, which was open to all and well maintained.

Immediately after World War I and during the 1920s, city population growth was outpaced by population growth in the suburbs by a factor of two. The focus at the time was on the single-family suburban dwelling. The 1920s were a time of growth, but the decade following the Great Depression, beginning in 1929, was one of deflation, cessation of building, loss of mortgage financing, and the plunge into unemployment of large numbers of building trade workers. Additionally, 1.5 million home loans were foreclosed during this period. In 1936, the housing market began to make a comeback however, the 1930s would come to be known as the beginning of public housing, with increased public involvement in housing construction, as demonstrated by the many laws passed during the era [5]. The National Housing Act was passed by Congress in 1934 and set up the Federal Housing Administration. This agency encouraged banks, building and loan associations, and others to make loans for building homes, small business establishments, and farm buildings. If the Federal Housing Administration approved the plans, it would insure the loan. In 1937, Congress passed another National Housing Act that enabled the Federal Housing Administration to take control of slum clearance. It made 60-year loans at low interest to local governments to help them build apartment blocks. Rents in these homes were fixed and were only available to low-income families. By 1941, the agency had assisted in the construction of more than 120,000 family units.

During World War II, the focus of home building was on housing for workers who were involved in the war effort. Homes were being built through federal agencies such as the newly formed Federal Housing Administration, formed in 1934 and transferred to HUD in 1965. According to the U.S. Census Bureau (USCB) [7], in the years since World War II, the types of homes Americans live in have changed dramatically. In 1940, most homes were considered attached houses (row houses, townhouses, and duplexes). Small apartment houses with two to four apartments had their zenith in the 1950s. In the 1960 census, two-thirds of the housing inventory was made up of one-family detached houses, which declined to less than 60% in the 1990 census.

The postwar years saw the expansion of suburban housing led by William J. Levitt&rsquos Levittown, on Long Island, which had a strong influence on postwar building and initiated the subdivisions and tract houses of the following decades Figure 1.2. The 1950s and 1960s saw continued suburban development, with the growing ease of transportation marked by the expansion of the interstate highway system. As the cost of housing began to increase as a result of increased demand, a grassroots movement to provide adequate housing for the poor began to emerge. According to Wright [5], in the 1970s only about 25% of the population could afford a $35,000 home. According to Gaillard [8], Koinonia Partners, a religious organization founded in 1942 by Clarence Jordan near Albany, Georgia, was the seed for Habitat for Humanity. Habitat for Humanity, founded in 1976 by Millard Fuller, is known for its international efforts and has constructed more than 150,000 houses in 80 countries 50,000 of these houses are in the United States. The homes are energy-efficient and environmentally friendly to conserve resources and reduce long-term costs to the homeowners.

Builders also began promoting one-floor mini homes and no-frills homes of approximately 900 to 1,200 square feet. Manufactured housing began to increase in popularity, with mobile home manufacturers becoming some of the most profitable corporations in the United States in the early 1970s. In the 1940 census, manufactured housing were lumped into the &ldquoother&rdquo category with boats and tourist cabins: by the 1990 census, manufactured housing made up 7% of the total housing inventory. Many communities ban manufactured housing from residential neighborhoods.

According to Hart et al. [9], nearly 30% of all home sales nationwide are of manufactured housing, and more than 90% of those homes are never moved once they are anchored. According to a 2001 industry report, the demand for prefabricated housing is expected to increase in excess of 3% annually to $20 billion in 2005, with most units being manufactured homes. The largest market is expected to continue in the southern part of the United States, with the most rapid growth occurring in the western part of the country. As of 2000, five manufactured-home producers, representing 35% of the market, dominated the industry. This industry, over the past 20 to 25 years, has been affected by two pieces of federal legislation. The first, the Mobile Home Construction and Safety Standards Act, adopted by HUD in 1974, was passed to aid consumers through regulation and enforcement of HUD design and construction standards for manufactured homes. The second, the 1980 Housing Act, required the federal government to change the term &ldquomobile home&rdquo to &ldquomanufactured housing&rdquo in all federal laws and literature. One of the prime reasons for this change was that these homes were in reality no longer mobile in the true sense.

The energy crisis in the United States between 1973 and 1974 had a major effect on the way Americans lived, drove, and built their homes. The high cost of both heating and cooling homes required action, and some of the action taken was ill advised or failed to consider healthy housing concerns. Sealing homes and using untried insulation materials and other energy conservation actions often resulted in major and sometimes dangerous buildups of indoor air pollutants. These buildups of toxins occurred both in homes and offices. Sealing buildings for energy efficiency and using off-gassing building materials containing urea-formaldehyde, vinyl, and other new plastic surfaces, new glues, and even wallpapers created toxic environments. These newly sealed environments were not refreshed with makeup air and resulted in the accumulation of both chemical and biologic pollutants and moisture leading to mold growth, representing new threats to both short-term and long-term health. The results of these actions are still being dealt with today.

    Schoenauer N. 6,000 years of housing. New York/London: W.W. Norton & Company, Inc. 2000. Chadwick E. Report on an enquiry into the sanitary condition of the labouring population of Great Britain and on the means of its improvements. London: Clowes and Sons 1842. Shattuck L, Banks N Jr, Abbot J. Report of the Sanitary
    Commission of Massachusetts, 1850. Boston: Dutton and Wentworth 1850. Available from URL: Cdc-pdf [PDF -876 KB] External . Griscom JH. The sanitary condition of the labouring population of New York. New York: Harper 1845. Wright G. Building the dream&mdasha social history of housing in America. Cambridge, MA/London: The MIT Press 1998. Von Hoffman A. The origins of American housing reform. Cambridge, MA: Joint Center for Housing Studies&mdashHarvard University August 1998. p. W98-2. US Census Bureau. Historical census of housing tables&mdashunits in structure 2002. Washington, DC: US Census Bureau 2002. Available from URL: External . Gaillard F. If I were a carpenter, twenty years of Habitat for Humanity. Winston-Salem, NC: John E. Blair 1996. Hart JF, Rhodes MJ, Morgan JT, Lindberg MB. The unknown world of the mobile home. Baltimore, MD: Johns Hopkins University Press 2002.

Additional Sources of Information

Dolkart A. The 1901 Tenement House Act: chapter 6, cleaning up the toilets. New York: Lower East Side Tenement Museum no date. Available from URL:

Hale EE. Workingmen&rsquos homes, essays and stories, on the homes of men who work in large towns. Boston: James R. Osgood and Company 1874.

History of plumbing in America. Plumbing and Mechanical Magazine 1987 Jul. Available from URL: External .

Housing Act of 1949, The US Committee on Agriculture Glossary.

Lang RE, Sohmer RR. Editors&rsquo introduction, legacy of the Housing Act of 1949: the past, present, and future of federal housing and urban policy.
Housing Policy Debate 2000 11(2) 291&ndash8. Available from URL: [PDF &ndash 131 KB].

Mason JB. History of housing in the US. 1930&ndash1980. Houston, TX: Gulf Publishing Company 1982.

Louis Pasteur (late 1800)

Louis Pasteur was a French biologist and chemist who made enormous contributions to germ theory, to prevention of food spoilage, and to the control of disease. In 1853 Pasteur began studying fermentation in wine and beer and rapidly concluded that microorganisms were responsible. He also discovered that microbes in milk could be killed by heating to about 130 degrees Fahrenheit, a process which is now known as 'pasteurization'. He discovered that some microorganisms require oxygen (aerobic organisms), while others reproduce in the absence of oxygen (anaerobic).

Pasteur pioneered the idea of artificially generating weakened microorganisms as vaccines. Edward Jenner's work had demonstrated the principle with the naturally occurring cowpox, which could be used to vaccinate against smallpox. Pasteur was able to artificially weaken strains of anthrax and cholera in order to generate vaccines. It was, in fact, Pasteur who coined the term 'vaccine' in honor of Jenner's discovery. Pasteur developed vaccines against anthrax in sheep and cholera in chickens. In 1885 he developed a vaccine for rabies by growing it in rabbits and then drying the nerve tissue that had been infected with the virus. This vaccine was successfully used to save the life of a boy who had been bitten by a rabid dog.

Key Concept: The impact of these developments is now clear. The idea of counting disease events and causes of death and then conducting analyses to make comparisons, e.g., between city dwellers and rural communities, paved the way for thinking about interventions to reduce disease and improve the health of the general population.

As an example, consider the remarkable decline in mortality from tuberculosis that occurred in Great Britain from 1850 to 1960 as a result of the implementation of the "Sanitary Idea." The decline is shown in the graph below, but note the temporary increases in TB mortality that occurred during World War I and World War II when nutrition declined and people were periodically forced into air raid shelters, cramped living quarters, troop transports, and barracks..

Other infectious diseases showed similar declines.

Content �. All Rights Reserved.
Date last modified: October 18, 2017.
Wayne W. LaMorte, MD, PhD, MPH

Epidemics in Western Society Since 1600

Chapter 1. The Sanitary Movement [00:00:00]

Professor Frank Snowden: This morning we’ll take up one of the themes — that is to say, we’ve described how the course is about specific diseases, but it’s also about a number of overarching themes, and one of those is the development of various public health strategies. So far, as you’ll remember, we’ve dealt with three public health strategies. One was the system of plague measures: sanitary cordons, lazarettos, quarantine, and all the rest of it. We’ve dealt with vaccination as a public health strategy, with regard to smallpox in particular. And we’ve talked about a third policy, if we want to dignify it in that way, and this was the strategy of concealment.

This morning I want to talk about a fourth approach to public health, and this was what’s called commonly the sanitary movement. This was pioneered in Britain in the 1830s and 󈧬s, and it was then exported to the continent in North America, assuming particular forms in France and Italy, with the actual rebuilding of cities in accord with sanitary principles. Now, the sanitary movement was the first to define itself as a public health movement, and it had two essential meanings for its term. The first was the prevention of infectious epidemic diseases, and the second was the removal of filth. So, it’s based, in a sense, on the relationship of filth and disease. Indeed, many people talk about the filth theory of disease as lying at the basis of the sanitary movement. Its focus, therefore, was on the towns and cities that had sprung up with urbanization and the industrial revolution.

Epidemic diseases disproportionately claimed their victims in the cities, and correspondingly the legacy of lasting effects was especially pronounced in urban areas, and the sanitary movement is one of those lasting legacies. Now, there is a theory that we may as well look at, just for a second, developed by the British physician and demographer, Thomas McKeown — and it’s often called his thesis — where he was dealing with the demographic fact of what he called a mortality revolution a demographic transition in which cities, for the first time, become places that are dependent for their expansion not only on inward migration to the towns, but on the fact that the longevity and the birthrate come to exceed the death rate which was something new, a real demographic revolution.

And why was this achieved? Many people have thought and postulated that it was due to medical science, to conscious policy and those sorts of explanations. McKeown instead stresses two factors. He sees this as largely unplanned and due to improved nutrition, but also — and that’s the point this morning — to the role of sanitation. In other words, the population explosion, the demographic revolution, is something that he postulates was due to, not to medical science, but rather to the sanitary movement, and also to nutrition.

Chapter 2. Background [00:04:13]

Well, what was the background to the sanitary movement? We’ve seen and mentioned that there really was a tremendous challenge to health in this period of the industrial revolution in European history. There were tremendous changes afoot in British society. There was the rise of a modern commercial agriculture, and with it enclosure, the driving of peasants off the land. We know about the major demographic growth that was underway by this period, supported by the new agriculture and the fading of the threat of famine and the fading of the threat of plague. There was the rise of manufacture, and then the factory system, especially the textile industry, and the associated and unregulated horrors of things such as long hours, low wages, child labor. You know, too, that across Europe, urban populations doubled in the first half of the nineteenth century, and in so doing overwhelmed the infrastructure of available jobs, the housing stock, sanitary arrangements, and all the rest, so that we see the rise of tenement slums, sweatshops.

There was a mass movement of population from countryside to town, and with that went psychological adjustments. There was a breakdown of older notions of social relations based on paternalism, of the customary notion of a moral economy based on moral obligation. And we see instead the rise of the principles of impersonal relations, of a free-market economy, and laissez-faire, epitomized in the new discipline of political economy, with such figures, of course, as Adam Smith, Ricardo, Jeremy Bentham, Thomas Malthus. The result, along with those transformations, was a rise of new social tensions. We’ve talked about the nineteenth century as the rebellious century.

Now, in Britain, there were no social and political revolutions, nothing comparable to 1789 in France, or to what happened on the continent in 1830, and in 1848 and ‘49. But contemporaries weren’t certain at all that this was going to be a lasting fortune for Britain, and indeed Britain did have a number of signs of severe social tension as well. There were large-scale riots. One could mention the Chartist Movement, and in the countryside the movement known as Captain Swing.

So, urban and industrial centers, also in Britain, were perceived as dangerous, politically, for fear of the so-called dangerous classes who rioted, perhaps committed crime, threatened revolution, and were dangerous medically, as well that is, they were infected with cholera and other diseases. And it was cholera in particular that was a real prod to action, this new and most feared disease of the nineteenth century. It’s not by chance, then, that the sanitary movement begins in the 1830s and 󈧬s in Britain, after, that is to say, the first pandemic and the second of Asiatic cholera. And it lasts intermittently down through the First World War.

And this really was a vast movement. It was nothing less than the retrofitting of the urban centers of the nation, with the specific goal of removing filth, because filth was held to be the cause of disease. So, we’re talking about one of the great public works projects of modern history: the establishment of sewer systems, a whole infrastructure of water mains, of waste removal, street cleansing, improved and less crowded housing, the creation of parks and public spaces. We can see that Victorian Britain truly was preoccupied with that combination of excrement and water.

All of this, of course, presupposed as well the emergence of a modern state. It was state power that alone provided the wealth and organizational structures that were needed to carry out this enormous project. And in turn we can see the causal chain working in both ways, because the sanitary movement was a very important factor in reinforcing state power. Its implementation meant that the state now invaded areas of life formerly regarded as private, and appropriated for itself enormous new powers. And the reformers were supported by Protestant and especially evangelical Christian churches.

Chapter 3. Sir Edwin Chadwick [00:10:15]

Well, who were the leaders of this movement? I think we should turn first of all to this man, Sir Edwin Chadwick. This is Edwin, Sir Edwin, in his younger days. This may be a slightly more familiar picture of him, I guess maybe at my age. In any case, Sir Edwin wrote a major work collaboratively — he produced it, let us say — which was called “The Report on the Sanitary Condition of the Labouring Population of Great Britain of 1842.” Now, Chadwick wasn’t a physician at all, and this is part of the background perhaps to the thesis I was mentioning earlier. He was instead a lawyer by training from Manchester. And he was already well known, in particular for his reform of welfare provisions in Britain that is, he was responsible in large part, for the passage, from the old poor law, which had provided relief as the birthright of every citizen in distress that is, the right to some form of assistance or aid in time of distress.

Chadwick’s idea was to economize, to minimize the cost of payments, to discourage the poor from applying for relief. He wanted to make the experience of receiving relief more painful than the experience of distress itself, a principle that was dubbed “the principle of least eligibility.” The workhouse, in other words, was to be a place of punishment, of pain and of suffering. So, work should be, in the workhouse, more unpleasant than any to be found in the labor market. And the diet should be intentionally made to be loathsome, more so than what could be found by the poor outside. The poor law bureaucracy was also invoked, and was an essential foundation of the information on which Chadwick relied for the sanitary report of the laboring population of Great Britain.

This was the man who was the same in both faces, with the new poor law and with the sanitary report. The sanitary reform was also a stark assertion of state power as a means of social control. The intention was to discipline and civilize the working classes in the interests of social stability. Following in the wake of the report was the establishment of a Public Health Act of 1848 in Britain, and a general Board of Health, and such champions of sanitary reform as John Simon, Thomas Southwood Smith and Neil Arnott.

Now, let’s talk for a minute about this man’s ideology and his intentions. This was a class-based movement. It was top-down and centralizing. In Chadwick’s mind, the poor were largely responsible for their own plight. They weren’t innocent, and they certainly weren’t harmless. His mission was to cleanse and civilize the dangerous classes. As I said, he wasn’t a physician, and his reforms were not based on any new medical discoveries, on scientific experimentation or observation to determine what measures were most effective by determining the causes of disease. His reform measures, enormous as they were, were based more on what was the commonsense of the period and a priori assumptions.

Public health, in this way, was separate from the development of medical science. His view — and this was widely accepted — was that medicine was about private persons, not so much public policy. And his idea was to use public policy to cleanse the urban environment, but not to deal with other social and economic determinants of disease. We’ll talk about that in a moment. We need to think about not only about what Chadwick wanted to do, but we also need to think about what he decided not to do, what wasn’t important to him. And so we should see this as progress, yes, but progress that came at a cost, and we want to know about that as well.

Now, an influence on Chadwick’s thinking was “The Essay on Population” of Thomas Malthus, who believed that there was a law that in every society population pressure sooner or later pressed against the limits of subsistence. So, real improvement for the poor was likely to be illusory, short-term, and perhaps counter-productive. In the long run, really significant improvement couldn’t occur, according to Malthus. It might even be self-defeating, leading to disease, starvation and war, those great positive checks on population increase. That idea of the limited nature of possible improvement was in Chadwick’s mind the poor will always be with us.

There was also, as I said, the filth theory of disease. We know it. We’ve talked about miasma and its long history in European thought. Well, filth now was associated very closely with smell. And if you are to read the report at some point, you would notice that smells constitute an important part of the report. The report is filled with descriptions of stench. The authorities consulted by Chadwick frequently used phrases such as, “I was assailed by a most disagreeable smell, and it was clear to me that the air was full of most injurious malaria.” By malaria, that’s another word that occurs throughout the report. And we should note that before malaria came to mean a specific disease, it meant “bad air,” from the Italian mal’ aria, bad air.

And, so, this report, in Britain in the 1840s, is filled with descriptions of what they called malaria. Let me give you an example from the town in the West Country of Truro. Reporting to Chadwick, the reporting official said, “Passing into St. Mary’s Parish, the proportion of sickness and deaths is as great as any part of Truro. But there’s no mystery at all in the causation. Ill-constructed houses with decomposing refuse, clothes upon their doors and windows, open drains, bring the oozings of pigsties and filth to stagnate at the foot of the walls. Such are a few of the sources of disease, which even the breezes from the hills cannot dissipate.”

Everywhere the reports discovered disease, and they correlated the disease with such findings as poisonous vapor, morbific effluvia, filth, obnoxious effluvia, poisonous exhalations, miasma and malaria. The moral of the texts of those conditions also preoccupied those who took part in the report. Vice, alcohol, intemperance, and then more poverty, and still worse, more filth. Poverty was partly the result of depravity and improvidence, and those in turn reinforced more poverty and more filth.

Well, there was a political aim behind the sanitary reform, and I think we might call this a transformation that Chadwick was aiming at in the demographic composition of the British population. In Chadwick’s mind, trade unions, which he abhorred, demonstrations, strikes, the Chartist Movement, and all the rest, were called by Chadwick “wild and dangerous assemblages.” But he noted that they were mainly led by the young. Older, experienced workmen, with family responsibilities, he found to be moderate and temperate, and not to take part in strikes and social unrest. Therefore a high early death rate, and poor sanitary conditions, were actually politically destabilizing, at least in his mind, because they led to the early death of workmen, and hence to an overrepresentation of the dangerous young, and an under-representation of moderating older workmen.

If we want to understand and explain this view, perhaps we could invoke an anachronism, to make an analogy. And we could use the analogy of a nuclear reactor, and compare social unrest to a meltdown of the reactor core, with disastrous consequences. Well, in terms of the reactor, to prevent such events reactors make use, as you know, of boron control rods that are inserted to control the rate of fission of uranium and plutonium, and to limit chain reactions. In this way, what Chadwick wanted to do, by analogy, was to use older people like control rods that would have the calming effect of preventing social meltdown and social revolution. But to do that you had to do something about infectious diseases, to achieve this demographic transformation of the population.

So, if infectious disease was destabilizing for the state and political order, a population subject to infectious disease moreover is unlikely to be educated and to be open to the moral influence of the clergy. And the absence of cleansing in towns, Chadwick felt, would lead also to demoralization and further depravity. Now, in all of this thinking, let’s remember too at what was lost. A striking feature of Chadwick’s view was the narrowness of its focus. The cause of ill health in Victorian Britain — I think we should say not the cause — the causes were undoubtedly multiple, and one could think about low wages, unregulated factories, inadequate diet, poor clothing, lack of education, working conditions in sweatshops, mines and factories, child labor, overcrowded housing. These I would call social and economic determinants of disease. And there were voices, particularly on the continent, for an alternative public health that would address precisely such broad interests.

Chapter 4. Social Medicine [00:23:27]

There was an older tradition of what was called a “medical police” on the continent, and a current of thought of what was called “social medicine”, whose most prominent figure was this man, Rudolph Virchow, a Prussian physician who lived from 1821 to 1902, and was one of the great figures of nineteenth century medicine a physician, anthropologist, biologist and radical politician. Now, his view was that disease was not simply a biological event, but a socially driven phenomenon. And his meaning of the term “social medicine” was that physicians should treat not just individual patients but entire societies, and that they should pay great attention to matters of the economy, to diet, wages, housing, child labor, working conditions.

Virchow was, in a sense, the anti-Chadwick. Chadwick’s intention instead was to focus on the narrow issue of filth and water, and his attention was confined to the working classes and the filth in which they lived. At stake was the issue of how broad should a public health movement be? And perhaps one could say that one of the sad features of the period was the triumph of the narrowest gauge vision of public health. The solution, in Chadwick’s hands — and this was a major event in public health, there’s no doubt about it. I’m trying to say — not that this was unfortunate — it was only unfortunately narrow. Chadwick’s solution involved technological measures, all good in themselves: drains, sewers, water pipes. But they didn’t include social, economic and educational reform. And the reforms all came from above, and reinforced a centralizing state, rather than finding ways to empower ordinary people to participate in defending their own health.

Let me give you an example of a simple technological improvement. It might be hard to recognize when you first look at it but — and I’m talking about some very humble movements that have enormous political and medical consequences. What we’re looking at is a sewer main, and these were established under the soil of cities in this period, and one of the technological inventions was to make the sewers egg shaped, so that you would maximize the flow and they would be self-cleaning and they would drain most efficiently. So, technological innovations of that sort were part of it.

Now, the victory of Chadwick’s vision of public health wasn’t simply automatic, and so it was worth to keep alternatives in mind. His side was the winning side in a debate of the early nineteenth century, and a wider view, like that of Virchow, was present, but lost the debate. Let’s be clear in summation. I’d argue that Chadwick’s vision of public health was highly successful, that it was a crucial part of the mortality revolution of nineteenth century Europe, but that at the same time something was lost, a broad vision of the causes of disease, and those causes weren’t addressed.

Although what Chadwick achieved was a major and positive advance, it perhaps fell short of what might have been, and it demonstrates the practical and positive impact of miasmatic theory. And public health, a theory — and this is perhaps something we ought to bear in mind — that a theory that is by now rejected — that is miasmatism, the filth theory of disease — did operate in such a way as to promote major and positive health results. And one of the causes of this movement was the epidemic disease that we dealt with the last couple of times, and that is Asiatic cholera. We might note there was a sidelight that may be of interest as well that this sanitary movement, the literal sanitary movement, was accompanied in some places by what we might call a figurative sanitary movement, and that is moral sanitation. And one of those was particularly notable in France where there was a great fear of another disease, that we’ll be talking about slightly later in the course, and that is syphilis.

Remember, the early nineteenth century, we’re dealing with the period in the wake of the Napoleonic wars. And with those wars, as always happens — or happened — there was a major upsurge in socially transmitted diseases, and in particular syphilis. And so this sanitary movement was accompanied by the movement for moral sanitation through the registration and surveillance of prostitutes. And in France those responsible for moral sanitation actually made the link explicit that is to say that they compared brothels with sewers, and said that they, the brothels, should become the target of sanitation. So this was a form of moral sanitation that was an offshoot of the literal sanitary movement that is our main theme.

Chapter 5. Rebuilding Cities and Urban Planning: Paris [00:30:25]

The sanitary worldview led also on the continent to further offshoots, and that — I want to talk now about a continental form of the sanitary movement, the rebuilding of cities in their entirety. This was actually much more comprehensive and systematic. It means urban planning. It’s more comprehensive than what happened in Britain, which was the retrofitting of cities with sewers and drains and sanitary provisions. It entailed the actual leveling of whole cities, or neighborhoods within them, to start afresh, in accordance with a comprehensive plan.

There were a number of prototypes. In France, Paris, Lyon and Marseilles. In Belgium, Brussels. In Naples — that is in Italy, there was Naples, as you know, but also Florence, La Spezia, and other places. But let’s begin in Paris, because that established the pattern. Here again we see the influence of epidemic cholera, which ravaged Paris in the 1830s and again in 1849. And this caused an enormous psychological shock, the idea that civilization was no sure-fire protection against sudden and agonizing disease. There was an unbearable contradiction that a city, that is Paris, that prided itself at being at the heart of European intellectual life, at being the leading city in the arts and culture, a world center, as you now know, of scientific medicine, could nevertheless be devastated by a disease that was associated with poverty, with filth, and with the colonial world.

Well, after the revolutions of 1848 to ‘49, we have a reactionary and authoritarian regime established by Louis Napoleon Bonaparte, or Napoleon III, that soon became the Second Empire, that lasted from 1851 ‘til 1870. There’s Napoleon III. He undertook a major movement to rebuild Paris. And I want to argue that this had enormous sanitary consequences, intentionally so, and that the experience of epidemic cholera was very important in the establishment of that. But I don’t want to say that the rebuilding of Paris was solely designed as a health measure, and solely to prevent the return of cholera. There were other gains as well.

Napoleon III wanted imperial splendor. He wanted a city that would be worthy of the role of France in the world, that would be a showcase for his new political regime. He too was thinking about social control. So, there was a political aim that was, to destroy the working class slums that had been the sites of rebellion. The idea was to use urban renewal to remove workers from the center of the city to distant suburbs, and in the center to construct wide boulevards that could not be defended by barricades, and that the troops could use to move quickly across the cities, and cannonballs could fire down the boulevards to demolish barricades. In other words, Paris was to be made revolution-proof, or at least that was the goal.

It was also a project of public works that is, it was a means of enormous patronage. It would provide employment and would defuse social tensions as well. So, Paris, under Napoleon III, became a vast public works project, enormous shovel-ready projects. The workers of Paris then would be employed and therefore largely pacified. It was thought that this would also have an economic role. The new boulevards, the wide spaces, would facilitate the movement of goods and assist free trade and commerce. And then there was the public health objective: to improve health, to prevent the return of infectious epidemics.

The task was entrusted to this man, Georges Haussmann, the Prefect of the Seine. And often what was accomplished is referred to as the “Haussmannization” of Paris, with the so-called great works, or grands travaux, that were undertaken from 1852 until 1870. Now, this project was authoritarian. The rights of individuals were disregarded. The population was not consulted about being moved, and it was an operation of colossal complexity. All of the affairs of one of the greatest cities in France, the great city in France, were gathered into a single pair of hands: finance, administration, transport, sanitation, engineering, architecture, evictions, expropriation of land by eminent domain, slum clearance, gas fixtures and lighting, sewers. All of this was an enormous assertion, then, of state power. The means were broad intersecting boulevards.

Let me show you the sorts of plans — were to have the great boulevards of Paris, that you can see today — such as the Rue de Rivoli, Boulevard de Strasbourg, Sébastopol, the Boulevard Saint-Michel. The average size width of a street in Paris was to be doubled, and underneath the streets there were to be sewers and drains. There was to be water supply, and there were to be broad parks and public spaces, such as the Bois de Boulogne. The aesthetics were the aesthetics of the straight line. We can see that there. We can see it also here. And you can see the intersection of these broad boulevards, and you can see how these were multi-purpose and would allow not only — part of the idea was the miasmatic one, that they would allow air and light to sweep through the city and remove the noxious smells, and purify and cleanse the city. And you can see as well that they would be good for commerce and for social control.

So, Paris, after Haussmann, was clearly much healthier as a city than before, and cholera did not return thereafter to the city center. But there is an irony here, that cholera did return, less vehemently than before. But in the 1890s it did return, but not to the center of the city. In other words, part of the sanitary problem of Paris was not entirely solved, but was exported to the suburbs, and it was the suburbs that experienced the return of cholera in 1892. We have to see this as an enormous sanitary success, but one that we ought to qualify. Let me look at — let’s look — this is a map — a picture of the demolition, to convince you of what a major undertaking this was. And there’s a view of the new open spaces, cleansed with light and air, and germ free. And also in Napoleon III’s mind, it would be also — make revolution much more difficult. Well there was — the political success, as well as the sanitary — was a success but one that needs to be qualified.

There was an enormous resentment among the working people of Paris at Haussmann’s project, and there was an enormous history from that time down to nearly our own of hostility of the suburbs. Paris becomes, not by chance, surrounded by a red belt of concluding hostility to the regime, and this exploded in the spring of 1871 in the Paris Commune that brought down the regime and led to the establishment of a republic. So, there are also political qualifications.

Chapter 6. Naples [00:40:51]

Well, I’ll move then to another example very quickly, and one that is in the reading, and that is the Italian version, and in particular the risanamento of Naples, which was Italy’s largest city.

As you know, there was a massive epidemic in the city — this is the plan of risanamento in Naples — and as you know, it led to the idea — and here is something that is actually unique that is to say that we’ve talked about the retrofitting of British cities and also American ones. We’ve talked about the rebuilding of Paris. Those were associated with a variety of disease experiences, and they had purposes other than a single disease. One can’t see the retrofitting of British cities as due solely to epidemic cholera, nor the rebuilding of Paris. Here in Naples we have something that’s unusual and probably unique, which is the actual rebuilding of a major European city for the specific purpose of preventing the return of cholera. And the way that the plan was developed reflected the specific medical understanding of the time of the cause of cholera. And we see here too a form of the filth theory of disease.

The rebuilding of Naples was for this single purpose, and the medical theory behind the rebuilding project was specifically the miasmatic theory of this physician from Bavaria, Munich in particular, who is Max von Pettenkofer, who had an enormous influence on public health. And one aspect of his influence was that his theory lay at the basis of the rebuilding of Naples. He developed the most sophisticated of miasmatic theories in the nineteenth century and was aimed — the aim then behind the rebuilding of Naples was to thin out the population. Overcrowding was a cause of disease, and poisonous vapors arising from underneath the city poisoned the air, people breathed in the poison and succumbed to cholera, in Max Pettenkofer’s view.

The purpose of risanamento then was first of all to raise the level of the streets that is to say, the danger and the miasma was, if we like, fermenting beneath the streets of the city. So, you want to place a greater distance between the population living above and the poisonous effluvia arising from below. And, so, the aspiration was to raise the level of the streets to the second storey of the houses. And there would be, if you like, then a massive cushion, including the mortar of the streets themselves, between the population of the city and the danger lurking in the groundwater beneath the soil.

In addition, the idea was that you would have Naples — there’s a picture of the old city that’s — in various aspects — that’s been demolished and here what I wanted to show was this, the great access at the center and then there were various cross streets. The great boulevard at the center was in the direction of the prevailing wind, and it was called a bellows of fresh air that would allow the wind to rush through the city, drying up the effluvia and blowing away the stenches and allowing the sunlight to reach ground level, and then it would be crossed by a series of wide boulevards as well. And then under the — if this happened above ground, there would also be work going on beneath, and you would have a whole sewage mains being built under the city.

So, risanamento, this enormous project, both above and below ground, was related — it was a cousin of the sanitary movement in Britain. It was a first-cousin of the rebuilding of Paris and Lyon. But it was distinctive too, because it’s the only example of a project conducted exclusively for the purpose of defeating a single disease, and that was cholera. Was it a success? Well, Naples was rebuilt. And there’s no doubt that the health of the city thereafter was greater than it had been before. But unfortunately there too there were qualifications. The rebuilding was marred, marred perhaps partly by the flaws in its conception from the outset, but marred also by the fact of corruption and the misuse of the funds that were used to carry it out.

And, so, we see thereafter that although Naples was rebuilt in the aftermath of 1884, that there was a return of cholera, a major epidemic again, in 1911. And there was even a small coda to that, which is another outbreak, even in 1973. So, the irony and conclusion. The sanitary movement in Britain, retrofitting of cities, the rebuilding of cities in France, therisanamento in Naples, did achieve major success. But it’s worth remembering that they often weren’t based on a medical theory that was to endure. And indeed in the case of Naples, it was a medical theory that very soon after the rebuilding was to be discarded.

No sooner had Naples been rebuilt than the theories of Pettenkofer were overturned, with the coming of the germ theory of disease. So, when we’re — one of the questions we ask, then, was the lasting impact of epidemic diseases. And I would argue that one of the senses of lasting impact is one that’s embodied in bricks and mortar, in urban planning. And if you visit these cities, then you can see the lasting legacy of epidemic disease in the urban landscape itself.

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