The Origins of Public Health in the United States By John B. Blake
During the second half of the 19th century the United States changed from a predominantly agricultural and rural to an industrial and urban civilization. The rise of the city forced upon the attention of the American people many problems which previously they had largely neglected; among these was public health. Spurred by social necessity and motivated by humanitarian idealism, economic and life-saving benefits, and increased popular faith in the value of science, public health officials and public spirited laymen advanced municipal public health practices from almost nothing to a vigorous and useful function of local government. Prior’ to the Civil War sporadic attempts were made to protect the public against infectious diseases by governmental action. Massachusetts Bay Colony, for example, set up quarantine regulations as early as 1647 when news arrived of a “great mortality” in the West Indies.’ Petersburg, Va., set. up what was probably the first board of health in 1780, and New York, Baltimore, and Boston took similar action in the 1 790’s.2 The outstanding Report of the Massachusetts Sanitary Commission in 1850, resulting from a survey undertaken by Lemuel Shattuck, reviewed the past history of sanitation and envisaged a remarkably comprehensive system of state public health administration far in advance of its time.READ: Primary Health Care Definition Goal Principles And Strategies
In 1857 Wilson Jewell of the Philadelphia ‘Board of Health arranged the first of four annual meetings of the National Quarantine and Sanitary Convention, but this promising organization was discontinued when the Civil War broke out. In the field of infectious diseases, effective methods of smallpox prevention, though not widely applied, had slowly been developed: inoculation and, later, vaccination had long been striving for recognition, and in addition laws requiring quarantine, notification, isolation in ” pesthouses,” and disinfection had found their way into the statute books and city ordinances. But despite these glimmerings of future light, little had in fact been actually accomplished prior to the Civil War. Typical was the board of health organized in New Haven, Conn., in 1806: it confined itself largely to matters of quarantine and nuisance removal; in some years when the town was generally healthy, it did not bother to meet. See : The Fathers Of The Disciplines In Public Health
Meanwhile, in England where the advent of the Industrial Revolution in the 18th century was already posing problems of urban health, steps were being taken which were to have a great influence on the United States. In London, effective legislation to end the gin drinking menace in 1751, improved care of parish children, extension of medical practice among the poor, together with street paving, better drainage and scavenging, and increased water- supplies helped to lower the death rate markedly.6 More significant were the investigations initiated in 1838 by Edwin Chadwick, a member of the British Poor Law Commission, on the relations of poverty and disease, culminating in the famous General Report on the Sanitary Condition of the Labouring Population of Great Britain in 1842. Presenting a picture of the filth and degradation of the city poor, Chadwick blamed their high mortality rate directly on ” atmospheric impurities produced by decomposing animal and vegetable substances, by damp and filth, and close and overcrowded dwellings.” He further declared that, when such conditions were removed ” by drainage, proper cleansing, better ventilation, and other means of diminishing atmospheric impurity,” epidemic and endemic diseases were abated or disappeared. Pointing out the economic and moral value of good health, Chadwick recommended sewerage, refuse removal from houses and streets, and better water supplies. Placed before Parliament, this report led to a series of investigations and acts which gave England by 1848 a public health administration superior to anything the United States was to achieve for many years. Read :Types of Sponge Forceps and Their Uses Pictured
In the United States, 1865 marks the date of an epochal step. In that year the Citizens’ Association of New York investigated sanitary conditions in the city, and blamed the high death rate from preventable disease in large part on the lack of any satisfactory health organization. Primarily as a result of this group’s report, the New York Metropolitan Health Law in 1866 established a board with wide powers, and its success in dealing with a cholera threat in its first year of existence greatlv helped to consolidate public support. Other cities, too, were founding or reorganizing their boards, and by 1890 it was exceptional for any city to lack one. Until the 1880’s action taken by these boards was based largely on the etiological theory implicit in Chadwick’s report of 1842. Despite the pioneer research of a few men such as Peter Ludwig Panum and John Snow, the majority of doctors in 1865 held to the filth or “pythogenic ” theory of epidemic disease causation. Although the contagious character of smallpox, was generally acknowledged, such ” zymotic ” diseases as cholera, typhoid fever, yellow fever, and diphtheria were attributed to “miasms ” or minute particles of morbific matter entering the body through the lungs. Decaying and decomposing organic matter was thought to be their chief source, and the belief was backed up by epidemiological evidence. On the basis of these assumptions. public health groups recommended certain procedures whose chief feature was environmental sanitation. Against diseases like cholera, typhus, and typhoid the methods were helpful and the theory was reinforced. Since the supposed miasms entered the body with the breath, the first requisite for healthful living was thought to be pure air. The obvious solution was to equip houses with good ventilation, to clean up streets and alleys, to remove refuse, to construct sewerage, and to provide a pure and plentiful water supply, essential to cleanliness. Proper drainage was considered of vital importance to prevent the production of miasms in moist soil, and the advocates of street paving received support from health officials anxious to prevent contamination of the soil. In line with this theory, American cities developed their water supplies extensively. See: Historical Public Health Figures
In Boston the first ” Water Works Company” was set up in 1652, the first important one in 1848. The first Croton water entered New York in 1842. In 1825 a total of 32 water works were in operation; in 1865, 162; in 1880, 598; in 1890, 1,878.1″ But while the quantitative aspect of the water-supply problem was being solved during the period from 1860 to 1890, the etiological criterion of decaying organic matter fostered by the pythogenic theory of disease led to a widespread and unfortunate belief in the self-purification of running water. Except for taste, color, odor, and chemical analysis to determine the amount of organic matter present was ordinarily the sole test of the purity of water, while filtration, except to make the water more palatable, was neglected. The technique in vogue had some value, of course, since a large amount of sewage increased the amount of organic matter and the danger of water-borne diseases, yet the two were not necessarily interrelated. Extensive dilution and oxidization of organic material meant that a comparatively short distance below a sewer outlet there might be, so far as chemical tests could indicate, nothing to fear from a river which actually contained infectious bacteria, while the danger from an isolated case of typhoid on a thinly inhabited watershed was completely passed over. Thus it was that in 1873 the president of the New York Board of Health, a chemistry professor at Columbia, advocated lakes or rivers for city water supplies, declaring that, ” although rivers are the great natural sewers, and receive the drainage of towns and cities, the natural process of purification, in most cases, destroys the offensive bodies derived from sewage, and renders them harmless.” There was, in fact, an increased use of rivers and lakes in preference to wells for water supplies, though convenience rather than medical theory was probably the chief reason, and some attempts were made to decrease pollution. READ Complete Guide for a Masters in Public Health in Nigeria
In Massachusetts, for example, an act of 1878 forbade pollution within twenty miles of any water intake. While Chicago continued to use Lake Michigan for both water supply and sewage disposal, in 1867 it began drawing some of its water through the first of several tunnels extending out under the lake These steps were exceptional, however, and the use of sewage-polluted rivers was common, while several cities besides Chicago-Milwaukee, Duluth, Buffalo, Cleveland, and others-drained their sewage into the same lake from which they drew their water. In 1883 a group of Philadelphia citizens complained that the city water, mostly drawn from the Schuylkill River without any purification, was at times so bad that it was ((not only distasteful and unwholesome for drinking, but offensive for bathing purposes.
According to the pythogenic theory, adequate sewerage was no less important to good health than a pure and abundant water supply. Fearing the emanations from decomposing organic matter as progenitors of zymotic disease, the miasmatists advocated. drainage to get rid of human filth and household and industrial wastes. They emphasized good engineering, since leaky sewers by polluting the soil caused noxious exhalations of ground air and excessive dampness, both considered dangerous to health. Proper drainage would also get rid of the sewage quickly before putrefaction could set in. Of special concern were the much discussed effluvia released by decomposition, the so-called ” sewer gas.” The list of diseases which it was supposed to cause reads like an account of the therapeutic claims of the most extravagant nostrum monger. Consequently sanitary experts also deemed well designed and carefully installed plumbing essential to prevent the gas from escaping into houses. Along with disinterested publicists, plumbers and plumbing companies did their bit to make their product a panacea.’ Sewerage development, while it advanced during the 1860’s and 1870’s, lagged behind the increase in water supplies, since it lacked the latter’s added value for fire protection and industrial use. Nevertheless, the number of urban communities with sewerage rose from only about 10 in 1860 to approximately 200 in 1880.’8 Even in these cities, however, privy vaults continued in widespread use, especially in the poorer sections, and only a small proportion of the streets were sewered. In 1877 Massachusetts enacted the first state law for plumbing inspection, but not until 1881 did Lawrence, Mass., become the first city to adopt a complete plumbing code. Meanwhile, beyond occasional relocation of outlets-little help to cities downstream-almost nothing was done toward proper sewage disposal. The demand for housing reform, in so far as it was connected with the public health movement, was also inspired during the 1860’s and 1870’s by the filth theory of disease. All the factors which worried the sanitarians-polluted soil, bad air, and contaminated water-were multiplied by the cfowded and filthy conditions of many of the dwellings of the urban poor. Historical Public Health Places
Overcrowding, defective drainage, malodorous privy vaults, improper refuse disposal, damp walls and wet cellars, evil working conditions, darkness, insufficient water supply, dirty and unpaved streets, and lack of bathing facilities all contributed to make the American slums prolific sources of disease. In New York, where the conditions were the worst in the nation, public spirited individuals and organizations concerned with the sanitary condition of the city and the welfare of the poor frequently agitated for reform. The Association for Improving the Condition of the Poor, a charitable society formed in 1843, took up the question in 1846. The first tenement house bill, product of two legislative commissions in 1856 and 1857, contained some able provisions but failed to pass. An investigation by the Citizens’ Association in 1865 brought on the first tenement house law two years later. Under its authority the board of health in 1869 ordered 46,000 windows cut in dark rooms, but it soon became apparent that the law was inadequate. Further agitation and investigation brought a new law in 1879 which made matters worse, if anything, by establishing the ” dumb-bell ” tenement -with its narrow, noisome airshaft. The .discretionary power given the board of health to dispense with certain good features combined with an insufficient inspection force to give powerful landlords the opportunity virtually to nullify the law. In relation to water supplies, sewerage, and housing, the pythogenic theory, when applied, proved helpful, but its inadequacv was effectively demonstrated during the frequent yellow fever epidemics which swept the South. As late as 1877, Henry M. Lyman, a professor at Rush Medical College, declared that while yellow fever could be imported and spread by contagion, it originated from a miasm formed by the decomposition of warm, moist human filth and thus could arise spontaneously wherever such conditions prevailed. READ Components of primary health care
In the epidemic year of 1878 the American Public Health Association devoted almost its entire meeting to this problem. The majority had by then come to believe that the disease was in some manner contagious, though of course the method of transmission was as yet unknown. Courageously if somewhat naively, in view of the commercial implications, Samuel Choppin, president of the Louisiana Board of Health, recommended absolute non intercourse from April to November with ports where yellow fever was indigenous. The following year, however, the merchants of New Orleans founded a voluntary sanitary organization whose activity was concerned almost entirely with environmental sanitation, and the epidemic prompted Memphis to organize an efficient board of health and to build a sewerage system and water works. READ : The 8 Types Of Personal Hygiene
Although the filth theory of disease remained the most prevalent basis for public health activity during the 1870’s, it was already undergoing modification by the influence of new theories developed by European medical research. The theory of contagion had, in fact, never been completely discarded. Quarantine and to a lesser extent isolation continued to be used for many diseases besides smallpox. Moreover, certain epidemiologists were laying a firm basis for the development of the contagion theory. Peter Ludwig Panum’s study of measles in the Faroe Islands in 1847, John Snow’s publications on cholera in the 1850’s, and William Budd’s work on typhoid fever beginning id 1856 indicated clearly the communicable nature of those diseases. To put the control of epidemic disease on a firm basis, however, the contagion theory had to be conclusively established by the germ theory of disease. In the 1850’s Louis Pasteur began his studies of fermentation. Further milestones came in 1870, with the publication of Pasteur’s Etudes sur les maladies des vers a soie, and in 1876, when Robert Koch showed conclusively that a specific bacillus could cause anthrax. In the following decade, greatly aided by Koch’s development of the solid culture method in 1881, new discoveries followed one another in rapid succession, definitely establishing the germ theory. As is so often the case, the implications of the new science of bacteriology were not at first fully perceived. Nursed in the filth theory, many public health advocates began to look on decaying organic matter as a breeding ground for germs instead of miasms. Studies showing the high bacterial content of dust arising from municipal highways were used to bolster arguments for street cleaning. In 1891 a committee of the American Public Health Association reported that the lax collection of garbage was a great danger to the health of the nation, that ” Heaps of garbage continue to be disease-breeders, furnishing the proper conditions for the rapid growth and development of any disease germs which may lodge therein.” Man, the committee complained, goes on piling up excrementitious matter ” until the earth, water, and the very air are charged with death-producing elements. While no one would deny that efficient garbage collection is beneficial, the recommendations thus made were still, in effect, based on a modified filth theory of disease. Gradually, however, the new etiological theory was more firmly grasped, and its effects became noticeable in board of health activities. For many years epidemiologists in both Europe and the United States had been publishing studies indicating that typhoid fever, for example, was often transmitted by water supplies contaminated with the excreta of infected persons. With the growth of the germ theory and the discovery of the typhoid bacillus in 1881, these past studies took on new meaning, and future investigators could direct their attention to the specific causative agent of America’s most prevalent waterborne disease. A penetrating analysis by the State Board of Health of a typhoid epidemic in Plymouth, in 1885helped to spur an interest already reviving among the members of the American Public Health Association and a small part of the general public in sewage polluted water. Realization of its danger, reinforced by high typhoid mortality rates in cities using such water, provoked a discussion of new remedies and new testing methods to fit the new theory. Chemical analysis was called inadequate and use of any sewage-polluted river as a water supply condemned Increasingly, American cities attempted to diminish pollution of their sources of water. In Chicago, for example, the previous policy of building tunnels continued, but it was not until 1892 that the last of the shore intakes was shut off, dropping the typhoid death rate from a high of 174 per 100,000 in 1891 to 54 per 100,000 in 1893. SEE: Equity Vs Equality: Understanding The Difference
In addition, interception sewers were built during the 1890’s to empty into the Chicago River while, despite the opposition of St. Louis, concerned over its own water supply, and of certain commercial interests, concerned over the level of the lake, construction of a drainage canal miles long served to reverse the river’s flow, sending all Chicago waste down the Illinois. In 1900 the typhoid death rate reached a new low of 20 per 100,000. In addition, new experiments were undertaken in filtration. The first important studies were at the Lawrence Experiment Station, set up by the Massachusetts Board of Health in 1887, where the slow sand method was developed. Although progress in applying this knowledge came largely after 1900, its value had already been proved in Lawrence. When an investigation showed that the city water supply, taken from the sewage-polluted Merrimac, was to blame for a severe typhoid epidemic in 1890 and 1891, a slow sand filtration plant was introduced in 1893, and the death rate from all causes fell from 24.0 per 1,000 in that year to 18.8 in 1894. READ Dental Instruments Pictures, Names and Uses
Meanwhile, the advent of bacteriology also made possible the development of greater purity in milk supplies. Although medical and scientific writers showed comparatively little interest in milk before 1880, Boston had appointed a milk inspector in 1859 to prevent the use of distillery slops as feed. It was not until the 1870’s and 1880’s, however, that inspection became significant, and then it was primarily directed, with more or less success, to the problem of adulteration. In the 1890’s an increasing scientific interest in the problems of milk supply brought new emphasis on bacteriological purity. Koch’s discovery of tuberculin in 1890 made possible accurate detection of tuberculosis in cattle, long known to exist and considered dangerous, and by 1900 several cities were requiring tuberculin tests. The first experimental bacterial counts in the United States came in Boston in 1892, and other cities followed, but it was not until 1900 that Montclair, N. J., instituted the first regular system of bacteriological examination. The movement for certified milk, inaugurated in 1892 by Henry L. Coit of Newark, N. J., greatly aided in improving production conditions in many dairies. While Pasteur and other Europeans had been working on means of sterilization since the 1860’s, pasteurization was largely in the discussion stage in the United States until after 1900. At the same time certain charitable organizations and philanthropic individuals, realizing that the children of the poor who needed this food most were least able to get it, began developing infant milk depots. The first, founded in Germany in 1889, was followed the same year in the United States at the Good Samaritan Hospital in New York. Especially important was the station set up by Nathan Straus in 1893, first of many supported by his contributions. Rochester, N. Y., in 1897 was the first city to undertake municipal distribution. See:Father of Public Health in Nigeria
While constant advances were being made in nearly all fields of environmental sanitation during the 1880’s and 1890’s, the developments in medical theory also prompted the extension and improvement of old techniques of infectious disease control long used for smallpox. In 1873 Brooklyn first required notification of scarlet fever and typhoid, and though this development was slow to spread, by 1900 states and many communities in others required notification of communicable diseases. In 1894 Boston introduced the first regular system of medical examination of school children, followed by Chicago in 1895, by New York in 1897, and by Philadelphia in 1898. Placarding of houses for infectious diseases became nearly universal by 1900. Except for smallpox facilities, in 1873 New York had only two small wards on Blackwell’s Island to serve as an isolation hospital, mostly for typhus, but by 1899 at least 15 of the nation’s largest cities had isolation hospitals for scarlet, fever, diphtheria, and other infectious diseases. Disinfection became so prevalent that by 1906 Charles V. Chapin termed it a ” fetich.”
In addition to the extension and improvement in notification, isolation, and disinfection, certain innovations were made possible by the advent of bacteriology. The most important, prior to 1900, was the introduction of bacteriological laboratories as an essential adjunct of boards of health. The first, established in Providence in 1888, proved its value that year by tracing an epidemic of typhoid fever to the city water supply. While the emphasis in this and similar early establishments was on the sanitary aspects of public health, New York in 1893 instituted the first diagnostic laboratory. The development of culture methods as the most valuable means of recognizing diphtheria caused many cities as well as states to follow this lead, and by 1900, 31 of the 40 largest cities and many smaller ones were so equipped. Although the original and principle purpose of most of these laboratories was to perform routine work in diagnosis and control of communicable diseases, some also produced antitoxins, vaccine, and tuberculin. Generously established facilities in such places as Boston, New York, Philadelphia, and Pittsburgh, provided an opportunity for original investigations and attracted able men who would otherwise have gone into state or university positions. According to the Review of Reviews the New York Health Department commanded ” scientific talent of a high order,” and this praise was well earned by its work in establishing the carrier principle for diphtheria. In the years that followed the laboratory, through work in controlling water, milk, and food supplies, diagnosis, and preparation of sera and vaccine, became the foundation of the public health movement in the United States.
The science of immunology, introduced by Pasteur, paved the way for another major development in the 1890’s, the use of diphtheria antitoxin. Although foreshadowed by smallpox vaccination, immunology had to await the germ theory before extension to other diseases was possible. When the news of the development of diphtheria antitoxin by Emil von Behring and Shibasaburo Kitasato reached the United States, one popular news magazine commented that, “nothing else in the world’s recent progress of which these pages could make note has an equal degree of interest or importance.” Convinced by its own investigations of the value of the new discovery, the New York Health Department, under Hermann M. Biggs, started manufacturing the antitoxin, partially supported by the New York Herald. Inaugurated by New York, free distribution of the cure was quickly taken up by other cities from Boston to San Francisco, from Chicago to New Orleans.The value of these measures was reflected immediately in the saving of life. In New York the death rate for diphtheria and croup had increased steadily from 118 per 100,000 in 1890 to 168 in 1894; the following year it dropped to 112, and in 1898 reached a low of 48 for the decade. In Boston the rate was over 100 every year but one from 1890 through 1896; in 1898 it reached a low of 35.42 In the fight against the nation’s greatest killer, tuberculosis, significant advances also occurred in the closing decade of the century. Development of effective means of treating tuberculosis came during the 1880’s and 1890’s. Deciding to test the rest and fresh air theory, Edward L. Trudeau in 1873 went to the Adirondacks where meditations on his own improvement led to the establishment of the Adirondack Cottage Sanatorium at Saranac Lake in 1884. By 1900, there were many successful private sanatoria and at least three supported by state and local governments. Meanwhile, Koch’s discovery of the tubercle bacillus in 1882 demonstrated the contagious nature of the disease.
Discovery of the germ in the sputum of patients led to the belief that dried expectoration was a particularly common means of spreading infection, whether found on linen, bedclothes, handkerchiefs, floors, or street pavements. In 1890 New York City began issuing the first pamphlets giving information on the contagious character of the white plague and on means to prevent its spread, and by 1894 was conducting an intensive campaign of prevention, emphasizing education. Soon the Department of Health was distributing 20,000 to 30,000 circulars a year to physicians and tenement house residents where the malady thrived on crowded conditions. By 1899, 22 state boards of health and many other cities had adopted this practice. New York also introduced enforced disinfection and renovation of infected premises. In 1896 the city passed the first anti-spitting regulation in the United States. The following year New York became the first to require notification of tuberculosis. The results of this fight against the white plague were markedly reflected in the death rates. In New York it dropped from 362 per 100,000 in 1890 to 257 in 1900; in Boston from 333 to 222; in Philadelphia from 264 to 210; in Chicago from 179 to 153. The campaign against tuberculosis also marked the first extensive use of another valuable weapon in the hands of health officers, education in personal hygiene. They had long recognized the importance of popular support, and the American Public Health Association had worked valiantly to spread knowledge. Most of this, however, was propaganda to convince the public of the general need for sanitary measures in order to gain support for boards of health and to promote cleanliness. Since the 1870’s, there had been pleas in lay as well as scientific periodicals for instruction in physiology, hygiene, and sanitary science in public schools. Early efforts, as far back as 1850 in Massachusetts, to introduce such subjects into the curriculum were largely abortive, but renewed attempts in the 1880’s proved more successful. Unfortunately, however, most of the resulting legislation came from the pressure of temperance and similar organizations, and the teaching was specifically directed at the effects of alcohol and tobacco.
According to one member of the American Public Health Association, most of the textbooks were ” unfair, unscientific, and untruthful. While some of the other publicity given to the public health movement was invaluable, it was in the field of tuberculosis prevention and cure that there occurred the first significant dissemination of information on specific methods of controlling communicable diseases. This technique was to become of increasing importance during the 20th century. One of the valuable aids to the development of education, public health nursing also saw its first beginnings during this period. The first modern district nursing association was founded in 1859 by a Liverpool philanthropist, William Rathbone, with the coperation of Florence Nightingale. SEE R 027 PILL XANAX?
The movement reached this country with the formation of a similar organization in 1877 by the Women’s Board of the New York City Mission. In 1886 the Instructive District Nursing Association was established in Boston, the first to include education in personal hygiene as a definite objective. By 1900 there were 58 organizations engaged in public health nursing employing 130 nurses. Again, the impetus had been given for a far greater development in the present century. In contrast to the movement for environmental sanitation, the development of bacteriological laboratories and of new methods of treating diphtheria, tuberculosis, and other communicable diseases owed comparatively little to non-professional humanitarian organizations. Especially in New York where the far-sighted administration of Hermann M. Biggs set an example for the world it was the big city health officials and their professional colleagues that led the way. Several reasons combined to bring about this change. The health officers were in a better position to realize the importance of new developments in medical science. Writing in 1900, Chapin declared that ” public sanitation in the popular mind consists chiefly in the removal of nuisances,” and even among many sanitarians the filth theory of disease still seemed, for all practical purposes, to hold first place. While the New York department was making its epochal researches in the control of diphtheria, a writer in Scribner’s Magazine charged it with ” pottering ” with tenement house reform.
Another factor was that these new activities were less likely to raise specific opposition. While a bacteriological laboratory could be set up fairly cheaply, and rarely injured important private interests, a new water works was expensive and changes frequently represented the virtual loss of a considerable investment, often of private capital. Tenement reform especially was opposed by vested interests. A third reason was the increased faith in the value of science arising in part from its more widespread teaching in the colleges and high schools but still more from its many successes in medicine and other fields. In addition, the idea of a social service state, though still in its infancy compared to today, was gaining in popularity. Not only were some men attacking the predominant belief in laissez faire, but tax supported schools, libraries, and fire departments-all of which developed extensively in the years following the Civil War-were akin to tax supported public health. Though the activities of the federal government in public health were slight, it was supporting scientific research in other fields with the establishment of the U. S. Geological Survey and the Bureau of Ethnology in 1879. Humanitarians had accustomed many to the idea of using government to effect their reforms. By the 1890’s the boards of health had proved their value and were securely established as part of American municipal administration. No longer under the compulsion of trying to get the authority to make rules for health, they were able to use their power, and, together with their professional colleagues, to lead the way in the public health movement. Nothing else shows more clearly the advance which New York had made since 1865, when a group of private citizens had to give the impetus to the formation of the health department
In the 1860’s and 1870’s the need for environmental sanitation and adequate administrative powers had been emphasized. During the 1880’s and 1890’s these became generally recognized, received widespread support, and developed rapidly. By 1900, there was much room for improvement left: many wells were still used for water supply; sewerage was often inadequate; housing of the urban poor was execrable; refuse removal was often neglected. Yet great strides had been made and the need for remedial action was firmly established in the public consciousness. Civic minded organizations were demanding cleanliness, and in 1901 New York passed the first effective tenement house law. In many cities the administrative details had already passed out of the purview of boards of health into the hands of various departments especially organized to cope with them. In the 1880’s the implications of new medical theory were beginning to reach public health experts, and during the 1890’s were producing significant results. In the developments deriving from bacteriology a sound start had been made toward pure water and milk supplies and toward the control of infectious diseases through increasing application of the techniques of notification, isolation, and disinfection, and by development of laboratories, diphtheria antitoxin, and education in personal hygiene. Much lay ahead in all these fields. Problems of rural health, mobilization of the physicians of the community to aid in public health, care of chronic and constitutional diseases, and industrial hygiene had as yet received little attention. But by 1900 the public health movement, virtually nonexistent in 1860, was firmly established, and had proved its value in lowering the death rate of the nation.SEE: Why Public Health Movements Are Important