Urban Public Health in America: Civil War to World War II

Introduction

America boasts a relatively healthy society. Its medical advances and capabilities are second to none, and people come from all over the world to see American specialists and surgeons who can save their lives or solve their medical problems. Through recent advances in medical technology, Americans live longer today than ever before, and with that longer life comes a high standard of living. Though the nation is relatively young compared to many of its worldwide peers, it has an excellent public health system in place that provides Americans with peace of mind regarding national health issues.

One of the more significant factors in the strong public health system currently in place is the focus that major cities have historically placed on water systems, waste management, and public education as they relate to public health. Following the Civil War, while the nation was still in its relative infancy and medical science had not yet discovered antibiotics, there were many health concerns in urban areas. Whether it was a yellow fever scare, a diphtheria epidemic, or another public health problem, major cities across the nation worked hard to eradicate germs, filth, and contaminated water supplies in the effort to provide a safe living environment for their residents. The efforts paid off, and America now has one of the safest public health systems in the world.

Public Health Before and After the Civil War

While America currently has one of the best public health systems on earth, there was a time in the nation's history when battling disease and filth was a constant problem. Major cities across the nation had to deal with waste and water issues and work to prevent disease epidemics from destroying their communities. Following the Civil War, many large American cities experienced outbreaks of disease that killed hundreds of thousands of residents. In 1847, for example, New Orleans had a yellow fever outbreak, only to suffer another in 1852. In Hawaii in the late 1800s there was a smallpox outbreak; in 1888, New York had a serious and deadly measles outbreak; and in 1863 the same city was struck by cholera. Throughout American history there have been health crises in metropolitan areas, but during the period between the Civil War and World War II, American cities began to tackle some of the larger issues surrounding public health.

Until the Civil War, most of America was at the mercy of whatever health crisis besieged its residents. While science had begun to pinpoint key elements that could help change the way public health was viewed, it was not yet widely accepted that water, waste, and environmental factors play such an important overall role in the health of urban populations. It was after the Civil War ended that the emergence of modern medical care began in the United States, including pediatric medicine. As one historical account notes: "Until the latter half of the nineteenth century there was no distinction in the medical care for the adult or the child. Children were treated as small adults. Only with the advent of modern medicine did pediatric theory and therapeutics come into being. During the nation's colonial era the high number of births was balanced by a devastating mortality rate among children. Two epidemic diseases which took a particularly high toll were smallpox and diphtheria."

Two factors that contributed to the disease death rate were unsanitary living conditions and poor diets. Prior to the Civil War, one out of every two children died before their tenth birthday. While the general state of medicine in America changed little from the early eighteenth century through the first part of the nineteenth, some advances were made — by 1820 the United States had a number of medical schools and hospitals.

It was not until the Civil War, however, that urban areas began to see an undeniable connection between water supplies, waste management, and public health outcomes. The development of American public health has traceable roots dating back to the Civil War era. It was public health that changed the face of medicine and was ultimately responsible for the shift from a reactive to a proactive mindset in addressing disease.

One significant factor in public health issues prior to the Civil War was that most of America was still very rural. This meant that large numbers of people were not living in close contact with one another, nor was there a pressing need for shared water supplies or formal waste management. People lived on farms or in spread-out communities and rarely had to contend with the hazards of dense urban living. Even given the lack of crowded conditions, disease and epidemics still managed to find their way to American populations. When urban areas began to grow, several new problems emerged, including waste management failures and water supply contamination. "In the small towns there were only spotty efforts to collect garbage and dispose of sewage — two major public health concerns which remained of primary importance until the start of the 20th century."

Prior to the Civil War, the main focus of public health in America was dealing with epidemics. After the Civil War and leading into World War II, other preventive approaches began to emerge. "The major impetus for 19th century public health reforms came from the general public's fear of and reactions to the various epidemics which periodically struck America's rapidly growing cities. While the public came to accept the public health problems of high infant mortality, polluted water, foul-smelling air, and overcrowding as everyday factors of life, the sudden appearance of an epidemic — which produced tremendous losses both in terms of life and economic activity — created a strong demand for direct governmental public health responses."

After the Civil War, American attention soon turned to reports from Britain about its new public health system. Those reports described successful public health reforms concerning the sanitary living conditions of the working class. The American population, still energized by its recent success in ending slavery, quickly took up public health as its next major social project. There were two significant developments in the first five years after the Civil War ended. New York City was experiencing severe public health challenges tied to crowded urban development and was arguably one of the worst public health hazards in the nation. By 1850, some 20,000 city residents were reported to be living in underground cellars with no running water or air circulation — conditions that set the stage for germs and filth to spread disease throughout the city. Any efforts to correct the problems were obstructed by the sheer scale of the situation and by widespread political corruption, as city politicians showed little concern for public health.

The second major development occurred in Massachusetts, where that state took the opposite approach from New York City and created the first state board of health in the nation. "By 1890 there were 28 state boards of health patterned after Massachusetts' model. Thus by 1870 the appropriate state and local public health administrative machinery had been created and would quickly be copied throughout the United States. What remained was for national-level public health organizations to be created, and this would be both the success and failure of the 1870s public health efforts."

"The urban population increased explosively, from 23 million in 1850 to 106 million by 1920 — an increase of 357%. This tremendous growth came from two sources: immigration from abroad, and the influx of rural populations into cities seeking jobs. Between 1880 and 1920, approximately 15 million people moved from the country into cities. This influx of humanity made American cities the most crowded in the world — in 1894, New York City had 986.4 persons per acre, compared to 759.7 persons per acre in Bombay, India at the same time. Infant mortality in New York City was 65% higher in 1870 than it had been in 1810. By 1900, infant mortality had reached as high as 317 per 1,000 in sections of some American cities."

The big cities also had to contend with public health hazards stemming from horse-drawn transportation on crowded city streets. Each horse typically excreted several gallons of urine and 20 pounds of fecal matter per day. Without a public health system in place, these materials were left in the streets to be breathed in and walked through daily. Engineering advances that produced large high-rise tenements only compounded the problem, as those buildings quickly filled beyond capacity while offering no fresh water or waste disposal.

New York City's Sanitation Crisis

The 1870s became the decade of urban public health reform as Congress reorganized the Marine Hospital Service and created the office of Surgeon General, which still exists today. The Surgeon General was charged with overseeing public health issues and providing advice, guidelines, and mandates for how they would best be addressed. During the 1880s, the movement toward public health shifted away from the political arena and into laboratories across the nation, where scientists began to learn how to isolate disease-producing organisms responsible for communicable diseases. This was a major breakthrough, particularly for large cities, as it helped them understand how diseases were being spread and pointed toward solutions: public education, fresh water systems, and waste disposal services. "With the growing acceptance of the germ theory of disease causation in the 1890s and the emergence of diagnostic laboratories as the focal point of public health activities, the American public health movement underwent several major changes. The main emphasis, which during much of the 19th century had been on cleaning up the environment, now shifted to direct control of communicable diseases."

By the late nineteenth century, New York City had one of the highest mortality rates in the nation due to poor sanitation citywide. Members of the New York Sanitary Association were convinced that the diseases contributing to this high rate were primarily due to the absence of proper sanitary practices and could be prevented. Sanitarians wanted to improve public health law and educate the populace about proper hygiene.

In 1864, New York undertook a large survey project to ascertain the exact living conditions of most residents. When the inspectors' reports came in, the city found that its residents were living in substandard conditions that promoted squalor and filth. Public and shared restrooms were overflowing with human waste. City streets were covered in filth created by horse manure, and local slaughterhouses were dumping blood and carcasses onto tenement properties and leaving them to rot. The blood and animal waste liquids were being washed into the same river that many city residents used for drinking and bathing water. "It was common knowledge that youngsters could earn nickels by standing along Broadway and sweeping a path through the muck for those who wanted to cross the wretched boulevard."

New York officials were appalled at what the survey results indicated and immediately set to work developing a comprehensive sanitation program to remove and dispose of waste. The city also secured representation on the American Public Health Association Board.

Conclusion

From the time the Civil War ended until World War II began, one can see the remarkable progress made with regard to public health concerns, especially in America's urban areas. As water supplies began to be cleaned up, society discovered that disease was becoming a thing of the past, and this success encouraged cities to step up their efforts even further. In addition to water supply improvements, many urban cities made significant changes to waste management and disposal during this era.