Public Health and Sanitation

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Public Health and Sanitation

Public health and sanitation in America during the Civil War era was virtually nonexistent, but the efforts of reformers—many of whom worked to improve conditions in U.S. Army camps on the Union side—led to intensive clean-up efforts later in the nineteenth century. Military camps and hospitals were breeding grounds for many of the diseases that regularly felled urban populations, such as typhoid fever, cholera, and dysentery.

Deadly Miasmas

The medical community was woefully unaware of many of the basic tenets of public health and sanitation when the Civil War began in 1861. There was little knowledge about the causes of preventable diseases, and the correlation between germs and sickness had not yet been established by scientific observation and controlled experimentation. The commonly held belief at the time was that diseases are caused by vaporous exhalations known as miasmas, from a Greek word that means "pollution." Miasmas were associated with the rank odors of such things as sewer gas or piles of garbage.

The United States Sanitary Commission (USSC), a civilian organization founded in 1861 under the auspices of the federal government, was set up to inspect Union camps and hospitals and offer recommendations and guidelines to prevent infections and infectious diseases. Despite the commission's valiant efforts, the casualty numbers from the war paint a stark picture of how poor conditions were: The total number of war dead was an estimated 690,000, but only 240,000 of that number died from battlefield injuries; a staggering 425,000 were killed by such diseases and wound complications as typhoid fever and gangrene (Sutherland 1989, p. 19).

In civilian life, the death rates from preventable diseases were also high. Indoor plumbing was a rarity found usually in only the wealthiest households, and even then, the pipes were not always hooked up to municipal sewer systems, which were also still uncommon. When the sewer pipes were connected to a sewer system, they often emptied into the same water source that supplied local drinking water. Most households used either an outhouse or an "earth closet" located inside the house. The latter was a specially constructed wooden chamber with a seat; waste went into a galvanized metal tube, but once too much waste had accumulated, the drain would have to be cleaned out. Outhouses, often located in the same backyard where livestock animals were kept, were similarly constructed and these, too, would overflow. At night, most families relied on relieving themselves in the chamber pot, the contents of which would be tossed onto the street the next day.

Garbage collection was also a rarity in most communities. In some cases, cities allocated funds for this task, but corrupt local district leaders often took the money without hiring collectors. In upscale urban neighborhoods, where residents banded together to pay for private collection, garbage did not pile up to the point of making certain avenues impassable, as it did elsewhere.

Overcrowded Manhattan

New York City presented a particularly foul scenario. Immigration over the past two decades had brought an influx of new inhabitants to the city, many of whom were relegated to living in abject squalor. Multistory tenement buildings began to crop up, which housed dozens of people in one or two rooms with a single window overlooking a garbage-strewn airshaft. Each floor usually had a version of the earth closet, but no running water or indoor heating. Cholera and typhus outbreaks were common.

Typhus is a highly communicable disease, and the organisms (rickettsiae) that cause it are transmitted by lice living on the human body. Typhus should not be confused with typhoid fever, which is contracted from ingesting food or water contaminated with the feces of an already infected person; however, both diseases are equally swift-moving and often deadly. Cholera also results from poor sanitary conditions, and regular outbreaks occurred in the nineteenth-century United States every spring when passenger ships began dislodging new immigrants and travelers at the international ports of arrival. These diseases reached every quarter—even President Abraham Lincoln's eleven-year-old son Willie died of typhoid fever in February 1862—a personal loss from which neither Lincoln nor his wife ever fully recovered. The decision to locate the federal capital in Washington had always been much maligned, for the city had been built on swampy land, which is known to be a breeding ground for mosquitoes, the carriers of deadly malaria.

Cities further south were usually even more dismally filthy, for the balmy weather only exacerbated the stench and the germ colonies that came from untreated sewage, garbage piles, and the waste droppings of horses.

Stephen Smith and the Report of the Council of Hygiene and Public Health

In the 1850s, the New York City physician Stephen Smith emerged as a prominent and tireless advocate for improved public health and sanitation. Early on, he was one of the few among the medical profession who recognized the link between the abominable living conditions of the poor and outbreaks of disease. A few years before the onset of the Civil War, Smith was appointed to supervise a quarantine facility on Roosevelt Island during a typhus outbreak in the city. When he realized that an extraordinary number of patients were coming from the same tenement building on East 22nd Street, he went to inspect the property himself. "The doors and windows were broken," he reported. "The cellar was partly filled with filthy sewage; the floors were littered with decomposing straw, which the occupants used for bedding…. The whole establishment was reeking with filth, and the atmosphere was heavy with the sickening odor of the deadly typhus, which reigned supreme in every room" (Rutkow 2005, p. 267).

In 1859 Smith founded the New York Sanitary Association, which worked to improve conditions in the city. He soon became known as a prominent Sanitarian, as public-health reformers were called. Some of his like-minded colleagues played a key role in the establishment of the United States Sanitary Commission (USSC). One of these fellow reformers was Frederick Law Olmsted, who resigned as New York City's parks commissioner to serve as executive director of the USSC. Smith also worked for the USSC, and served as acting assistant surgeon at a Union Army base at Fort Monroe, Virginia, during the war. Once back in civilian life, he refocused his efforts to clean up New York City, and established a commission that funded a groundbreaking 1864 sanitary survey of the island of Manhattan. He chaired the commission and sent physicians to inspect each of the thirty-one districts into which he divided the borough. The conditions these doctors found were so dreadful that the report of their findings, Report of the Council of Hygiene and Public Health of the Citizens' Association of New York, upon the Sanitary Condition of the City, caused a major public outcry. Its publication became the turning point for public health and sanitation efforts in New York City.

Smith's Report detailed horrendous overcrowding in the city, where about half a million people lived in a two-square-mile area (Rutkow 2005, p. 270). Some lived in tenements, but others who had their own plots of land raised hogs in their backyard and lived right next to manufacturing enterprises, in an era when zoning laws were nonexistent. One of Smith's inspectors wrote of "a sausage and fat-boiling establishment… [where the ] heads and of animals are received…and and the parts which can be profitably [used] are selected, while the rest is thrown upon the ground or buried[;] adjoining streets have no sewerage, and this building no drainage" (Rutkow 2005, p. 310). Another physician hired for the job visited a residence near Avenue B and Attorney Street, and found "two of the scrofulous children in that house on crutches. The grave has a strong claim upon others." The inspector noted several livery stables nearby, and remarked that "the prevalence and fatality of pulmonary diseases among horses in overcrowded and neglected stables is only equalled by the fatality of like maladies in the women and children of tenant-houses" (Rutkow 2005, p. 175).

Smith took his Report to Albany and testified before the New York state legislature. Finally, in 1866 a new Metropolitan Health Bill—part of it drafted by Smith — was enacted. Two years later, Smith became commissioner of the New York City Board of Health. The Metropolitan Health Bill was a groundbreaking piece of legislation that was widely copied by other cities in their efforts to curb disease outbreaks. Some of its most significant reforms included the removal of slaughterhouses to locations outside city limits, new health standards for the dairy industry, and the regular removal of horse droppings from city streets.


Citizens' Association of New York. Report of the Council of Hygiene and Public Health of the Citizens' Association of New York, upon the Sanitary Condition of the City. New York: D. Appleton, 1865.

Rutkow, Ira M. Bleeding Blue and Gray: The Untold Story of Civil War Medicine. New York: Random House, 2005.

Smith, Stephen. The City That Was. New York: F. Allaben, 1911.

Sutherland, Daniel E. The Expansion of Everyday Life, 1860-1876. New York: Harper & Row, 1989.

Carol Brennan

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