Draining the swamp

From Jason Crawford, Emergent Ventures winner in Progress Studies:

…the surprising thing I found is that infectious disease mortality rates have been declining steadily since long before vaccines or antibiotics…

In 1900, the most deaths came from tuberculosis, influenza/pneumonia, and gastroenteric diseases such as dysentery. All of these were effectively conquered by antibiotics in the 1930s and ’40s, but were on the decline since at least the beginning of the century…

Indeed, digging further into the UK data from the late 1800s, we can see that TB was declining since at least 1850 and gastroenteric disease since the 1870s. And similar patterns hold for lesser killers such as measles, which didn’t have a vaccine until the 1960s, but which by then had already declined in mortality by more than 90% from its 1900 levels.

So what was going on? If you read my survey of technologies against infectious disease, you know that other than drugs and immunization, there is one other way to fight germs: cleaning up the environment.

I was surprised to learn that sanitation efforts began as early as the 1700s—and that these efforts were based on data collection and analysis, long before a full scientific theory of infection had been worked out.

There is much more at the link, including the footnotes for citations to the claims made here.

Comments

I can't believe Cutler and MIller (2004) is still being cited. Please read:

Anderson, Charles, and Rees, "Re-Examining the Contribution of Public Health Efforts to the Decline in Urban Mortality" (AER:AJ Forthcoming). Or the NBER WP version. See the discussion between the authors at Anderson's website: http://dmarkanderson.com/research.

Also, it's a bit strange the author talks as if "I found" when the history of Public Health is quite clear on this point (although they clearly cites historical sources).

"Using data on 25 major American cities for the period 1900-1940, we explore the effects of municipal-level public health efforts that were viewed as critical in the fight against food- and water-borne diseases. In addition to studying interventions such as treating sewage and setting bacteriological standards for milk, which have received little attention, we provide new evidence on the effects of water filtration and chlorination, extending the work of previous scholars. Although water filtration is associated with an 11-12 percent reduction in infant mortality, none of the other interventions under study appear to have contributed to the observed mortality declines. "

Among other inconsistencies in C&M, the kicker in ACR is this:

"In the fourth column, we correct a series of transcription errors in C&M’s infant mortality counts (79 of 410 infant mortality counts were incorrectly transcribed). These errors are detailed in Appendix Table 6. Correcting them reduces the estimated effect of filtration on infant mortality by almost two-thirds, from -37 log points to -13 log points"

Thanks for the links.

Let's hope they get the same signal boost that Tyler gives Roots of Progress.

Have you read anything else on that blog? If you do, it's not surprising. All the information he presents is known--to someone. The problem is, it's NOT widely known to the average person. How many people were taught the history of Public Health in school? I certainly wasn't--not from my teachers anyway, the civil engineers in my life taught me that.

Also TC was talking about the 19th century, not just the 20th century which Red references. Further, it's well known (to people like me who are well read, maybe not for the average Joe) that mortality rates for all disease decrease over time since the human body immune system learns to fight the disease. Hence the bubonic plague, 14th century version, was more virulent than subsequent strains, and that holds true for many diseases.

Bonus trivia: up until like 1910 the average doctor was more likely to kill you than cure you, and IMO it's not that radically different today?! The Economist even ran a leader last week about how back surgery is vastly overrated as a cure.

Ahh, Doctor Dunning-Kruger Lopez

You must have been bangin' another Filipina when the Immunology lectures were given:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3582124/

I hate to sound cranky, but isn't this quite well known?

Yes - I mean just a few minutes of research on 19C attempts to eradicate things like yellow fever and typhoid would tell you this. Antibiotics were definitely late to the game. Once the germ theory was known and publicized, the ideas like sterilizing water and avoiding contaminated food, and even quarantine become obvious. Antibiotics are mostly about recovery from surgery not infectious diseases.

But another theory of mine that some of the improvement in health is due to that we really only started to live in big cities in the 19C, and of course there were existing diseases that benefited from this, but after the initial period we have become more resistant to them as you would expect, all the really susceptible people died off, mostly in childhood. That is why we see these appalling fatality rates in children 200 years ago.

You are wrong. Antibiotics is a HUGE factor in saving lives. AND people don't become "resistant" to a deadly disease they either get it and live or they die from it. The "appalling fatality rates in children 200 years ago" was mostly because there was no vaccines. NOT because we became more resistant or the less resistant died off.

Your thinking is not only wrong but dangerous. Without Vaccines those appalling fatality rates will reoccur. Without antibiotics appalling rates of deaths from infection will reoccur.

Yes. Yes it is. But I guess lots of things are "surprising" when you're a 30-something software engineer who just started reading a couple of years ago. I like the dude's blog. He provides solid background info. It's nice to see someone take up learning about history at anytime in their lives, but he's not a serious scholar. Maybe he'll turn out to be a decent popularizer, but he's going to have to cover ground that has not been heavily paved before.

Precisely. A little knowledge is a dangerous thing, to a man with a hammer everything looks like a nail, re-inventing the wheel, etc. etc. Good for him that he's educating himself, but a person with such ignorance should not be put in positions of influence (except in those areas where he has knowledge and wisdom rather than influence).

One of my refrains is that for all the billions of dollars and well-meaning busybodies shipped to Haiti, nobody seems able to get them sewage treatment plants or a stormwater system.

Because of corruption.

We can deal with the corruption. We build infrastructure in corrupt environments all the time.

I think it's more that most charities are vanity enterprises with no incentive to get at the root cause of the problem they're perenially "solving." So their employees tend not to have any skills beyond handing out protein powder and getting raped.

"nobody seems able to get them sewage treatment plants or a stormwater system."

That's not true. Spain built Haiti a sewage treatment plant. It ran until it broke, and the local government never fixed it.

"The initial budget inscribed on a now-faded sign at the entrance was $1.9 million — it would later grow to $2.1 million — to be paid by the Spanish government ... Construction began immediately, but just three months later, it stopped.

Powerful people had leveraged their connections to the president, alleging that they owned the land under the sewage plant and demanding compensation under eminent domain before construction could go forward.
...
For nine months, nothing was built ...In the end, the Haitian government had little choice but to pay the alleged landowners,
...
the sewage treatment plant finally opened in May 2012,
...
The facility operated for just 18 months before a technical problem
...Since then, it has remained closed. DINEPA says the aid agency plans to spend an additional $617,000 to repair it beginning this fall."

https://www.npr.org/sections/goatsandsoda/2017/07/29/537945957/you-probably-dont-want-to-know-about-haitis-sewage-problems

AEJ:AE Forthcoming*

Amazing - public clean water sewage handling systems actually predated antibiotics and most vaccinations. As did doctors starting to wash their hands and sterilize their instruments. Almost as if by a coincidence, right around the 1850s.

Public health as a data based system ever so coincidentally, can at least be considered to start after this incident - "The Broad Street cholera outbreak (or Golden Square outbreak) was a severe outbreak of cholera that occurred in 1854 near Broad Street (now Broadwick Street) in the Soho district of the City of Westminster, London, England, and occurred during the 1846–1860 cholera pandemic happening worldwide. This outbreak, which killed 616 people, is best known for the physician John Snow's study of its causes and his hypothesis that germ-contaminated water was the source of cholera, rather than particles in the air (referred to as "miasmata").[1][2] This discovery came to influence public health and the construction of improved sanitation facilities beginning in the mid-19th century." https://en.wikipedia.org/wiki/1854_Broad_Street_cholera_outbreak

As a suggestion, possibly this Progress pioneer can next explore how nutrition improved dramatically between 1850 and 1950, and its effects on the health of individuals, since he seems to have missed that diet is yet another way to fight germs.

Mohenjo-Daro had baths, toilets and sewers circa 3000 BC. So did the Romans.

The Minoans predated the Romans by 1500 years or so, and were the first civilization to have a flushing toilet.

It would be worth adding that any number of modern practices were used by earlier civilizations. However, the knowledge as to why they were effective was lacking, and when those civilizations went away, so did such practices.

Leaving aside apocalyptic scenarios, it is unlikely that knowledge of why clean water is important to public health will disappear.

The real progress is in knowledge, not material goods. But getting people to dig deep enough latrines is not a matter of knowledge, it is a matter of stopping people from cutting corners.

An area where progress generally runs up against an unyielding wall.

Yes, the Romans had baths. Giant vats of warm water that thousands of people bathed in, filled with oil (they would rub themselves with oil and scrape it off to clean themselves), sweat, fecal matter (their methods of wiping were....questionable), and all kinds of other nastiness. And the water was seldom, if ever, changed.

Roman baths, far from being a beacon of sanitation in the ancient world, were more akin to open sewers.

This isn't hard information to find, being widely known in archaeological circles--which illustrates the value of Roots of Progress. ;)

Roman latrines were pretty crude and not just in aesthetic ways, like the lack of privacy. Significant rainfall tended to flood the sewers and overflow the latrines. Animal wastes still clogged the streets and people emptied chamberpots and practiced open defecation in the gutters as in India today. To the extent Rome was healthier, aqueducts bringing on freshwater from a distance was more responsible.

Sanitation doesn't automatically give you a lower mortality rate but it does give you a lower infection rate. Cleaning the streets won't do a thing for you if you already have the disease. So what's the real driver behind declining mortality?

Progress was obviously the driver. Thus proving the need for further funding for Progress Studies, to bridge the gap between commonplace ideas and well funded academic positions.

Basically, the driver was a basket of things together, which is useful if you wish to create a sinkhole of discussion that is never resolved, as everyone who disagrees with your cherished beliefs can be accused of mood affiliation or virtue/status signalling.

If you're less likely to contract an infectious disease, you're less likely to die as a result of one(since you never fell ill in the first place)

Abundant food for the average people? Agricultural technology?

Plenty of food yields body fat that nourishes you when you get one of those nasty illness. Having a reserve makes you resilient to not eating for some days or eating badly for some weeks, which lowers mortality.

The evidence for the abundance of food is in the average height of the population, ~10cm more compared to 150 years ago.

And to further bolster that fact, look at the results of war on a population which is no longer able to adequately feed itself. Europe provides a fair amount of well documented evidence in this regard. The author misses this point completely, to the extent that diet is talked about as if it is some sort of curative regimen.

I was surprised to learn that sanitation efforts began as early as the 1700s—and that these efforts were based on data collection and analysis
--
Concurrently newspapers arrived about 1650 which allow warnings of epidemic from afar so pre-warning masses of people and stay away.

Romans build water plus sewer thousands of years ago, similar in China, and later in the Amrricas before Columbus discovered millions of people living in cities in the Americas.

Water and sewer are required for cities to have populations at least as rural populations.

But that is not sufficient to maintain health in city, or rural, populations, as the deaths of tens of millions from Europpean and African disease in the century after Columbus discovered people had gathered lots of treasures in the Americas, but hadn't learned to make steel or gun powder yet, two technologies Europeans stole from Asians.

Necessary but not sufficient.

Dozens of technologies and practices need to be adopted by almost all peoples/communities for improved public health, extended life

Each might contribute 5%, maybe even 10%, in some cases, but it's the 1-2% contributions of dozens, and the 0.1% contributions of hundreds.

This was a point Deming made repeatedly, but since circa 1980, economists increasingly look for, demand, magic bullet solutions for everything.

Get rid of the FDA and allow profits of 99% on drugs and magically drugs will cure every I'll, extend every life. Charter cities run for profit by libertarians will produce high economic growth, fantastic health, education, happiness, etc.

It's like the Spanish looking for the fountain of youth, the city of gold.

There are no magic bullets. Individually, public health measures, or lack of, have little impact of health.

It's like rocket science. The Shuttle flew over a hundred times with some very serious safety flaws, with each causing no risk to life most of the time. But then again, just one minor problem and iit turned into a fireball.

Society and our long lives of good health are the result of five thousand years of continuous improvement in public health that we can point to in historical records, such as "the bible". "Hebrew law" is a public health manual. Not all mitzvahs are based in sound science, but we can guess from common hog diseases we (should) fear today why eating "pork" was banned.

Eating pork was probably banned because the leaders of a new religious cult wanted to inhibit their members attending festivals held by other religions.

"Eating pork was probably banned because the leaders of a new religious cult wanted to inhibit their members attending festivals held by other religions."

Exactly right. My sister is a professor of Biblical Studies and this is the origin of the Biblical prohibition.

What is the basis for this remarkably false belief?

Rabbits are also not kosher. Were they also used in other religions?

I've often heard it said that health issues are the basis for religions dietary restrictions. However, no one has been able to provide documentation or other evidence that the people at that time gave any thought to these issues. That they sometimes cause healthy outcomes is not sufficient--with as many rules and regulations as are in the Bible some are bound to help Bronze Age populations live healthier lives, because they're firing a lot of rounds and it's a target-rich environment.

It's not sufficient to demonstrate that public health is an outcome; you need to demonstrate the thought process that went into it. Not "speculate what it could be", but DEMONSTRATE.

This is not a uniquely anti-religious argument, by the way. In taphonomy (a field of paleontology) it's something of a running gag. Many beautiful solutions that deserve to be true have shattered merely because the evidence is against them. My statements above are merely re-stating this principle.

Or as expressed by one journalist/physician, to avoid the coronavirus, wash your hands: https://www.nytimes.com/2020/01/28/opinion/coronavirus-prevention-tips.html

Lol, Tyler has jokes!

Maybe you should have the White House read this column, because

"E.P.A. Is Letting Cities Dump More Raw Sewage Into Rivers for Years to Come"

Here is the link to the NYT article: https://www.nytimes.com/2020/01/24/climate/epa-sewage-rivers.html

Also,

From the article: "Farmers and property developers will now be able to release pesticides, fertilizers and other pollutants directly into many of those waterways, as well as destroy or fill in wetlands for construction projects."

It’s kind of the current administration to give our immune systems this sort of workout regimen.

But also, NY Times?

NYT is not a reliable source, might as well have used RT or Sputnik.

So what the correct story? Trump has made it abundantly clear that he intended to -- and has -- weakened environmental regulations. What are the errors in that NY Times article?

The NYT's is paywalled, but here's the Chicago Tribune's article.

https://www.chicagotribune.com/nation-world/ct-nw-nyt-epa-raw-sewage-waste-water-20200124-v3p7bmckpjgefpbpagdlbc7ab4-story.html

There's nothing wrong with the facts of the article, but it's really describing minor changes as if they were major effects.

"The Environmental Protection Agency has made it easier for cities to keep dumping raw sewage into rivers by letting them delay or otherwise change federally imposed fixes to their sewer systems"

So, these sewage levels are the same levels that prevailed for the entire Obama administrations 8 years. Where was the NYT's public outcry at the time? Nothing has physically changed. There's no more harm occurring now than there was 4 years ago. And yet most people won't actually understand that given the Headline.

"While officials in many of these cities praise the Trump administration’s flexibility, environmentalists said that the changes threaten safety by allowing pathogens and chemicals to keep flowing into rivers and along beaches and back up into streets or basements during storms."

I, as many above, thought this fact was well known. Sanitation and learning about what causes the spread of a disease is going to help. Duh.

https://www.sfchronicle.com/bayarea/article/SF-Public-Works-Director-Mohammed-Nuru-arrested-15010510.php

Draining the swamp indeed. 3/4 of the comments above are about how obvious this stuff is, how old, and everyone knows it. The problem is that an app ain't going to do it, nor good intentions or some academic blathering on about it. It requires simple and effective public administration.

I would suggest something very simple that would fix the problem within a week. Someone defecates on the sidewalk and that day the Mayor, Police Chief and head Administrator of the city gets horsewhipped publicly. Every time someone defecates on the street. The problem would be solved tomorrow.

Civil engineers have saved more human life than doctors.

Correct.

Also, "preventive medicine" is moderation and exercise.

Not to snark, but this has been known for a long time. 2nd year med students are all taught this in their epidemiology class.
Also, antibiotics do not cure or kill influenza.

How about evolution? Technology created urbanization with concentration of populations in the 18th century. These concentrated populations were ravaged by diseases. The survivors were resistant and formed the populations with declining rates of morbidity from Tb, etc, by the mid 19th century. Simple population dynamics; no fancy explanations needed. Children who did not survive measles didn’t reproduce. I’d be interested in measles survival on reservations compared to immediately after Columbus’ arrival.

Except that cities were mostly populated by outsiders moving in, not people born in the city.

Yeah... I don't think it was until the late 1800s or early 1900s that cities became self-sustaining in terms of births > deaths. If it weren't for in-migration, cities would've had short histories.

Doesn't follow.

First, what we are calling "rural areas" were actually pretty packed in many areas. "The Lord of the Rings" and American West give a false impression here; the reality was that rural areas had a fairly high population density when compared against, say, the Mojave. People tended to be where people were; you needed to be close enough to the castle to run for cover. You also had to attend various political functions (even serfs had some rights). Many farms were small by today's standards (look up the history of the acre to see why), so they were pretty closely-packed.

What this means is that epidemics could--and did--readily sweep through even ostensibly rural areas. Remember, 1IN 4 people died in Europe due to the Black Death, despite the continent mostly being populated by farmers.

Once people began to understand the mechanism of contagion, notably microbial infection, they began taking steps to guard against it, most especially in regards to water supplies Cities built sewage systems and required their use. In rural areas pumps and outhouses (and later, septic tanks) were located a safe distance apart. People began washing their hands more. Food was more closely scrutinized for safety. Hospitals instituted antiseptic measures.

As other commenters have said, this guy's seemingly eye-opening discovery has been known for decades arguably centuries.

Everyone has to have their "aha" moments where they learn important new things, ideally this process goes on our entire lives. I only hope that he recognizes that he has areas of ignorance and knows to consult people more knowledgeable than himself before he makes major policy recommendations.

My aha moment was when I saw the excellent documentary film "Water and the Dream of the Engineers" (1983) which covered this exact topic. It appears to be available on Kanopy, which has fees but my public library gives users limited subscriptins.

Another way to put it: before one attempts to study Progress or find an Emergent venture, one needs to know some history: otherwise how will you know what's truly Emergent versus what's reinventing the wheel?

I don't think you understand the point of this blog. (No, I'm not affiliated with the blog.) If you read some of his earlier posts, you'll see that the point isn't to provide new information, but to provide existing information in a new framework so as to better allow the general public to understand it. Given his posting history, I seriously doubt this guy's going to make any recommendations on public health--nor will he on steel manufacturing, or farming, or bicycle construction. His topic isn't any of these, it is, for want of a better term, pedagogy.

The two great inventions of the world that created the Eastern and Western Civilizations and allowed higher population densities were the toilet and sanitation of manure in the west and, in the east, the "wok" and a cooking style to boil, blanch and deep fry everything before you eat it. People can't see their own cultures. These great inventions and cultural evolutions occurred long before antibiotics.

In the West, the sanitary engineers saved more lives than all the doctors and political leaders combined. However, this limited the recovery of nutrients from manure and required the development of the Haber process for making ammonia to expand to modern population densities. The cultural viewpoint of manure being dangerous spread through the West and into animal husbandry where manure control was desired with health effects on animals as a byproduct.

In the East in China, the invention of the wok cooking style allowed human and other manures to be viewed by the culture as fertilizer and, thus, an effective resource. This culture of input sanitation extended to boiling water and Mao drinking "white tea" (boiled water) on the long march.

Although the Eastern sanitation culture allows the recycling of nutrients in manure it also allows transmission of pathogens via fecal/oral routes in animals. Being a culture item, even some Asian scientists don't automatically perceive manure as something dangerous and can subsequently make animal husbandry mistakes.

These Eastern cultural values help produce the animal husbandry conditions that allow the latest viral problem in China.

Animal manure is still used as fertilizer in the West. Drive through farmland at certain times of year and it's hard not to notice. The practice of using human "nightsoil" exported from cities to farmland is what we've discontinued.

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