EUROCONFERENCE: HYGIENE AND

HEALTH
The Institut Pasteur sponsors and organizes a series of conferences on important topics in biology, medicine, and environmental 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 institutions 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 hospitals.
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 harmful 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
human health, was supposedly better than it is today,
From Ben Gurion University.
Presented at the Institut Pasteur Euroconference, Hygiene and
Health, Paris, France, January 25-27, 2001.
Reprint requests: Velvl W. Greene, MD, Ben Gurion University,
Mivtza Nahshon 51/1, Beer Shiva, Israel.
Am J Infect Control 2001;29:203-6
Copyright 2001 by the Association for Professionals in
Infection Control and Epidemiology, Inc.
0196-6553/2001/$35.00 + 0
doi:10.1067/mic.2001.115686

17/47/115686

are a myth. The documented history of Western civilization describes an endless and unromantic struggle
with sickness and death, tragically high infant mortality
rates, and the premature death of young adults. Deathdealing epidemics attacked helpless communities nearly as often as summer and winter came to pass, and
were followed every few years by major catastrophes.1
Even during the good years when no serious epidemics occurred, the baseline mortality rate was often
4 times higher than what we experience today. In
Victorian England, the average age of death among the
urban poor was 15 to 16 years.2
This dismal situation started to improve dramatically
about 150 years ago. Mortality records from different
203

AJIC

204 Greene
communities in Western Europe and America3-6 indicate a veritable health revolution by the middle of the
19th centurya significant increase in life expectancy
and a marked decline in crude mortality rates, followed
a few decades later by a gratifying drop in the infant
mortality rates. Moreover, each decade since then, a
lower mortality rate has been recorded than in the
decade immediately preceding it. Although the greatest
relative improvements were seen in infant and child
mortality rates, the life expectancy of every age group
improved: young adults, the middle-aged, the old, and
the very old.7-9
How did this revolution commence, and what contributed to its amazing success? Obviously, many factors contributed to its successsome by design, others
by accident, some with a direct and immediate impact
on life and health and death, and others with a less
direct and often delayed effect. The 19th century was a
ferment of new scientific discovery and inventions,
laws, and insights. New social-political ideologies
encouraged improvements in the environment and
modifications in the behavior and practices of individuals and communities. Many 19th-century innovations
could have contributed to the health revolution. The
list of candidates for honors is long, and no unanimity exists among historians about which innovation is
the most important.
To be seriously considered, an innovation must show
a plausible, biologic relationship to mortality prevention, it must have influenced a substantial proportion
of the population, and it must have preceded the
decrease in mortality with which it is credited. In this
respect, the following 3 general innovations are generally accepted8,10,11:
1. improved housing and consequent reduction of
overcrowding;
2. improved nutrition resulting from innovations in
agriculture and technology; and
3. improved hygiene, including environmental sanitation and personal cleanliness.
Determining which of these 3 innovations was the
most important is not relevant. Each innovation meets
the aforementioned criteria and undoubtedly played a
significant role in reducing mortality rates. More importantly, all 3 innovations were essential components of
the war against infectious disease in the 19th century.12
In the 1800s, smallpox, scarlet fever, measles, and
diphtheria were so familiar that people regarded them as
necessary features of childhood. Cholera and malaria
epidemics were common, typhus and typhoid were rampant among the poor, and tuberculosis was common
among the rich and poor alike.13 Any struggle to improve
life and health had to start with the control of infectious
disease. The early battle strategies were based on faulty

August 2001

hypotheses and naive logic. Until Pasteur elucidated his

Germ Theory of Disease in 1878, the microbial cause of
infectious disease was unknown; the very concept of
infection was still foreign.14 However, it is difficult to
argue with success. Between 1850 and 1900, the commonly recurring epidemics of cholera, smallpox, malaria, and typhoid were gradually brought under control.1
During the next 50 years, gratifying victories over such
endemic diseases as tuberculosis, diphtheria, measles,
and scarlet fever were witnessed. These diseases were
less dramatic than epidemics, but each was among the
leading causes of death before 1900.12 By the middle of
the 20th century, except for the 1918 influenza pandemic, death from infectious disease in Western industrialized countries was no longer a major component of mortality statistics.15
The conquest of infectious disease and the health revolution it initiated is arguably one of the greatest achievements of Western civilization. Yet the phenomenon is
largely unknown and rarely taught, even in history courses. Conventional wisdom usually assumes that the conquest of infectious disease can be credited to well-known
lifesaving innovations in medicine such as vaccines,
antibiotics, and surgical asepsis. These icons are truly
essential ingredients of modern medicine, and their contribution to human life and health in this century can
never be minimized. However, except for the smallpox
vaccination, which was introduced in 1798 and made
compulsory in England in 1853,16 the overall contribution
of medical innovations to the health revolution of the
1800s is difficult to validate. Diphtheria, tetanus, and pertussis vaccine arrived on the scene only after disease mortality rates already had been reduced significantly;
measles, rubella, and polio vaccines did not become available until the middle of the 20th century, when most infant
deaths were the result of other causes. The same holds
true for the sulfa drugs and antibiotics. Their contribution
is unequivocal, but they did not affect mortality rates until
the 1940s.11,17 Antiseptics and disinfectants were used successfully as early as the 1840s, and by 1900 the autoclave
and sterile gloves had been invented.18 Lister and
Semmelweis and their contemporaries certainly deserve
credit for their vision and lifesaving innovations, but many
decades passed before their recommendations became
widely accepted, and the actual number of lives they influenced was probably too small to have a significant impact
on national mortality rates. The modern hospital is largely a phenomenon of the 20th century. Before then, there
were relatively few surgical patients and hospital deliveriesthe population groups that would most benefit from
hospital infection control practices.
On the other hand, urban living (and dying) in Europe
and the United States in the early 1800s took place under
extraordinarily filthy conditions.2,9,13 Putrescible refuse,

AJIC
Volume 29, Number 4

human and animal waste, and dead carcasses piled up in

the streets and courtyards. There were open sewers and
too few privies, and chamber pots were emptied into
courtyards. The stench, particularly in warm weather,
was legendary. In fact, foul odors or miasmas were considered to be the cause of most prevalent diseases. The
triad filth, poverty, and disease appears so frequently in
19th century writings that it is easy to see how they
became identified as having some type of cause-andeffect relationship. To break this chain and to relieve the
suffering of the laboring classes in England, an improbable and informal coalition of social activists, prison
reformers, physicians, clergy, and scientists started advocating sanitary reform in the early 1800s.12 They maintained that both illness and poverty resulted from insanitary conditions and practices that could be remedied.
This sanitary movement was instrumental in getting
legislation passed in Great Britain during the 1850s and
1860s (and in the United States a decade later) to create
public health authorities with power to regulate sewage
collection, water supply, environmental nuisances, and a
remarkable list of other relevant matters, such as physician licensing and child labor abuses.19 The pioneers of
the movement were fervent advocates of personal
hygiene, particularly bathing and laundering. Some of
their very early efforts focused on reducing the tax on
soap (1833), building a bathhouse and laundry for the
working class in London (1844), and passage of the
Public Baths and Wash-Houses Act (1846) to finance
local bathing facilities (later, swimming pools) throughout England.16
In addition to the seminal and recognized role of
environmental hygiene, a substantial but overlooked
component of the health revolution was the transformation in personal hygiene practices and cleanliness.
The transformation probably started in the early 1800s,
became extremely popular from 1890 to 1915, and has
since become an essential feature of civilized behavior in the United States and Europe. It is proposed that
this mass behavioral change in washing, bathing, laundering, and domestic hygiene practices contributed significantly to the continuing reduction of illness and
death rates at the beginning of the 20th century.
Historic evidence of this behavioral transformation
can be gathered from contemporary writings in newspapers and books, governmental reports, medical
records, commercial data, and the mirror of social
changeadvertising directed to the consumer.2,9,20 The
literature of the 1850s reveals that the term unwashed
masses was not a literary allegory but rather a clinical
description of the common folk. Running water was
not available, heating water was prohibitively expensive, soap was hard to get or make, and homes had no
facilities or space for washing or bathing. Keeping a

Greene 205
households linen clean was an unbelievably grim and
laborious task. The rich and titled gathered at Turkish
baths or spas; members of the wage-earning class often
went through life without a bath, with only an infrequent change of underwear, and with only an occasional ablution in a cold stream or polluted river. In
Great Britain, bathing and laundry facilities built by
local governmental units started appearing throughout
the country after the 1850s, usually in the dreariest
slums of cities. Despite the stigma associated with their
use, 10 such facilities in London provided more than a
million baths, and more than 300,000 women used the
laundry in any given year of the 1860s. By 1905, more
than 6 million baths were sold, evidently fulfilling an
unmet need.21,22 In the United States, the big transformation in personal hygiene started after cities instituted water works, which piped filtered water directly
into the home from a central distribution system. By
1890, 1.4% of the urban population was so served by
water works; by 1910, this number increased to more
than 25%. As water became available, sinks, bathtubs,
showers, and indoor toilets were installed. The sale of
soap and washing machines increased in a parallel
fashion.23,24 The personal hygiene transformation was
on the way, fueled by aesthetics, social pressures, commercial advertising, and even theologic incentives
(Cleanliness is next to Godliness).
According to the public health literature, the transmission of 35 to 40 human diseases can be interrupted
by improved levels of personal and environmental
hygiene.25 Logic implies that the incidence of all such
illnesses would decline consequent to the described
changes in hygienic behavior. (The decline of trachoma
in Appalachia after 1915 and the essential disappearance of louse-borne typhus from the United States
since 1921 are particularly tempting subjects for analysis.) However, population-based data for most of these
conditions are too scarce to support more than anecdotal speculation. On the other hand, a strong case can
be made that personal hygiene played an important
role in the reduction of infant mortality. However, reliable data, particularly about cause-specific mortality,
are very difficult to find before 1900. Since then, nearly all available data reinforce the following 2 relevant
observations:
1. The dramatic decline in the US and British infant mortality rates coincided with or closely followed the personal hygiene transformation in the decades circa 1900.
2. In the United States, the leading cause of infant mortality until 1920 (when it yielded its infamous title to
low birth weight) was unquestionably infant diarrhea.3,4
It should be emphasized that a very plausible, biologic association exists between improved personal

AJIC

206 Greene
hygiene and the decline of infant diarrhea, with a subsequent impact on overall infant mortality rates. Most
etiologic agents responsible for infant diarrhea (bacterial, viral, and parasitic) are common inhabitants of
the human gut and gain access to their new hosts by
the fecal-oral route. In a population that neglects personal hygiene, the increased probability of infection
and subsequent illness is self-evident. It is also clear
that any practice that reduces the number of potential
pathogens on the mothers skin will effectively minimize the probability of infecting her infant.
Considering the number of times in a day that each
child would be exposed to potential infection from a
caregiver whose skin is seeded with enteric microbes, it
is quite credible that a growing behavioral trend such
as improved personal hygiene would generate a perceptible decline in infant diarrhea cases and in the
mortality rate with which infant diarrhea is associated.
In much of the world today, particularly in underdeveloped nations, infant mortality rates are as high as
they were in Europe and the United States at the beginning of the health revolution. Moreover, the leading
cause of infant mortality in those countries also is,
overwhelmingly, infant diarrhea. Charts that plot
infant mortality rates in different countries against
respective per-capita soap consumptionan excellent
index of personal hygiene statusdemonstrate a clear
inverse relationship between the 2 factors.26 Care
should be taken in interpreting these data; it is not really a simple cause-and-effect phenomenon. This crosscultural evidence adds consistency and perhaps some
specificity to the web of circumstantial historic evidence that attributes human health and life expectancy
improvements to personal hygiene changes during the
last century.
References
1. Smillie WG. The period of the great epidemics in the United States
(1800-1875). In: Top FH, editor. The history of American epidemiology. St Louis: Mosby; 1952. p. 52-73.
2. Chadwick E. Report on the sanitary condition of the laboring population of Great Britain. London: 1842 (reprinted by Edinburgh
University Press; 1965).
3. US Bureau of the Census. Vital statistics rates in the United States
1900-1940. Washington (DC): US Government Printing Office; 1943.

August 2001

4. National Center for Health Statistics. Vital statistics rates in the United
States 1940-1960. Washington (DC): US Government Printing Office;
1968. PHS publication No. 1677.
5. National Center for Health Statistics. Vital statistics of the United
States 1977. Vol II. Mortality. Washington (DC): US Government
Printing Office; 1981.
6. Registrar Generals statistical review of England and Wales. London:
HM Stationery Office; 1972.
7. US Bureau of the Census. Historical statistics, colonial times to 1970.
Washington (DC): US Goverment Printing Office. Available at: http://
www.census.gov/prod/1/gen/95statab/opp4.pdf. Accessed May 8, 2001.
8. Sydenstriker E. Health and environment. New York: McGrawHill; 1933.
9. Shattuck L, Banks NP, Abbot J. Report of a general plan for the promotion of public and personal health. Massachusetts Sanitary
Commission. Boston: 1850 (reprinted by Arno Press, New York 1972).
10. Kass EH. Infectious disease and social change. J Inf Dis 1971;123:110-4.
11. McKeown T. The role of medicine: dream, mirage or nemesis.
Princeton (NJ): Princeton University Press; 1979.
12. Wislow C-EA. The conquest of epidemic disease. Princeton (NJ):
Princeton University Press; 1943.
13. Smith S. Report of the sanitary condition of the city of New York. New
York: Appleton; 1865 (reprinted by Am Public Health Assoc 1911).
14. Vallery-Radot R. The life of Pasteur. Translated by Devonshire RL. New
York: Doubleday; 1926.
15. Gordon JE. The 20th centuryyesterday, today, and tomorrow (1920___) In: Top FH, editor. The history of American epidemiology. St
Louis: Mosby; 1952. p. 114-67.
16. Simon J. English sanitary institutions. 2nd ed. London: John
Murray; 1897.
17. Morbidity and Mortality Weekly Reports. Annual summary 1978.
Atlanta: Centers of Disease Control; 1979. HEW publication No.
79-8241.
18. Perkins JJ. Principles and methods of sterilization in health sciences.
2nd ed. Springfield (IL): Charles Thomas; 1969.
19. Winslow C-EA. The evolution and significance of the modern public
health campaign. New Haven (CT): Yale University Press; 1923.
20. Sears Roebuck and Company. Catalogues. Chicago: Sears Roebuck
and Company; 1897, 1902, 1930.
21. Encyclopedia Britannica. 11th ed, vol 3. New York and Cambridge:
Cambridge University Press; 1911. Baths; p. 514-20.
22. Mapothen ED. Lectures on public health. Dublin: Royal College of
Surgeons; 1867.
23. Ravenal MP. A half century of public health. New York: American
Public Health Association; 1921.
24. US Bureau of the Census. Decennial reports on population, manufacture, housing, etc. Washington (DC): The Bureau; 1870-1980.
25. Benenson AS. Control of communicable diseases in man. 12th ed.
Washington (DC): American Public Health Association; 1975.
26. Greene VW. Cleanliness and the health revolution. New York: The
Soap and Detergent Association; 1984.