Sanitation

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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.