By careful observation of different communities, they discovered that people who lived in dirty, overcrowded and unsanitary conditions with little food were much more likely to die of infectious disease. In 1850 Shattuck reported on the sanitary conditions in Massachusetts and revealed great inequalities in the life span between one social class and another.1 He concluded that life expectancy could be very much extended and general health improved by action directed towards sanitary reform, improvements in living and working conditions and other preventive measures. Shattuck argued that preventive measures would achieve infinitely more than remedies for the cure of disease.
Chadwick’s observations had already led to similar conclusions and paved the way for the Public Health Act of 1848, the renaissance of public health in Britain.1 The resulting improvements in nutrition, hygiene and sanitation, and in living and working conditions, led to a rapid fall in death rates with mortality from virtually all the infectious diseases declining before, and in most cases long before, specific therapies or vaccines became available. In 1971 the president of the Infectious Disease Society of America, Edward Kass, stated that the decline of infectious disorders, correlated with improving socio-economic conditions, is “the most important happening in
the history of the health of man.”2
In the United States for instance, tuberculosis mortality had already declined from nearly 200 per 100,000 of the population in 1900 to around 35 per 100,000 by the time streptomycin was introduced in 1947.3 And by the time chloramphenicol treatment became available in the late l940s, typhoid had been virtually eradicated.3 In Britain, around 90% of the reduction in deaths from the commonest infections of childhood - scarlet fever whooping cough, diphtheria and measles - had already been achieved before the introduction of antibiotics and widespread immunization against diphtheria.4 In the 1860s the death rate from whooping cough in England and Wales was over 130 per 100,000 children but had fallen to around 0.5 per 100,000 by the time a nationwide vaccination program was initiated in the late 1950s.5
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