Sanitation and Public Health: A Heritage to Remember and Continue

During a hygiene promotion campaign, residents of Cap Haitien, Haiti, are taught proper hand washing to avoid cholera infection. Printed with permission of Corbis.

Carolini's research article about public vulnerabilities to unsanitary conditions in Maputo, Mozambique reminds us that more than a billion people lack basic sanitary services that North Americans and most Europeans have taken for granted for more than a century.¹ She focuses on variations in public understanding of sanitation's four A's (adequacy; accessibility; affordability of water, sanitation facilities, and waste management; and awareness of disease outcomes and hygiene practices) as contributors to sanitation-related mortality and morbidity. Unsanitary conditions in Maputo—caused by inadequate infrastructure and staff to manage the systems, as well of a lack of public knowledge are mirrored in poor neighborhoods and rural areas in much of the global south. In this editorial, I revisit the commendable contribution of the American Journal of Public Health® (AJPH) to the sanitary movement and describe today's international challenges.

SUCCESS IN SANITARY PRACTICE IN THE UNITED STATES

AJPH published more than 230 articles, editorials, and book reviews about sanitary practices during the 1911–1960 period, and that effort was needed. The last cholera epidemic in the United States started more than a century ago in Asia. In 1911, the steamship Moltke (Hamburg, Germany, to New York City) brought infected people to New York City. The small public health community responded quickly, isolating the population on Swinburne Island (a tiny island just east of Staten Island in the New York Bay).² Eleven people died, including a health care worker. This episode should be distinguished from others in which quarantine was used as an instrument to reinforce xenophobic values.³ It comes as no surprise that the first article in the first issue of AJPH in 1911 was about controlling the spread of cholera,⁴ and the first decade of the Journal was marked by 90 publications about the rapid development of industrial hygiene and sanitary practices associated with industrialization, urbanization, and internationalization, and more specifically the demands of the First World War,⁵ the newly opened Panama Canal Zone, and rural areas.

The 1920s and 1930s saw a decrease in the number of articles about sanitation and a shift in focus from battlefields and barracks to recreation (tourist camps, resorts, summer camps, swimming pools, playgrounds) and schools. Articles focused on foods and beverages of every variety (ice cream, fruits and vegetables, bottled beverages, oysters, fish, livestock) and the places that served them (kitchens, bakeries and restaurants). The 1940s and 1950s included 2 wars, an economic depression that gave way to unprecedented economic growth, and the beginning of postwar suburban-oriented America. Sanitary-related war issues temporally returned, including special problems associated with sanitary conditions in South Pacific. With the end of the war, restaurants, schools, hospitals, and rural areas reappeared as the focus. The Journal emphasized the need for training to inspect and record data about sanitary conditions.

By 1960, the US sanitary movement was institutionalized. In 1949, Wolman summarized key accomplishements.⁶ He reported that 85 million US residents (national population was 149 million at the time) were connected to public potable water supply systems, 70 million were connected to sewerage systems, 42 million were served by sewage treatment plants, and 70% of the commercial milk supply was pasteurized. Wolman linked these accomplishments to the decline in typhoid fever cases and the decrease in dysentery and diarrhea-enteritis rates, which dropped to tiny numbers from more than 100 000 a half century earlier. Wolman challenged the public health community to provide better garbage collection and disposal; to address the needs of populations, especially in rural areas that lacked proper water and sewage systems and lived in houses without baths and toilets; and to address the issues of food safety, air quality, and workplace accidents. Many of these challenges became core components of the National Environmental Policy Act (1970), the Safe Drinking Water Act (1974), the Clean Air Act (1970), the Occupational Safety and Health Act (1970), the Federal Water Pollution Control Act Amendments (1972), and about a dozen other federal laws and follow-up regulations. Solving US local unsanitary problems remained the priority during the first 50 years of the Journal. Yet global sanitation had not been totally ignored. Among the more than 200 articles were presentations about Brazil, Columbia, India, the Near East and Middle East, Palestine, Peru, Serbia, and Venezuela.

THE POST-1960 GLOBAL FOCUS

After 1960, AJPH articles about sanitation dropped to one tenth of the 1911–1960 numbers. I found only 25 more articles that focused on sanitation, and most were about global sanitation. In 1951, Henry Van Zile Hyde—who was a US member of the World Health Assembly that helped build the WHO—wrote that it was not possible to accurately estimate the toll taken by the world's unsanitary environment.⁷ He then tried by citing the 3 million deaths a year from malaria and the hundreds of millions survivors suffering from its debilitating effects, as well as naming other diseases like bilharzias. Van Zile Hyde concluded that 1.5 billion (out of a total of 2.6 billion) persons lived in primitive unsanitary conditions without a water supply or sewage and waste disposal and suffered as a result of food contamination and spoilage and a lack of industrial hygiene. Van Zile Hyde summarized the WHO's efforts and the ongoing need for more resources.

With Van Zile Hyde's article as the broad context, contributors to AJPH articulated key issues, all of which remain. For example, writing in 1988, Okun questioned the assumption that oral rehydration therapy is an adequate solution for diarrheal diseases among children, underscoring that it averts deaths but should not be used as a substitute for water supply and sanitation improvements that are a long-term investment in public health,⁸ a theme revisited in the Journal by Eisenberg et al. two decades later.⁹ In 1958, Paul¹⁰ acknowledged the need for resources but reminded us that people are cultural animals and that some technological and behavior-based solutions to sanitary problems will not be acceptable, a theme at the heart of the article by Carolini. In 1964, Pineo¹¹—then chief of the community water supply branch for the US Agency for International Development—pointed to limited financial resources and challenged the public health community to develop affordable solutions that would work in the global south and be acceptable to the local populations. In 2011, Govender et al.¹² underscored the association of poverty with unsanitary conditions by reporting on exposure to an unsanitary environment in low-income housing settlements in Cape Town, South Africa.

THE CHALLENGE OF UNSANITARY CONDITIONS IN THE GLOBAL SOUTH

The United States faces political and social challenges associated with high public debt, chronic underfunding of pensions, rising health care costs, high unemployment, low tax rates for the wealthy, and ongoing national and global security concerns. The economic implications of these issues have lead to tough-minded questions about devoting a great deal of resources to Medicare, Medicaid, and Social Security; environmental protection and risk analysis programs; efforts to protect the public against terrorism; and other health-related programs. The questions are not just coming from elected officials and experts who are supposed to argue about priorities. Many people are questioning long-standing government programs. With rare exception, when I speak with US colleagues and my students about unsanitary conditions in the global south I get a response similar to the one I get when talking about the possibility of the world being hit by a large celestial body (that is, the observation is interesting but there are more pressing concerns).

In the United States, unsanitary conditions are the concern of soldiers, contractors, and international travelers; those who live in US migrant labor camps and in the most extreme poverty; or those who eat raw fish and shellfish. As a potential threat, the National Intelligence Council¹³ is more concerned about influenza, TB, and HIV/AIDS than it is about malaria, cholera, and other diseases primarily attributable to unsanitary conditions; also, bioterrorism has become a notable issue.¹⁴ Unless our sanitary facilities are allowed to deteriorate because of a lack of maintenance or are destroyed by acute hazard events like tornadoes, floods, and sabotage, I assume that the US government and population will not focus on the global challenges of sanitation.

Yet, the problems of sanitation in the global south are titanic.¹⁵ The basic facts are that problems exist in major cities and rural areas, placing well more than a billion people (disproportionately children and other vulnerable people) at risk for death and chronic morbid conditions. We also know that diseases associated with an unsanitary environment for the most part are preventable with investments in sanitary technology, education, research, and practice. Even without substantial capital support, the US public health community cannot turn away from the challenge of unsanitary conditions. Carolini suggests that at a minimum we need to be deeply involved in risk communication about unsanitary conditions. Our history implies that we should be engaged in debate and policy persuasion regarding management of sanitary systems; we need to also utilize our traditional niches of epidemiology and sanitary engineering.^16–18 Our research and educational skills, along with whatever dollars we can allocate as a people, can make a difference even during this resource-limited time.