EUROCONFERENCE: HYGIENE AND

HEALTH
The Institut Pasteur sponsors and organizes a series of conferences on important topics in biology, medicine, and envi-
ronmental sciences. These Euroconferences are delivered by recognized scientists in selected areas. The conferences are
designed to facilitate an exchange of ideas between basic and applied scientists from the Institut and other academic insti-
tutions and pharmaceutical companies. The main purpose of the conferences is to strengthen industrial connections and
provide a high-quality service to the community. The conferences are aimed primarily at scientists, physicians, and
research and development managers in the biopharmaceutical industry, public health laboratories and agencies, and hos-
pitals.
We are pleased to serve as the official publication of the Institut Pasteur Euroconference, “Hygiene and Health,” which
was held in Paris from January 25-27, 2001. Even in the 21st century, infectious diseases continue to exert a heavy toll on
human health and existing resources in the developed and developing regions of the world. Researchers, clinicians, and
policy makers recognize the role of hygiene and education in promoting public health. Understanding the potential harm-
ful nature of microbes, the risk factors in various populations and the means of reducing exposure to potential pathogens
can help lay the strategies for enhancing hygiene, thus reducing infection rates and promoting public health. The
Euroconference provided a forum for discussion of global issues related to hygiene and health. This issue of AJIC includes
16 extended abstracts from presenters at the conference.

Elaine Larson, RN, PhD, FAAN, CIC

AJIC Editor

Personal hygiene and life expectancy

improvements since 1850: Historic and
epidemiologic associations
Velvl W. Greene, PhD, MPH
Beer Sheva, Israel

Do not say ‘How was it that the former times were better than these?’ For that is not a question
prompted by wisdom. —Ecclesiastes 7:10

The “good old days,” when everything, particularly are a myth. The documented history of Western civi-
human health, was supposedly better than it is today, lization describes an endless and unromantic struggle
with sickness and death, tragically high infant mortality
rates, and the premature death of young adults. Death-
From Ben Gurion University.
dealing epidemics attacked helpless communities near-
Presented at the Institut Pasteur Euroconference, “Hygiene and ly as often as summer and winter came to pass, and
Health,” Paris, France, January 25-27, 2001.
were followed every few years by major catastrophes.1
Reprint requests: Velvl W. Greene, MD, Ben Gurion University, Even during the “good” years when no serious epi-
Mivtza Nahshon 51/1, Beer Shiva, Israel.
demics occurred, the baseline mortality rate was often
Am J Infect Control 2001;29:203-6 4 times higher than what we experience today. In
Copyright © 2001 by the Association for Professionals in Victorian England, the average age of death among the
Infection Control and Epidemiology, Inc. urban poor was 15 to 16 years.2
0196-6553/2001/$35.00 + 0 17/47/115686 This dismal situation started to improve dramatically
doi:10.1067/mic.2001.115686 about 150 years ago. Mortality records from different

203
 AJIC
204 Greene August 2001

communities in Western Europe and America3-6 indi- hypotheses and naive logic. Until Pasteur elucidated his
cate a veritable “health revolution” by the middle of the “Germ Theory of Disease” in 1878, the microbial cause of
19th century—a significant increase in life expectancy infectious disease was unknown; the very concept of
and a marked decline in crude mortality rates, followed “infection” was still foreign.14 However, it is difficult to
a few decades later by a gratifying drop in the infant argue with success. Between 1850 and 1900, the com-
mortality rates. Moreover, each decade since then, a monly recurring epidemics of cholera, smallpox, malar-
lower mortality rate has been recorded than in the ia, and typhoid were gradually brought under control.1
decade immediately preceding it. Although the greatest During the next 50 years, gratifying victories over such
relative improvements were seen in infant and child endemic diseases as tuberculosis, diphtheria, measles,
mortality rates, the life expectancy of every age group and scarlet fever were witnessed. These diseases were
improved: young adults, the middle-aged, the old, and less dramatic than epidemics, but each was among the
the very old.7-9 leading causes of death before 1900.12 By the middle of
How did this revolution commence, and what con- the 20th century, except for the 1918 influenza pandem-
tributed to its amazing success? Obviously, many fac- ic, death from infectious disease in Western industrial-
tors contributed to its success—some by design, others ized countries was no longer a major component of mor-
by accident, some with a direct and immediate impact tality statistics.15
on life and health and death, and others with a less The conquest of infectious disease and the health revo-
direct and often delayed effect. The 19th century was a lution it initiated is arguably one of the greatest achieve-
ferment of new scientific discovery and inventions, ments of Western civilization. Yet the phenomenon is
laws, and insights. New social-political ideologies largely unknown and rarely taught, even in history cours-
encouraged improvements in the environment and es. Conventional wisdom usually assumes that the con-
modifications in the behavior and practices of individ- quest of infectious disease can be credited to well-known
uals and communities. Many 19th-century innovations lifesaving innovations in medicine such as vaccines,
could have contributed to the health revolution. The antibiotics, and surgical asepsis. These icons are truly
list of “candidates for honors” is long, and no unanim- essential ingredients of modern medicine, and their con-
ity exists among historians about which innovation is tribution to human life and health in this century can
the most important. never be minimized. However, except for the smallpox
To be seriously considered, an innovation must show vaccination, which was introduced in 1798 and made
a plausible, biologic relationship to mortality preven- compulsory in England in 1853,16 the overall contribution
tion, it must have influenced a substantial proportion of medical innovations to the health revolution of the
of the population, and it must have preceded the 1800s is difficult to validate. Diphtheria, tetanus, and per-
decrease in mortality with which it is credited. In this tussis vaccine arrived on the scene only after disease mor-
respect, the following 3 general innovations are gener- tality rates already had been reduced significantly;
ally accepted8,10,11: measles, rubella, and polio vaccines did not become avail-
1. improved housing and consequent reduction of able until the middle of the 20th century, when most infant
overcrowding; deaths were the result of other causes. The same holds
2. improved nutrition resulting from innovations in true for the sulfa drugs and antibiotics. Their contribution
agriculture and technology; and is unequivocal, but they did not affect mortality rates until
3. improved hygiene, including environmental sanita- the 1940s.11,17 Antiseptics and disinfectants were used suc-
tion and personal cleanliness. cessfully as early as the 1840s, and by 1900 the autoclave
Determining which of these 3 innovations was the and sterile gloves had been invented.18 Lister and
most important is not relevant. Each innovation meets Semmelweis and their contemporaries certainly deserve
the aforementioned criteria and undoubtedly played a credit for their vision and lifesaving innovations, but many
significant role in reducing mortality rates. More impor- decades passed before their recommendations became
tantly, all 3 innovations were essential components of widely accepted, and the actual number of lives they influ-
the war against infectious disease in the 19th century.12 enced was probably too small to have a significant impact
In the 1800s, smallpox, scarlet fever, measles, and on national mortality rates. The modern hospital is large-
diphtheria were so familiar that people regarded them as ly a phenomenon of the 20th century. Before then, there
necessary features of childhood. Cholera and malaria were relatively few surgical patients and hospital deliver-
epidemics were common, typhus and typhoid were ram- ies—the population groups that would most benefit from
pant among the poor, and tuberculosis was common hospital infection control practices.
among the rich and poor alike.13 Any struggle to improve On the other hand, urban living (and dying) in Europe
life and health had to start with the control of infectious and the United States in the early 1800s took place under
disease. The early battle strategies were based on faulty extraordinarily filthy conditions.2,9,13 Putrescible refuse,
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Volume 29, Number 4 Greene 205

human and animal waste, and dead carcasses piled up in household’s linen clean was an unbelievably grim and
the streets and courtyards. There were open sewers and laborious task. The rich and titled gathered at Turkish
too few privies, and chamber pots were emptied into baths or spas; members of the wage-earning class often
courtyards. The stench, particularly in warm weather, went through life without a bath, with only an infre-
was legendary. In fact, foul odors or miasmas were con- quent change of underwear, and with only an occa-
sidered to be the cause of most prevalent diseases. The sional ablution in a cold stream or polluted river. In
triad “filth, poverty, and disease” appears so frequently in Great Britain, bathing and laundry facilities built by
19th century writings that it is easy to see how they local governmental units started appearing throughout
became identified as having some type of cause-and- the country after the 1850s, usually in the dreariest
effect relationship. To break this chain and to relieve the slums of cities. Despite the stigma associated with their
suffering of the laboring classes in England, an improba- use, 10 such facilities in London provided more than a
ble and informal coalition of social activists, prison million baths, and more than 300,000 women used the
reformers, physicians, clergy, and scientists started advo- laundry in any given year of the 1860s. By 1905, more
cating sanitary reform in the early 1800s.12 They main- than 6 million baths were “sold,” evidently fulfilling an
tained that both illness and poverty resulted from “insan- unmet need.21,22 In the United States, the big transfor-
itary” conditions and practices that could be remedied. mation in personal hygiene started after cities institut-
This “sanitary movement” was instrumental in getting ed “water works,” which piped filtered water directly
legislation passed in Great Britain during the 1850s and into the home from a central distribution system. By
1860s (and in the United States a decade later) to create 1890, 1.4% of the urban population was so served by
public health authorities with power to regulate sewage water works; by 1910, this number increased to more
collection, water supply, environmental nuisances, and a than 25%. As water became available, sinks, bathtubs,
remarkable list of other relevant matters, such as physi- showers, and indoor toilets were installed. The sale of
cian licensing and child labor abuses.19 The pioneers of soap and washing machines increased in a parallel
the movement were fervent advocates of personal fashion.23,24 The personal hygiene transformation was
hygiene, particularly bathing and laundering. Some of on the way, fueled by aesthetics, social pressures, com-
their very early efforts focused on reducing the tax on mercial advertising, and even theologic incentives
soap (1833), building a bathhouse and laundry for the (“Cleanliness is next to Godliness”).
working class in London (1844), and passage of the According to the public health literature, the trans-
Public Baths and Wash-Houses Act (1846) to finance mission of 35 to 40 human diseases can be interrupted
local bathing facilities (later, swimming pools) through- by improved levels of personal and environmental
out England.16 hygiene.25 Logic implies that the incidence of all such
In addition to the seminal and recognized role of illnesses would decline consequent to the described
environmental hygiene, a substantial but overlooked changes in hygienic behavior. (The decline of trachoma
component of the health revolution was the transfor- in Appalachia after 1915 and the essential disappear-
mation in personal hygiene practices and cleanliness. ance of louse-borne typhus from the United States
The transformation probably started in the early 1800s, since 1921 are particularly tempting subjects for analy-
became extremely popular from 1890 to 1915, and has sis.) However, population-based data for most of these
since become an essential feature of “civilized” behav- conditions are too scarce to support more than anec-
ior in the United States and Europe. It is proposed that dotal speculation. On the other hand, a strong case can
this mass behavioral change in washing, bathing, laun- be made that personal hygiene played an important
dering, and domestic hygiene practices contributed sig- role in the reduction of infant mortality. However, reli-
nificantly to the continuing reduction of illness and able data, particularly about cause-specific mortality,
death rates at the beginning of the 20th century. are very difficult to find before 1900. Since then, near-
Historic evidence of this behavioral transformation ly all available data reinforce the following 2 relevant
can be gathered from contemporary writings in news- observations:
papers and books, governmental reports, medical 1. The dramatic decline in the US and British infant mor-
records, commercial data, and the mirror of social tality rates coincided with or closely followed the per-
change—advertising directed to the consumer.2,9,20 The sonal hygiene transformation in the decades circa 1900.
literature of the 1850s reveals that the term “unwashed 2. In the United States, the leading cause of infant mor-
masses” was not a literary allegory but rather a clinical tality until 1920 (when it yielded its infamous title to
description of the common folk. Running water was low birth weight) was unquestionably infant diar-
not available, heating water was prohibitively expen- rhea.3,4
sive, soap was hard to get or make, and homes had no It should be emphasized that a very plausible, bio-
facilities or space for washing or bathing. Keeping a logic association exists between improved personal
 AJIC
206 Greene August 2001

hygiene and the decline of infant diarrhea, with a sub- 4. National Center for Health Statistics. Vital statistics rates in the United
sequent impact on overall infant mortality rates. Most States 1940-1960. Washington (DC): US Government Printing Office;
1968. PHS publication No. 1677.
etiologic agents responsible for infant diarrhea (bacte-
5. National Center for Health Statistics. Vital statistics of the United
rial, viral, and parasitic) are common inhabitants of States 1977. Vol II. Mortality. Washington (DC): US Government
the human gut and gain access to their new hosts by Printing Office; 1981.
the fecal-oral route. In a population that neglects per- 6. Registrar General’s statistical review of England and Wales. London:
sonal hygiene, the increased probability of infection HM Stationery Office; 1972.
7. US Bureau of the Census. Historical statistics, colonial times to 1970.
and subsequent illness is self-evident. It is also clear
Washington (DC): US Goverment Printing Office. Available at: http://
that any practice that reduces the number of potential www.census.gov/prod/1/gen/95statab/opp4.pdf. Accessed May 8, 2001.
pathogens on the mother’s skin will effectively mini- 8. Sydenstriker E. Health and environment. New York: McGraw-
mize the probability of infecting her infant. Hill; 1933.
Considering the number of times in a day that each 9. Shattuck L, Banks NP, Abbot J. Report of a general plan for the pro-
motion of public and personal health. Massachusetts Sanitary
child would be exposed to potential infection from a
Commission. Boston: 1850 (reprinted by Arno Press, New York 1972).
caregiver whose skin is seeded with enteric microbes, it 10. Kass EH. Infectious disease and social change. J Inf Dis 1971;123:110-4.
is quite credible that a growing behavioral trend such 11. McKeown T. The role of medicine: dream, mirage or nemesis.
as improved personal hygiene would generate a per- Princeton (NJ): Princeton University Press; 1979.
ceptible decline in infant diarrhea cases and in the 12. Wislow C-EA. The conquest of epidemic disease. Princeton (NJ):
Princeton University Press; 1943.
mortality rate with which infant diarrhea is associated.
13. Smith S. Report of the sanitary condition of the city of New York. New
In much of the world today, particularly in underde- York: Appleton; 1865 (reprinted by Am Public Health Assoc 1911).
veloped nations, infant mortality rates are as high as 14. Vallery-Radot R. The life of Pasteur. Translated by Devonshire RL. New
they were in Europe and the United States at the begin- York: Doubleday; 1926.
ning of the health revolution. Moreover, the leading 15. Gordon JE. The 20th century—yesterday, today, and tomorrow (1920-
___) In: Top FH, editor. The history of American epidemiology. St
cause of infant mortality in those countries also is,
Louis: Mosby; 1952. p. 114-67.
overwhelmingly, infant diarrhea. Charts that plot 16. Simon J. English sanitary institutions. 2nd ed. London: John
infant mortality rates in different countries against Murray; 1897.
respective per-capita soap consumption—an excellent 17. Morbidity and Mortality Weekly Reports. Annual summary 1978.
index of personal hygiene status—demonstrate a clear Atlanta: Centers of Disease Control; 1979. HEW publication No.
79-8241.
inverse relationship between the 2 factors.26 Care
18. Perkins JJ. Principles and methods of sterilization in health sciences.
should be taken in interpreting these data; it is not real- 2nd ed. Springfield (IL): Charles Thomas; 1969.
ly a simple cause-and-effect phenomenon. This cross- 19. Winslow C-EA. The evolution and significance of the modern public
cultural evidence adds consistency and perhaps some health campaign. New Haven (CT): Yale University Press; 1923.
specificity to the web of circumstantial historic evi- 20. Sears Roebuck and Company. Catalogues. Chicago: Sears Roebuck
and Company; 1897, 1902, 1930.
dence that attributes human health and life expectancy
21. Encyclopedia Britannica. 11th ed, vol 3. New York and Cambridge:
improvements to personal hygiene changes during the Cambridge University Press; 1911. Baths; p. 514-20.
last century. 22. Mapothen ED. Lectures on public health. Dublin: Royal College of
Surgeons; 1867.
References 23. Ravenal MP. A half century of public health. New York: American
1. Smillie WG. The period of the great epidemics in the United States Public Health Association; 1921.
(1800-1875). In: Top FH, editor. The history of American epidemiolo- 24. US Bureau of the Census. Decennial reports on population, manufac-
gy. St Louis: Mosby; 1952. p. 52-73. ture, housing, etc. Washington (DC): The Bureau; 1870-1980.
2. Chadwick E. Report on the sanitary condition of the laboring popula- 25. Benenson AS. Control of communicable diseases in man. 12th ed.
tion of Great Britain. London: 1842 (reprinted by Edinburgh Washington (DC): American Public Health Association; 1975.
University Press; 1965). 26. Greene VW. Cleanliness and the health revolution. New York: The
3. US Bureau of the Census. Vital statistics rates in the United States Soap and Detergent Association; 1984.
1900-1940. Washington (DC): US Government Printing Office; 1943.