Sanitation

GLOBAL STATISTICS

EVOLUTIONIST VIEWS: SURVIVAL INSTINCT

CIVILIZATION PROCESS

CULTURAL SYMBOLICS AND RELATIONAL CONCERNS

RELATIONAL CONCERNS

SANITATION POLICY

BIBLIOGRAPHY

Sanitation (from the Latin sanitas, meaning health) refers to the maintenance and delivery of clean, hygienic conditions that help prevent disease through services such as drinking water supply, garbage collection, and safe disposal of human waste. Sanitation is the focal point of public health policy, but in the experience of local communities much more than health is at stake in “sanitation.”

GLOBAL STATISTICS

World Health Organization (WHO) reports show that in 2004, 5.3 billion people (83% of the world population) had access to clean water sources (in 1990 that percentage was 78). Of the 1.1 billion people without access to clean drinking water, 84 percent live in rural areas. The situation is particularly critical in sub-Saharan Africa, where 44 percent of the population remains without clean drinking water, and in Eastern and Southern Asia.

Similar statistics apply to the coverage of “basic sanitation” (improved toilet facilities). According to the same 2004 WHO report, only 59 percent of the world population had access to a hygienic toilet in 2004. It is again sub-Saharan Africa (38 percent) and Eastern Asia (45 percent) that have the highest populations without basic sanitation.

Unsanitary conditions are the main cause of ill health and premature death in poor societies. WHO statistics of 2004 report that 1.8 million people die every year from diarrheal diseases (including cholera), 90 percent of whom are children under five. Eighty-eight percent of diarrheal disease is attributed to poor sanitation. Malaria, another sanitation related disease, kills 1.3 million people each year; again, 90 percent of these deaths are children under five. Other diseases that originate in poor sanitary conditions include schistosomiasis (a parasitic infection), intestinal helminthes (ascariasis, trichuriasis, hookworm), and hepatitis-A. Although the health consequences of sanitation are overwhelming, people often have reasons to pursue—or refuse—better sanitation.

EVOLUTIONIST VIEWS: SURVIVAL INSTINCT

Social scientists have developed various theories to interpret or explain human concern about avoiding dirt and promoting hygiene. Evolutionist thinkers believe that there is medical wisdom in the human fear of dirty things. Dirty objects and activities pose a danger, so it is wise to avoid them. Disgust of dirt is a survival strategy (usually a non-conscious one). A 2001 study by Valerie Curtis and Adam Biran list five disgust elicitors derived from research in India, Burkina Faso, The Netherlands, Britain, and an international airport. The five elicitors are: (1) body excretions and body parts; (2) certain animals; (3) decay and spoiled food; (4) certain categories of “other people;” and (5) violations of morality. Bodily excretions were mentioned most frequently as causing disgust and among them, feces topped the list, but vomit, sweat, spittle, blood, pus, and sexual fluids were also regarded with aversion. Animals that were mentioned most often included pigs, dogs, rats, snakes, worms, cockroaches, maggots, lice, and flies. People that were found disgusting were those with signs of sickness, dirt, or deformity, and strangers with whom one was forced to come into close contact, for example in crowded places. People who behaved immorally also evoked aversion.

Curtis and Biran’s hypothesis is that humans have evolved behavioral defenses against disease and that “disgust is one of the mechanisms crafted by natural selection to keep our distance from contagion” (Curtis and Biran 2001, p. 22). The researchers found support for their hypothesis by checking the routes of transmission for a selection of common infectious diseases. In all of them, one or more elicitors of disgust were mentioned as playing an important role in transmission. Feces were named as the source of more than twenty infectious diseases. Breath, saliva, lice, rats, and sexual organs were also important sources or transmitters of infection. All of these score high for human disgust.

William Ian Miller’s 1997 study of disgust is difficult to place in any disciplinary tradition. His own expertise mainly lies in literature and history but his study also draws on psychologists, moral philosophers, and political and social theorists. Trying to decipher the origin and working of emotion, Miller derives most inspiration from psychology.

The disgust Miller discusses applies to many phenomena and activities, such as defecation, sex, food, and drink. He distinguishes two types of disgust. The first, which is clearly Freudian, prevents the activation of unconscious desire. It defends against pollution, denies access to objects and acts that would block the psychic development of the human person. The evolutionist perspective of disgust as a survival instinct returns here at the level of the human psyche. The second type of disgust is “disgust of surfeit,” it punishes after having indulged in a “disgusting” activity. The two types complement each other. In the aversion of things perceived as dangerous because of their power “to contaminate, infect, or pollute by proximity, contact, or ingestion” it is first of all the unconscious reaction to psychic dangers that is at work (Miller 1997, p. 2).

CIVILIZATION PROCESS

Most authors writing on hygiene and sanitation from a sociological point of view refer to Norbert Elias’s study on the civilization process. Elias studied etiquette books, letters, and other documents in France and England from the eleventh century onward and describes how the authors of those guides for proper conduct gradually became more particular about body functions, body parts, and body products.

He talks about a general process of civilization, which implies a “privatization” or “intimization” of human behavior. More and more, public activities became shameful and were confined to the private world. The human body was a focal point. The body itself had to be well covered and activities such as sex, sleep, urination, and defecation became embarrassing when carried out in front of other people. Modern hygiene facilities are regarded as expressions of the civilizing process.

CULTURAL SYMBOLICS AND RELATIONAL CONCERNS

The symbolic anthropologist Mary Douglas, in her classic Purity and Danger, turns away from evolutionist and “medical materialist” (a term used by American psychologist and philosopher William James, meaning reducing ritual to its supposed positive medical effect) explanations of hygiene and presents dirt as “matter out of place,” a definition that became famous for its beautiful simplicity and provocation. Shoes on the table (Douglas’s example) are dirty; under the table they are clean. Saliva safely caught in a handkerchief is hygienic, but when it falls in a plate it turns disgusting. Her claim that absolute dirt does not exist opened new windows in the study of hygiene as a cultural phenomenon. Dirt is defined by its context. It is disorder and carries an invitation or rather an obligation to restore order: “Ideas about separating, purifying, demarcating and punishing transgressions have as their main function to impose system on an inherently untidy experience” (Douglas 1970, p. 15). Hygiene, in short, is a basic cultural act: it distinguishes dirt from what is clean and thus, creates cultural order. Enculturation of small children starts with teaching them what is clean and what is not clean. Hygiene is the essence of culture. What is dirty is of less importance. Crucial is that dirt exists. Without the concept of dirt people could not formulate the norms and values of culture.

RELATIONAL CONCERNS

What makes an object abject and threatening? Douglas suggested: its out-of-place condition. Others claimed it depends on the matter itself. Too little attention has, however, been given to the identity of the person who is directly associated with something dirty, to the social life of the dirty matter. The answer to the question “whose?” determines the experience of disgust much more than has been suggested by Douglas and other authors who wrote about the cultural meaning of dirt. By adding a sociological dimension to dirt, Douglas’s theory of matter out of place becomes more true to life and effective as an interpretative tool.

The humanist Erasmus’s dictum that one’s own shit has a pleasant smell (Suus cinque crepitus bene olet ) is a humorous exaggeration, but it is not exaggerating to say that people usually are not disturbed by the smell (and sight) of their own feces. Objects, substances, and acts become dirtier as the person behind them is less close or less liked. Animals that produce dirt are also placed in categories of less and more disturbing. Animals that are “part of the family” are experienced as cleaner than those who belong to another family. And so on. Acts and gestures from a loved person that are cherished as dear and intimate (bodily contact, sex) turn into horrifying violence when another person performs them. Good or bad, clean or dirty, in this case, depends entirely on the actor. The “matter” remains the same. The urge for “hygienic action” also depends a great deal on such relational concerns. Washing hands after toilet use or before eating, for example, is as much a social as a healthful act.

SANITATION POLICY

Hygiene, in the medical sense, is a core value in modern societies. Objects, activities, and people are judged by their medical qualities. Food, houses, streets, markets, working places, holiday camps, public transport, and visitors should be clean and not pose a danger to health. Dirty things and people are rejected and rejected things and people are called dirty.

Anthropologists and historians argue, however, that people do not always make that explicit link between health and dirt. After studying the hygienic ideas and practices by mothers in Burkina Faso, Curtis concluded that their cleanliness and dirt avoidance were primarily a matter of “etiquette and social acceptability rather than to avoid illness” (Curtis 1998, p. 110). In a 2005 study, conducted in Bénin, Jenkins and Curtis observed that modern toilets were popular because they were seen as a sign of social prestige and success.

Michel Foucault argues that in the modern state, medicine is a major instrument of control by societal and political institutions. His concept of “Bio-power” suggests that the state can reward or punish its citizens by providing or withholding health. Sanitation, preventive heath care, implies the imposition of a regime. Sanitary policy legitimizes the state’s interference in households and private lives of people and thus helps to establish more effective disciplinary power. Bio-power—and sanitation in particular—constitutes the link between macro and micro (Foucault 1990; Gastaldo 1997).

Sanitation policies have been most successful when they also appealed to other values in people’s lives, such as social decency, respect, comfort, and religion. Cultural ignorance and lack of respect for local knowledge and practices of hygiene are major problems in sanitation projects by both foreign organizations and local governments in low-income societies. Tiokou Ndonko’s 1993 anthropological study in Cameroon for example, analyzed cultural and religious resistance against the government’s sanitation policy. Hygiene, seemingly a purely medical concern, lies at the heart of culture and is both a means of political control and resistance.

SEE ALSO Civilization; Cultural Relativism; Disease; Freud, Sigmund; Health in Developing Countries; James, William; Public Health; Taboos; Toilets

BIBLIOGRAPHY

Curtis, Valerie. 1998. The Dangers of Dirt: Household, Hygiene and Health. PhD diss., Agricultural University Wageningen.

Curtis, Valerie, and Adam Biran. 2001. Dirt, Disgust and Disease: Is Hygiene in Our Genes? Perspectives in Biology and Medicine 44 (1): 17–31.

Douglas, Mary. [1966] 1970. Purity and Danger. An Analysis of Concepts of Pollution and Taboo. Harmondsworth, U.K.: Penguin.

Elias, Norbert. [1939] 1982. The Civilizing Process. New York: Pantheon.

Foucault, Michel. 1990. The History of Sexuality, vol. 1: An Introduction. London: Penguin.

Gastaldo, Denise. 1997. Is Health Education Good for You? Rethinking Health Education through the Doncept of Biopower. In Foucault: Health and Medicine, ed. Alan Petersen and Robin Bunton, 113–133. London: Routledge.

Goudsblom, Johan. 1986. Public Health and the Civilizing Process. Milbank Quarterly 64 (2): 161–188.

Jenkins, Marion W., and Val Curtis. 2005. Achieving the “Good Life”: Why Some People Want Latrines in Rural Benin. Social Science and Medicine 61 (1): 2446–2459.

Miller, Ian. 1997. The Anatomy of Disgust. Cambridge, MA: Harvard University Press.

Ndonko, Flavier Tiokou. 1993. Répresentations Culturelles des Excrements. Münster, Germany: Lit Verlag.

World Health Organization. 2004. Water, Sanitation and Health. http://www.who.int/water_sanitation_health/publications/facts2004/en.

World Health Organization. 2005. Meeting the MDG Drinking Water and Sanitation Target. The Urban and Rural Challenge of the Decade. Geneva: World Health Organization.

Sjaak van der Geest

SANITATION

SANITATION The word "sanitation" only entered the English language in the nineteenth century, and the term is inextricably linked with integrated water and sewer systems. Lacking such technologies, early modern Europeans are often reckoned to have lived without sanitation. Their epidemiology of the time might seem to support this contention: three out of every ten babies born in Geneva between 1580 and 1739 died by their first birthday and the infant mortality rate in late seventeenth-century London was over one in four. Many of these deaths were caused by dirt-related infections like infantile diarrhea—what contemporaries termed "griping in the guts." Moreover, there are many vivid complaints of noxious conditions in early modern cities—one account of 1670s Edinburgh, for instance, claimed that one could not step anywhere in the streets without treading on turds.

Appearing in an Englishman's denunciation of all things Scottish, this claim was designed to promote prejudice. The charge also reveals how early modern people did indeed discriminate between cleanliness and dirt. Their sanitary technology rarely consisted of more than cesspits, chamber pots, and carts to carry ordure from their communities, but early modern Europeans possessed notions of public health and collective salubrity. Furthermore, scholars are now revealing the extent to which they sought to regulate and cleanse their environments.

URBAN DIRT AND URBAN ORDER

Such efforts were rarely entirely successful—early modern utopian writing appreciatively delineated the cleanliness of the ideal community—but civic authorities regularly commanded that streets be swept and nuisances removed. Such sanitary regulation was linked to wider conceptions of order. Noxious wastes shaped social and symbolic geographies. Offensive trades such as butchers and tanners were generally confined to particular districts, often downstream or outside city walls. In Paris the bodies of condemned criminals were buried in the municipal dump at Montfaucon. In central Europe the emptying of cesspits and the removal of waste were associated with other "dishonorable" trades. Between the sixteenth and nineteenth centuries, for instance, the "night-king" (chief latrine-cleaner) of Augsburg had to share a residence with the city executioner. Furthermore, precepts for cleansing streets often coincided with drives to rid communities of vagrants and "disorderly persons."

MIRE AND MEDICINE

Medical beliefs further encouraged sanitary care. Throughout the early modern period it was generally believed that plague and other epidemic diseases were caused or spread by corrupt airs or miasma produced by rotting organic matter. Environmental regulation thus sought to prevent evil smells. Perfumes and fumigants were used to purify infected spaces; street cleaning often intensified in periods of epidemic. In late-sixteenth- and early-seventeenth-century London, for instance, householders were required to sweep in front of their houses every morning and evening. During the early seventeenth century the boards of health of northern Italian states energetically sought to remove dunghills and other sources of miasma from the towns and villages under their jurisdiction.

Early modern doctors knew of "miasma" from a range of classical works, especially those of the ancient Greek physician Hippocrates. From the mid-seventeenth century medical authors became preoccupied with one strand of his work—the relation between epidemics and the airs, waters, and weather of particular places. Population statistics derived from bills of mortality and parish registers revealed geographical variations in the incidence of fevers and other fatal diseases; eighteenth-century analyses of air by natural philosophers like the English chemist Joseph Priestley sought to isolate mephitic substances that caused disease. Many eighteenth-century doctors proposed ways of reducing mortality by draining marshes, ventilating buildings, and reorganizing the environments and the ways in which people lived. Such interventions in the physical environment were often associated with proposals for the police of national populations. The term "police" had wider connotations than does its modern usage. It expressed a desire for the regulation of all aspects of life in order to achieve a smoothly functioning polity and (crucially) a healthy and productive population. The work of the German professor Johann Peter Frank exemplified the scale of this concept. His six-volume System of Medical Police (1779–1817) recommended the regulation of everything from midwifery and marriage to water supply and street cleaning.

The impact of medical police was less than the ambition of its advocates. Nevertheless, eighteenth-century Europe did see medically inspired reforms of daily life. In the 1750s, for instance, the British physicians Stephen Hales and John Pringle oversaw the installation of ventilators in the notoriously disease-ridden London prison of Newgate. In the 1780s the French Royal Society of Medicine not only declared that the Cemetery of the Holy Innocents in Paris was so full that it was a threat to public health but also had it closed and all human remains removed from it. More generally there was a considerable extension of new forms of sanitation, bathing and hygiene in hospitals, barracks, and similar institutions.

WATER SUPPLIES

These reforms were restricted by the general scarcity of water in preindustrial Europe. Clearly, this was a pressing problem in arid regions like southern Spain, where elaborate systems of water regulation were developed during the Middle Ages. But water was also a limited and costly resource in northern European communities not associated with drought. In eighteenth-century Paris, for example, a cubic meter of water would have cost a laborer more than two days' wages. Households spent much time and energy fetching water from rivers, streams, and wells. Communal life literally revolved around water sources. In larger urban centers public authorities maintained wells and sponsored schemes to pipe water to public fountains or conduits. In 1585–1587, for instance, Pope Sixtus V established the Acqua Felice, redeveloping the waters of an ancient aqueduct, the Aqua Alexandrina, in order to supply the eastern districts of Rome. Princely and aristocratic fountains like those at Louis XIV's palace of Versailles were, by contrast, ostentatious displays of conspicuous consumption.

The comparative scarcity of water remained a structural characteristic of European society throughout the early modern period. However, the sixteenth and seventeenth centuries saw the establishment of the first water companies piping supplies to the houses of private paying customers. The London Bridge Water Company (established 1582) and New River Company, which began supplying London in 1613, were among the first such concerns. They soon had imitators. By around 1700 one could rent a piped water supply in nine of the ten largest English provincial towns. Such companies were unevenly spread across Europe—no water company operated in Paris until after the French Revolution—and the supplies they offered were unreliable and intermittent. However, they did pioneer new technology. Eighteenth-century water companies were among the first users of steam power, and thus laid the foundations for the subsequent industrialization of urban water supplies. In the nineteenth century the intellectual heritage of medical police combined with such technological developments to produce the public reforms that are conventionally associated with the term sanitation.

See also City Planning ; Public Health .

BIBLIOGRAPHY

Corbin, Alain. The Foul and the Fragrant: Odor and the French Social Imagination. Cambridge, Mass., 1986.

Jenner, Mark S. R. "From Conduit Community to Commercial Network? Water in London 1500–1725." In Londinopolis: Essays in the Cultural and Social History of Early Modern London. Edited by Paul Griffiths and Mark S. R. Jenner. Manchester, U.K., and New York, 2000.

Riley, J.C. The Eighteenth-Century Campaign Against Disease. Basingstoke, U.K., and London, 1987.

Roche, D. "Le temps de l'eau rare: Du Moyen Age à l'Epoque Moderne." Annales: Economies, sociétés, civilisations 39 (1984): 383–399.

Rosen, George. A History of Public Health. Reprint. New York, 1993. Chaps. 3–5.

Stuart, Kathy. Defiled Trades and Social Outcasts: Honor and Ritual Pollution in Early Modern Germany. Cambridge, U.K., and New York, 1999.

For a website devoted to the history of the water supply of the city of Rome: http://www.iath.virginia.edu/waters/.

Mark Jenner

Sanitation

William Osler and Public Health

Book excerpt

By: William Osler

Date: 1921

Source: William Osler, "Sanitation," in The Evolution of Modern Medicine. New Haven, Ct.: Yale University Press, 1921.

About the Author: William Osler (1848–1919) was "the best known physician in the English-speaking world at the turn of the [twentieth] century." Appointed physician and chief at the Johns Hopkins Hospital in 1888, William Osler revolutionized modern medical education in the United States based on principles used to train physicians in England and Germany. He initiated the practice of teaching physicians about disease by bringing them to the patient's bedside, believing that they learned best by doing.

INTRODUCTION

This excerpt from the medical educator and policy-maker William Osler's book on the evolution of modern medicine uses a famous example of the importance of public health measures to society by showing its crucial role in a massive public works project—the building of the Panama Canal. Endemic diseases such as yellow fever, plague, and malaria had frustrated early attempts to build a canal through the Isthmus of Panama by disabling and killing thousands of project workers and managers. Osler described the work of Dr. William Crawford Gorgas (1854–1920), chief of sanitary affairs for the project, who made the canal possible by organizing public health and sanitation efforts. (Earlier, Gorgas had protected the health of U.S. soldiers with sanitary measures during the Spanish-American War.) Osler pointed out that it was not ignorance of public health principles that had doomed earlier efforts to build the canal, but a lack of effective public health organization and the thorough implementation of disease control measures.

Osler went on to further point out that it was not ignorance of the science regarding the value of sanitation that had resulted in typhoid fever epidemics in the U.S. and Canada in the early years of the twentieth century. Instead it was the lack of public health infrastructure and organization in an otherwise sophisticated and "sensible" society. This lack of infrastructure, he argued, was fostered by a corresponding lack of a sense of common purpose and interest in the common good where public health was concerned.

Osler lived and taught medicine according to practical principles emphasizing organization and implementation. He applied these principles in using health knowledge in the service of broader social progress and public good.

PRIMARY SOURCE

When, in 1904, the United States undertook to complete the Canal, everyone felt that the success or failure was largely a matter of sanitary control. The necessary knowledge existed, but under the circumstances could it be made effective? Many were doubtful. Fortunately, there was at the time in the United States Army a man who had already served an apprenticeship in Cuba, and to whom more than to anyone else was due the disappearance of yellow fever from that island. To a man, the profession in the United States felt that could Dr. Gorgas be given full control of the sanitary affairs of the Panama Zone, the health problem, which meant the Canal problem, could be solved. There was at first a serious difficulty relating to the necessary administrative control by a sanitary officer. In an interview which Welch and I had with President Roosevelt, he keenly felt this difficulty and promised to do his best to have it rectified. It is an open secret that at first, as was perhaps only natural, matters did not go very smoothly, and it took a year or more to get properly organized. Yellow fever recurred on the Isthmus in 1904 and in the early part of 1905. It was really a colossal task in itself to undertake the cleaning of the city of Panama, which had been for centuries a pest-house, the mortality in which, even after the American occupation, reached during one month the rate of 71 per thousand living. There have been a great many brilliant illustrations of the practical application of science in preserving the health of a community and in saving life, but it is safe to say that, considering the circumstances, the past history, and the extraordinary difficulties to be overcome, the work accomplished by the Isthmian Canal Commission is unique. The year 1905 was devoted to organization; yellow fever was got rid of, and at the end of the year the total mortality among the whites had fallen to 8 per thousand, but among the blacks it was still high, 44. For three years, with a progressively increasing staff which had risen to above 40,000, of whom more than 12,000 were white, the death rate progressively fell.

Of the six important tropical diseases, plague, which reached the Isthmus one year, was quickly held in check. Yellow fever, the most dreaded of them all, never recurred. Beri-beri, which in 1906 caused sixty-eight deaths, has gradually disappeared. The hookworm disease, ankylostomiasis, has steadily decreased. From the very outset, malaria has been taken as the measure of sanitary efficiency. Throughout the French occupation it was the chief enemy to be considered, not only because of its fatality, but on account of the prolonged incapacity following infection. In 1906, out of every 1000 employees there were admitted to the hospital from malaria 821; in 1907, 424; in 1908, 282; in 1912, 110; in 1915, 51; in 1917, 14. The fatalities from the disease have fallen from 233 in 1906 to 154 in 1907, to 73 in 1908 and to 7 in 1914. The death rate for malarial fever per 1000 population sank from 8.49 in 1906 to 0.11 in 1918. Dysentery, next to malaria the most serious of the tropical diseases in the Zone, caused 69 deaths in 1906; 48 in 1907; in 1908, with nearly 44,000, only 16 deaths, and in 1914, 4. But it is when the general figures are taken that we see the extraordinary reduction that has taken place. Out of every 1000 engaged in 1908 only a third of the number died that died in 1906, and half the number that died in 1907.

In 1914, the death rate from disease among white males had fallen to 3.13 per thousand. The rate among the 2674 American women and children connected with the Commission was only 9.72 per thousand. But by far the most gratifying reduction is among the blacks, among whom the rate from disease had fallen to the surprisingly low figure in 1912 of 8.77 per thousand; in 1906 it was 47 per thousand. A remarkable result is that in 1908 the combined tropical diseases—malaria, dysentery and beriberi—killed fewer than the two great killing diseases of the temperate zone, pneumonia and tuberculosis—127 in one group and 137 in the other. The whole story is expressed in two words, effective organization, and the special value of this experiment in sanitation is that it has been made, and made successfully, in one of the great plague spots of the world….

One disease has still a special claim upon the public in this country. Some fourteen or fifteen years ago, in an address on the problem of typhoid fever in the United States, I contended that the question was no longer in the hands of the profession. In season and out of season we had preached salvation from it in volumes which fill state reports, public health journals and the medical periodicals. Though much has been done, typhoid fever remains a question of grave national concern. You lost in this state in 1911 from typhoid fever 154 lives; every one sacrificed needlessly, every one a victim of neglect and incapacity. Between 1200 and 1500 persons had a slow, lingering illness. A nation of contradictions and paradoxes—a clean people, by whom personal hygiene is carefully cultivated, but it has displayed in matters of public sanitation a carelessness simply criminal: a sensible people, among whom education is more widely diffused than in any other country, supinely acquiesces in conditions often shameful beyond expression. The solution of the problem is not very difficult. What has been done elsewhere can be done here. It is not so much in the cities, though here too the death rate is still high, but in the smaller towns and rural districts, in many of which the sanitary conditions are still those of the Middle Ages.

SIGNIFICANCE

William Osler has been the subject of several biographies aimed at showing how one individual can have such sweeping influence on the development of an entire profession. As vitally important as was his contribution, to the current generation he is essentially a "medical icon" whose work is now embedded in the everyday learning and practice of medicine. The essence of Osler's contribution was in his comprehensive, holistic, and empathetic interest in human health, which developed during a simpler time when a single thinker was able to span much of medical knowledge. Medicine is now scientific, compartmentalized, and technical, and dominated by specialists. Some physicians have lamented that a broad and influential career such as Osler's is "no longer available" to contemporary physicians.

Public health, however, remains a very broad and multifaceted field that is somewhat congenial to generalists and medical activists. With his multifactorial outlook on life and health, Osler was keenly interested in public health and the organization of society to deal with health threats. In the excerpt, he admires the way in which the U.S. government confronted such threats in Cuba and Panama. He seems puzzled by the lack of motivation of civilian society to take strong preventive action in dealing with unsanitary conditions that result in disease outbreaks. He expresses impatience with the complacency of society in not moving to eradicate obvious threats, such as typhoid fever, that could be alleviated with simple sanitary environmental practices.

Osler's critique of the public health and sanitation practices common in the U.S. and Canada are interesting because it remains relevant to contemporary society. Currently we have the knowledge to understand the spread of epidemics from AIDS to SARS, and appreciate the need to deal proactively with potential threats from bioterrorism to avian influenza. Yet it seems that when public health threats can be couched in either military or economic terms, policymakers begin to strongly focus on improving public health infrastructure and fully funding disease monitoring and control capabilities such as the U.S. Public Health Service and the Centers for Disease Control and Prevention. Expert knowledge about dire threats to human life by itself has historically not galvanized politicians to act in the interest of public health.

For example, with regard to a potential avian influenza (bird flu) outbreak, it became clear to economic analysts in early 2005 that an epidemic on the scale of the 1918 influenza epidemic could bring about a collapse in the globally integrated economy. After that analysis, there was suddenly a great increase in discussion, planning, and establishment of contingency supplies of vaccines and antiviral medications. Yet, expert predictions of another flu pandemic similar to the one in 1918 have been routinely issued periodically by world health authorities ever since the 1918 catastrophic outbreak occurred.

In 2001, a bioterrorist attack on the U.S. with anthrax electrified the country and caused federal, state, and local officials to review public health infrastructure and local capabilities to deal with another attack. Only a few people died from anthrax in that assault, yet the military nature of the attack outraged policymakers and brought about a general improvement in funding and organization of U.S. public health. In this case, bioterrorism warnings had frequently been issued by experts long before 2001, but it took a real attack to make bioterrorism more than a hypothetical possibility and spur resolute action.

Having seen the effective way in which people could come to grips with health threats when economic and military issues were at stake, as in the invasion of Cuba and the Panama Canal construction, Osler wanted to channel the same kind of concerted action and energy into confronting the public health issues of everyday life. Perhaps a short supply of Osler's characteristic energy and empathy explains the inaction of the society of his time and ours, in the face of health threats and suffering that have befallen others, but have not yet hit home.

FURTHER RESOURCES

Books

Bliss, Michael. William Osler: A Life in Medicine. Oxford: Oxford University Press, 1999.

Cushing, Harvey. Life of Sir William Osler. London: Oxford University Press, 1925.

Osler, William. The Principles and Practice of Medicine. 6th edition. New York: D. Appleton, 1906.

Periodicals

Groen, Frances K. "Three Who Made an Association: I. Sir William Osler, 1849–1919, II. George Milbry Gould, 1848–1922, III. Margaret Ridley Charlton, 1858–1931, and the Founding of the Medical Library Association, Philadelphia, 1898." Bulletin of the Medical Library Association 84 (July 1996): 311-319.

Web sites

University of Medicine and Dentistry of New Jersey. "Sir William Osler." 〈http://www4.umdnj.edu/camlbweb/osler.html〉 (accessed December 3, 2005).

Sanitation

Sanitation can be defined as the measures, methods, and activities that prevent the transmission of diseases and ensure public health. Specifically, "sanitation" refers to the hygienic principles and practices relating to the safe collection, removal and disposal of human excreta, refuse, and wastewater .

For a household, sanitation refers to the provision and ongoing operation and maintenance of a safe and easily accessible means of disposing of human excreta, garbage , and wastewater, and providing an effective barrier against excreta-related diseases.

The problems that result from inadequate sanitation can be illustrated by the following events in history:

1700 b.c.: Ahead of his time by a few thousand years, King Minos of Crete had running water in his bathrooms in his palace at Knossos. Although there is evidence of plumbing and sewerage systems at several ancient sites, including the cloaca maxima (or great sewer) of ancient Rome, their use did not become widespread until modern times.

1817: A major epidemic of cholera hit Calcutta, India, after a national festival. There is no record of exactly how many people were affected, but there were 10,000 fatalities among British troops alone. The epidemic then spread to other countries and arrived in the United States and Canada in 1832. The governor of New York quarantined the Canadian border in a vain attempt to stop the epidemic. When cholera reached New York City, people were so frightened, they either fled or stayed inside, leaving the city streets deserted.

1854: A London physician, Dr. John Snow, demonstrated that cholera deaths in an area of the city could all be traced to a common public drinking water pump that was contaminated with sewage from a nearby house. Although he could not identify the exact cause, he did convince authorities to close the pump.

1859: The British Parliament was suspended during the summer because of the stench coming from the Thames. As was the case in many cities at this time, storm sewers carried a combination of sewage, street debris, and other wastes, and storm water to the nearest body of water. According to one account, the river began to "seethe and ferment under a burning sun."

1892: The comma-shaped bacteria that causes cholera was identified by German scientist, Robert Loch, during an epidemic in Hamburg. His discovery proved the relationship between contaminated water and the disease.

1939: Sixty people died in an outbreak of typhoid fever at Manteno State Hospital in Illinois. The cause was traced to a sewer line passing too close to the hospital's water supply.

1940: A valve that was accidentally opened caused polluted water from the Genesee River to be pumped into the Rochester, New York, public water supply system. About 35,000 cases of gastroenteritis and six cases of typhoid fever were reported.

1955: Water containing a large amount of sewage was blamed for overwhelming a water treatment plant and causing an epidemic of hepatitis in Delhi, India. An estimated one million people were infected.

1961: A worldwide epidemic of cholera began in Indonesia and spread to eastern Asia and India by 1964; Russia, Iran, and Iraq by 1966; Africa by 1970; and Latin America by 1991.

1968: A four-year epidemic of dysentery began in Central America resulting in more than 500,000 cases and at least 20,000 deaths. Epidemic dysentery is currently a problem in many African nations.

1993: An outbreak of cryptosporidiosis in Milwaukee, Wisconsin, claimed 104 lives and infected more than 400,000 people, making it the largest recorded outbreak of waterborne disease in the United States.

The problem of sanitation in developed countries, who have the luxury of adequate financial and technical resources is more concerned with the consequences arising from inadequate commercial food preparation and the results of bacteria becoming resistant to disinfection techniques and antibiotics. Flush toilets and high quality drinking water supplies have all but eliminated cholera and epidemic diarrheal diseases. However, in many developing countries, such as the Pacific islands, inadequate sanitation is still the cause of life or death struggles.

In 1992, the South Pacific Regional Environment Programme (SPREP) and a Land-Based Pollutants Inventory stated that "[t]he disposal of solid and liquid wastes (particularly of human excrement and household garbage in urban areas), which have long plagued the Pacific, emerge now as perhaps the foremost regional environmental problem of the decade."

High levels of fecal coliform bacteria have been found in surface and coastal waters. The SPREP Land-Based Sources of Marine Pollution Inventory describes the Federated States of Micronesia's sewage pollution problems in striking terms: The prevalence of water-related diseases and water quality monitoring data indicate that the sewage pollutant loading to the environment is very high. A recent waste quality monitoring study (as part of a workshop) was unable to find a clean, uncontaminated site in the Kolonia, Pohnpei, area.

Many central wastewater treatment plants constructed with funds from United States Environmental Protection Agency in Pohnpei and in Chuuk States have failed due to lack of trained personnel and funding for maintenance.

In addition, septic systems used in some rural areas are said to be of poor design and construction, while pour-flush toilets and latrines—which frequently overflow in heavy rains—are more common. Over-the-water latrines are found in many coastal areas, as well.

In the Marshall Islands, signs of eutrophication—excess water plant growth due to too much nutrients—resulting from sewage disposal are evident next to settlements, particularly urban centers. According to a draft by the Marshall Islands NEMS, "one-gallon blooms occur along the coastline in Majuro and Ebeye, and are especially apparent on the lagoon side adjacent to households lacking toilet facilities." Stagnation of lagoon waters, reef degradation, and fish kills resulting from the low levels of oxygen have been well documented over the years. Additionally, red tides plague the lagoon waters adjacent to Majuro.

There is significant groundwater pollution in the Marshall Islands as well. The Marshall Island EPA estimates that more than 75% of the rural wells tested are contaminated with fecal coliform and other bacteria. Cholera, typhoid and various diarrheal disorders occur.

With very little industry present, most of these problems are blamed on domestic sewage, with the greatest contamination problems believed to be from pit latrines, septic tanks, and the complete lack of sanitation facilities for 60% of rural households. As is often the case, poor design and inappropriate placement of these systems are often identified as the cause of contamination problems. In fact, even the best of these systems in the most favorable soil conditions allow significant amounts of nutrients and pathogens into the surrounding environment, and the soil characteristics and high water table typically found on atolls significantly inhibit treatment. In addition, the lack of proper maintenance, due to a lack of equipment to pump out septic tanks, is likely to have degraded the performance of these systems even further.

Forty percent of the population in the Republic of Palau is served by a secondary sewage treatment plant in the state of Koror, which is generally thought to provide adequate treatment. However, the Koror State government has expressed concern over the possible contamination of Malakal Harbor, into which the plant discharges. Also, some low-lying areas served by the system experience periodic back-flows of sewage which run into mangrove areas, due to mechanical failures with pumps and electrical power outages. In other low-lying areas not covered by the sewer system, septic tanks and latrines are used, which also overflow, affecting marine water quality.

Rural areas primarily rely on latrines, causing localized marine contamination in some areas. Though there have been an increasing number of septic systems installed as part of a rural sanitation program funded by the United States, there is anecdotal evidence that they may not be very effective. Many of the septic tank leach fields may not be of adequate size. In addition, a number of the systems are not used at all, as some families prefer instead to use latrines since the actual toilets and enclosures are not provided with the septic tanks as part of the program.

Wastewater problems also result from agriculture. According to the EPA, pig waste is considered to be a more significant problem than human sewage in many areas.

Because sanitation has become a social responsibility, national, state and local governments have adopted regulations that, when followed, should provide adequate sanitation for the governed society. However, the very technologies and practices that were instituted to provide better health and sanitation now have been found to be contaminating ground and surface waters. For example, placing chlorine in drinking water and waste water to provide disinfection, has now been found to produce carcinogenic compounds called trihalomethanes and dioxin . Collecting sanitary waste and transporting them along with industrial waste to inadequate treatment plants costing billions of dollars has failed to provide adequate protection for public health and environmental security.

Increasingly, the solution seems to be found in methods and practices that borrow from the stable ecosystems model of waste management . That is, there are no wastes, only resources that need to be connected to the appropriate organism that requires the residuals from one organism as the nutritional requirement of another. New waterless composting toilets that destroy human fecal organisms while they produce fertilizer , are now the technology of choice in the developing world and have also found a growing niche in the developed world. Wash water, rather than being disposed of into ground and surface waters, is now being utilized for irrigation . The combination of these two ecologically engineered technologies provides economical sanitation, eliminates pollution, and creates valuable fertilizers and plants, while reducing the use of potable water for irrigation and toilets.

Simple hand washing is now re-emerging as the most important measure in preventing disease transmission. Handwashing breaks the primary connection between surfaces contaminated with fecal organisms and the introduction of these pathogens into the human body. The use of basic soap and water, not exotic disinfectants, when practiced before eating and after defecating may save more lives than all of the modern methodologies and technologies combined.

[Carol Steinfeld ]

RESOURCES

BOOKS

Salvato, J. Environmental Engineering and Sanitation. 4th ed. 1992.

"Sanitation Problems in Micronesia." A report. Concord, MA: Sustainable Strategies, 1997.

PERIODICALS

Fair, G., J. Geyer, and A. Okun. Water and Wastewater Engineering 1 (1992).

Sanitation

Civil War army camps were notorious as filthy, fetid places and breeding grounds for disease. As one soldier lamented, a military camp in wartime was more often than not essentially "a city without sewerage" (quoted in Hummel 1996, p. 192). These conditions were created by a combination of indifference to basic hygiene, careless disposal of human and animal waste, limited access to clean water, close quarters, and complete ignorance of the ways in which disease-carrying bacteria could move from soldier to soldier.

Old Abe

When soldiers left their homes, they deeply missed their families, wives, and neighbors. Such separation from the home and hearth was mitigated in many sectors of the military by the adoption of mascots, or regimental pets. Mascots have included such unusual pets as geese, hens, pigeons, owls, foxes, hedgehogs, bears, scorpions, raccoons, goats, llamas, and lion cubs as well as the usual dogs and cats (Cooper 2002, pp. 174–181). They have accompanied armies—and navies—into battle since at least the seventeenth century to bolster the troops' morale. Mascots were comforting objects for every soldier's affection far away from home. In addition, mascots were also thought to be symbols of good luck that would bring the soldiers or sailors who cared for them safely home from war (Cooper 2002, pp. 171–173). The Union Navy allowed mascots on board ship; the USS Monitor had a black cat as its mascot (Hoehling 1993, pp. 190–191), while a naval surgeon aboard the USS Fernandina was given a live owl that he kept as a mascot in the vessel's sick bay (Boyer 1963, p. 65).

Perhaps the most famous of these military mascots during the American Civil War, however, was a bald eagle, lovingly nicknamed "Old Abe" by the Eighth Wisconsin Infantry. As Adelaide Smith, an army nurse, recounts in her memoir, "Old Abe" was the soldiers' best friend and not only became a symbol of pride and victory for the men in his regiment, but also a legendary figure throughout the Union.

The Eighth Wisconsin Infantry had some time before sent home their mascot "Old Abe," the hero of twenty battles and many skirmishes. The eagle was taken from its nest by an Indian and presented to Company C., where it became the pet of the regiment. During attacks he was carried at the front on a standard, near the flag—sometimes held by a long cord or chain—he would rise up flapping his great wings, and screeching defiance at the enemy loudly enough to be heard along the line. His reputation made thousands of dollars at fairs and elsewhere. His portrait was painted, and hangs in the Old South Church, Boston. The State pensioned Old Abe and supported an attendant to care for him. He died at last of old age, and his skin is stuffed and safely preserved in the state archives at Madison, Wisconsin. (Smith 1911, pp. 205–206)

carly s. kaloustian

BIBLIOGRAPHY

Boyer, Samuel P. Naval Surgeon: Blockading the South, 1862–1866, ed. Elinor and James A. Barnes. Bloomington: Indiana University Press, 1963.

Cooper, Jilly. Animals in War. Guilford, CT: Globe Pequot Press, 2002.

Hoehling, A. A. Thunder at Hampton Roads. New York: Da Capo Press, 1993.

Smith, Adelaide W. Reminiscences of an Army Nurse during the Civil War. New York: Greaves Pub. Co., 1911.

Squalid Conditions

Most military camps, whether flying the flag of the Union or the Confederacy, acquired a decidedly grimy appearance—and foul odor—over time. Nearby water supplies were often treated carelessly, resulting in contamination from the waste of soldiers or their horses. As long as the water looked relatively clean, soldiers (and cooks) believed that it was perfectly acceptable to use.

In addition, many camps failed to adequately separate privies from cooking tents, or to implement basic "housekeeping" measures that would have spared some troops from typhoid, dysentery, and other maladies that struck down thousands of soldiers during the course of the conflict. As a result, germ-spreading flies routinely transferred germs from human waste to food stores. One inspector touring Union camps outside Washington, DC, described a grim but typical scene:

In most cases the only sink is merely a straight trench some thirty feet long, unprovided with pole or rail; the edges are filthy, and the stench exceedingly offensive; the easy expedient of daily turning fresh earth into the trench being often neglected. … From the ammoniacal odor frequently perceptible in some camps it is obvious that men are allowed to void their urine, during the night, at least, wherever convenient. (Williams 2005, pp. 208–209)

These failures, coupled with the crowded and poorly ventilated shelters in which soldiers were housed, enabled a wide range of dreaded diseases to stalk the Civil War camps of Rebel and Yankee soldiers. It also became fairly commonplace for new companies, upon reporting for duty, to endure outbreaks of childhood illnesses such as measles and mumps.

Virtually the only exceptions to these squalid conditions were the camps of the regular federal army or those led by West Pointers. In these camps, it was far more likely that at least a few sensible sanitation guidelines would be posted—and obeyed.

Perils for the Wounded

When Confederate and Union troops were on the move during the spring, summer, and fall, they gained respite from the more permanent camps that were such fertile breeding grounds for disease. But although the escape from crowded and poorly ventilated tents and barracks reduced exposure to airborne communicable diseases, it also increased exposure to the natural elements and often made clean drinking water harder to come by. More importantly, if an army was on the march, that generally meant that combat was approaching, and poor sanitation standards posed an enormous threat to wounded soldiers who managed to survive the battlefield.

During the Civil War, scientific and medical knowledge and training was far inferior to what it would be a mere generation later. This essential reality, combined with the sheer volume of casualties in the war, made medical treatment an extremely dicey proposition for wounded troops. Neither field surgeons nor doctors at hospital facilities hundreds of miles from the front lines had any knowledge of the root causes of infections or even basic germ theory. Indeed, army hospitals were notorious breeding grounds for disease. One glimpse at a typically overwhelmed facility explained why: "A more perfect pestilence box than this I never saw," exclaimed the author Louisa May Alcott, who served as an army nurse at Union Hotel Hospital in Washington, DC. "Cold, damp, dirty, full of vile odors from wounds, kitchens, and stables" (Robertson 1984, p. 94). Blood poisoning, erysipelas, pneumonia, and even the measles ravaged army hospitals, and with the medical knowledge and technology of that era, these diseases proved difficult, if not impossible, to treat (Ward 1994, p. 219).

"RULES FOR PRESERVING THE HEALTH OF THE SOLDIER"

On July 12, 1861, the U.S. Sanitary Commission published a report containing its "Rules for Preserving the Health of the Soldier." Written by William H. Van Buren, M.D., and signed by twelve other members of the commission, these rules were shortly afterward reprinted in Harper's Weekly.

Diet and food preparation were among the issues the report addressed. Food rations for the Union Army were generous by the standards of other nineteenth-century armies; as the commissioners noted, "the amount allowed for each man is greater in quantity than the similar allowance for any European soldier" (Harper's Weekly, August 24, 1861, p. 542). Some of the recommendations for food preparation, however, would no longer be accepted, given present-day knowledge that vitamins are destroyed by overcooking: "The bread must be thoroughly baked, and not eaten until it is cold. The soup must be boiled at least five hours, and the vegetables always cooked sufficiently to be perfectly soft and digestible" (p. 542). Similarly, the commission's recommendations about water intake are no longer followed:

Water should be always drank [sic] in moderation, especially when the body is heated. The excessive thirst which follows violent exertion, or loss of blood, is unnatural, and is not quenched by large and repeated draughts; on the contrary, these are liable to do harm by causing bowel complaints. Experience teaches the old soldier that the less he drinks when on a march the better, and that he suffers less in the end by controlling the desire to drink, however urgent. (p. 542)

On the other hand, many of the commission's recommendations were sensible, such as their remarks concerning vaccination against smallpox: "Every officer and soldier should be carefully vaccinated with fresh vaccine matter, unless already marked by small-pox; and in all cases where there is any doubt as to the success of the operation it should be repeated at once" (p. 542). The vaccine in question was supplied by the Surgeon General.

Considerable detail was devoted to personal hygiene and camp sanitation:

There is no more frequent source of disease, in camp life, than inattention to the calls of nature. Habitual neglect of nature's wants will certainly lead to disease and suffering. A trench should always be dug, and provided with a pole, supported by uprights, at a properly selected spot at a moderate distance from camp…. The strictest discipline in regard to the performance of these duties is absolutely essential to health, as well as to decency. Men should never be allowed to void their excrement elsewhere than in the regularly established sinks. In a well regulated camp the sinks are visited daily by a police party, and a layer of earth thrown in, and lime and other disinfecting agents employed to prevent them from becoming offensive and unhealthy….

The tents for the men should be placed as far from each other as the [Army] Regulations and the dimensions of the camp permit (never less than two paces); crowding is always injurious to health. No refuse, slops, or excrement should be allowed to be deposited in the trenches for drainage around the tents. Each tent should be thoroughly swept out daily, and the materials used for bedding aired and sunned, if possible; the canvas should be raised freely at its base, and it should be kept open as much as possible during the daytime, in dry weather, in order to secure ventilation, for tents are liable to become very unhealthy if not constantly and thoroughly aired….

On a march, take especial care of the feet. Bathe them every night before sleeping, not in the morning. Select a shoe of stout, soft leather, with a broad sole, and low heel. (p. 542)

And the commissioners did not neglect morale: "The men should not be over-drilled. It is likely to beget disgust for drill, and to defeat its object…. When practicable, amusements, sports, and gymnastic exercises should be favored among the men, such as running, leaping, wrestling, fencing, bayonet exercise, cricket, baseball, foot-ball, quoits, etc" (p. 542).

rebecca j. frey

SOURCE: "Rules for Preserving the Health of the Soldier." In Report of the U.S. Sanitary Commission. Washington, DC: 1861. Reprinted in Harper's Weekly, August 24, 1861, p. 542.

Conditions were particularly appalling around surgical tables. Equipment was never sterilized, and often water shortages prevented surgeons from even washing their hands. Instead, surgeons would wipe their hands and instruments on towels (Robertson 1984, p. 94). Thus, surgeons passed on diseases and caused infections in the patients they treated. Given these fundamental flaws in medical treatment, it is little wonder that for every Civil War soldier who lost his life on the battlefield, two others were felled by disease.

BIBLIOGRAPHY

Catton, Bruce. The Civil War. Boston: Houghton Mifflin, 1960.

Robertson, James I., Jr., and the editors of Time-Life Books. Tenting Tonight: The Soldier's Life. Alexandria, VA: Time-Life Books, 1984.

Shannon, Fred A. "The Life of the Common Soldier in the Union Army, 1861–1865." In The Civil War Soldier: A Historical Reader, ed. Michael Barton and Larry M. Logue. New York: New York University Press, 2002.

Ward, Geoffrey, with Ric Burns and Ken Burns. The Civil War. New York: Vintage, 1994.

Wiley, Bell Irvin. The Common Soldier of the Civil War. New York: Scribner, 1973.

Kevin Hillstrom