{"id":35799,"date":"2025-08-26T14:33:55","date_gmt":"2025-08-26T18:33:55","guid":{"rendered":"https:\/\/www.thenewatlantis.com\/?post_type=article&p=35799"},"modified":"2025-11-25T12:33:31","modified_gmt":"2025-11-25T17:33:31","slug":"two-hundred-years-to-flatten-the-curve","status":"publish","type":"article","link":"https:\/\/www.thenewatlantis.com\/publications\/two-hundred-years-to-flatten-the-curve","title":{"rendered":"Two Hundred Years to Flatten the Curve"},"content":{"rendered":"\n

The first time people in New Orleans truly understood their refrigerators was the summer of 2005, after Hurricane Katrina struck the city. Because big storms are common in New Orleans, families there were accustomed to evacuating for a couple-three days, then coming back to streets covered with branches and trash and maybe a few roof shingles.<\/p>\n\n\n\n

Katrina was different \u2014 the worst natural disaster in North America in decades. Flooding was so bad that people couldn\u2019t return for two months. And this was New Orleans: sunny and hot. The hurricane had knocked out the electricity. Across the city, 250,000 refrigerators became accidental demonstrations of the biology of putrefaction.<\/p>\n\n\n\n

The government warned homeowners not to open their refrigerators. Many did anyway. All realized instantly that something comprehensively bad had happened in their kitchens.<\/p>\n\n\n\n

Throughout the fall, returnees duct-taped their refrigerators shut and lugged them out to the curb. White metal boxes lined the streets, painted with do-not-open warnings. Teams of workers in hazmat uniforms slowly loaded them into trucks and drove them to a giant toxic-waste dump in the outskirts of the city. Occasionally people got tired of waiting for the hazmat guys and illegally dumped their refrigerators in faraway neighborhoods only to find when they came home that people from those neighborhoods had dumped refrigerators on their<\/em> streets.<\/p>\n\n\n

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With electricity knocked out by Hurricane Katrina, a refrigerator now containing toxic food awaits removal to a dump outside New Orleans.
Wikimedia<\/a><\/cite><\/figcaption><\/figure><\/div>\n\n\n

Thousands of families were discovering that refrigerators are not only appliances: they are also a key component in the public health system. By sealing food into a clean, cold box and constantly filtering the air inside, refrigerators defend families against the legions of bacteria, viruses, molds, insects, fungi, and parasites that otherwise would contaminate their suppers. Suddenly living without refrigerators, Katrina\u2019s victims couldn\u2019t keep their food safe. Emergency rooms filled with food poisoning victims. People in New Orleans were learning the hard way that they could not take for granted one of the pillars of modern life: public health.<\/p>\n\n\n\n

Medicine is not the same as public health. The medical system focuses on individuals. The public health system works to safeguard communities<\/em>. If children get sick from drinking spoiled milk, they go to doctors, who may treat severe cases with antibiotics. That is medicine. The rules setting out how companies treat, store, and package milk, the criteria for how and when it can be sold, the regulations governing the functions of refrigerators, the inspectors that monitor compliance: that is public health.<\/p>\n\n\n\n

Public health is generally pictured in terms of doctors and medical researchers setting guidelines for disease prevention and treatment \u2014 the kind of actions associated with the Centers for Disease Control and Prevention and the Food and Drug Administration. But that\u2019s not how the originators of public health thought of it. Nor does that image adequately describe what they set up \u2014 the arrangement we live with now. Built up for more than a century, today\u2019s public health system is a massive, interlocking set of laws, standards, institutions, and technologies that undergirds much of our daily lives.<\/p>\n\n\n

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Refrigerator testing<\/figcaption><\/figure><\/div>\n\n\n

Paradoxically, the public health system is so omnipresent that its effects are often invisible. But the numbers tell the tale. In 1875, the median age of death in Great Britain, then by many measures the world\u2019s most affluent nation, was 45<\/a>. Today it is 82. The rise is astonishing. For tens of thousands of years, the average human life expectancy hardly changed. Then, in just 150 years, it almost doubled. The increased food supply created by modern agriculture played a big role in this jump. So did clean water and the electric grid. But the great bulk of the improvement was due to the creation of the public health system.<\/p>\n\n\n\n

Its biggest effects were on our smallest. In 1875, about one out of every four British children died before the age of five \u2014 \u200a248 out of every 1,000<\/a>, to be exact. Today the equivalent figure is 4 out of every 1,000, a drop of more than 98 percent<\/em>. The primary causes of infant and child death at the time were measles, diphtheria, whooping cough, and a host of poorly understood respiratory and gastrointestinal diseases. All were specially targeted by the public health system, mainly through vaccination and sanitation programs. All have been reduced so much that diseases that were common sources of tragedy in 1875 are completely unfamiliar to most parents today.<\/p>\n\n\n

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Julie Wallace<\/cite><\/a><\/figcaption><\/figure><\/div>\n\n
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\r\n\t\t\u2018In Street and Shop and Home\u2019\t<\/h5>\r\n<\/div><\/div>\n\n\n

The public health system had many beginnings, but among the most important was tuberculosis. TB, as it is called, attacks the lungs, filling them with fluid and pus. Victims can\u2019t take in oxygen and slowly suffocate, coughing so hard they spit blood. In the nineteenth century, the disease was stunningly widespread. It was the single greatest overall cause of death in the United States, Europe, and Asia \u2014 nothing else came close. In crowded places like New York and London, more than nine out of ten inhabitants were infected (though a sizable number had no symptoms). No effective treatment existed. About 70 percent of symptomatic victims died within ten years, and most died within three. TB is thought to have killed a billion or more people in the last two hundred years, more in that time than any other infectious disease.<\/p>\n\n\n\n

In 1882, the German microbiologist Robert Koch discovered its cause: Mycobacterium tuberculosis<\/em>, a group of closely related bacteria. Doctors had believed tuberculosis was a hereditary disease, which meant they could do nothing about it. Koch found that TB instead is due to microorganisms passed from one person to another by coughing, sneezing, or shouting, all of which spray tiny, contagious droplets into the air. People who inhale the droplets suck M. tuberculosis<\/em> into their lungs, where it wreaks havoc. Galvanized by this discovery, volunteers created hundreds of anti-tuberculosis associations across the United States that sought to stop M. tuberculosis<\/em> from spreading \u2014 and launched, along the way, today\u2019s public health system.<\/p>\n\n\n

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The rules of health to fight TB in 1941: rest, sunshine, and good food
Works Progress Administration \/ Library of Congress<\/cite><\/a><\/figcaption><\/figure><\/div>\n\n\n

Some of the reformers\u2019 ideas were off-base, such as their campaigns to abolish floor-length dresses (thought to pick up deadly bacteria from the ground) and beards (seen as bacterial time-bombs on men\u2019s faces). Others are now so widely accepted that it is hard to believe that anyone had to advocate them. Among these are the notions that people should cover their mouths when they sneeze, wash their hands after visiting the toilet, and not spit on the floor or sidewalk.<\/p>\n\n\n\n

All the while, the TB associations were establishing a novel infrastructure of health: hundreds of new TB dispensaries, TB open-air tent camps, and TB sanatoria (specialized hospitals for long-term care). The dispensaries were information centers where technicians diagnosed TB cases and shunted patients to camps (if the case was mild) or sanatoria (if it was severe). The camps and sanatoria served two main functions. The first was a kind of quarantine. By packing TB sufferers into dedicated facilities, the reformers prevented them from infecting others. The second was to provide rest, sunshine, fresh air, and a balanced diet: improved living conditions that would, activists hoped, let TB patients get better by themselves. Mostly, these treatments had little impact. The first real cure for M. tuberculosis<\/em> was an antibiotic, streptomycin, proven effective against tuberculosis in 1944. But the camps and sanatoria represented the first systematic, nationwide effort to provide a clean environment to improve health.<\/p>\n\n\n\n

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Tuberculosis patients receive fresh air and sunshine at the Jewish Consumptive Relief Society sanatorium in Lakewood, Colorado.
Denver Public Library Special Collections, X-28623<\/cite><\/figcaption><\/figure>\n\n\n\n

Coupled with these measures was a raft of new laws and regulations. In the early twentieth century, for example, many urbanites got water from municipal water pumps, drinking from metal cups that hung by the pump handle. Similarly, conductors carried buckets of water on trains, offering drinks to passengers from a common cup. Reformers denounced the cups as vehicles for transmitting M. tuberculosis<\/em>, and by 1912 they had convinced 24 states to ban<\/a> them at drinking fountains and the federal government to restrict<\/a> them on interstate railways. In addition, they had managed to pass 150 urban anti-spitting laws, though apparently these were lightly enforced.<\/p>\n\n\n

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Hospital protocols <\/figcaption><\/figure><\/div>\n\n\n

The anti-TB effort set the template for other, later medical campaigns, such as those against hookworm (a parasite that then infected more than a third of the people in the southeast) and typhoid (a disease caused by a lethal variant of salmonella that at the time was rampant in American cities). More importantly, the effort was a launchpad for what became a broader movement to improve Americans\u2019 physical and mental well-being.<\/p>\n\n\n\n

In 1904, the Charity Organization Society, an umbrella group for the nation\u2019s numerous private philanthropical organizations, argued that controlling tuberculosis would require not only direct medical interventions but \u201cpublic sanitary preventive measures in street and shop and home.\u201d The idea was that the rise of industrialized societies, with their dangerous factories and dirty cities, was fostering the conditions for not only tuberculosis and other infectious diseases but also unsafe foods, deadly accidents, and dying children. And those industrialized societies were so complex and operated on such a grand scale that it was folly to imagine that people could overcome these problems individually; governments and large institutions had to step in. Eventually businesspeople, politicians, doctors, economists, and muckraking journalists joined what would become a crusade to increase the safety and salubriousness of American life.<\/p>\n\n\n

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\r\n\t\tTens of Thousands of Standards\t<\/h5>\r\n<\/div><\/div>\n\n\n

The ensuing reforms created an enormous system that, in theory, can be thought of as covering four main areas:<\/p>\n\n\n\n

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  1. Providing clean inputs: water, air, food;<\/li>\n\n\n\n
  2. Preventing disease: both infectious diseases like tuberculosis, and chronic diseases like cancer;<\/li>\n\n\n\n
  3. Forestalling injury: safety regulations like requiring \u201cdead man\u2019s switches\u201d on chainsaws that turn off the saw if the user lets go of the handle; and<\/li>\n\n\n\n
  4. Surveilling the community to measure its conditions.<\/li>\n<\/ol>\n\n\n
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    Electrical code <\/figcaption><\/figure><\/div>\n\n\n

    In practice, the public health system is an overwhelming pile-up of rules and procedures that affect everything from the packaging of milk to the contour of highway curves, from the standards for electric plugs to the performance of automobile bumpers, from noise limits in factories to air conditioning norms in offices, from apartment fire safety requirements to water testing guidelines for sewage plants. Local statutes regulating the design of sidewalks to protect pedestrians from cars, state vaccination mandates to protect children from disease, nationwide environmental laws to protect citizens from dirty air and water: the public health system encompasses them all. It sets down how chlorine must be administered to swimming pools and fluoride to drinking water. How children\u2019s playgrounds in many states must have a foot of impact-absorbing material (wood chips, safety-tested rubber) around each piece of equipment. How construction workers must don protective equipment like respirators, hardhats, and safety glasses. How coaches, pharmacists, electricians, park rangers, and veterinary technicians must be trained in cardiopulmonary resuscitation (CPR), a technique for restarting a person\u2019s heartbeat after it has stopped. And so on. And so on.<\/p>\n\n\n\n

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    China News Service \/ Getty Images<\/cite><\/a><\/figcaption><\/figure>\n\n\n\n

    The immense network of health regulations is administered by an equally large network of state, local, and federal agencies. The Occupational Safety and Health Administration, the Health Resources and Services Administration, the Federal Occupational Health, the Administration on Aging, the National Highway Traffic Safety Administration, the Food and Drug Administration, the Centers for Disease Control and Prevention, the Environmental Protection Agency, the National Institutes of Health, the fifty state and thousands of municipal health departments \u2014 a full list would take many pages.<\/p>\n\n\n

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    Handicap access <\/figcaption><\/figure><\/div>\n\n\n

    Much of the information used to lay out these rules is contained in the 86 volumes of ASTM standards, most of them fat black paperbacks. (ASTM initially stood for American Society for Testing and Materials, but the organization now calls itself simply ASTM International.) Generated by countless research teams over more than a century, ASTM standards are the results of testing the safety and performance of a staggering variety of materials in an equally staggering variety of circumstances. To glance at their titles is to reveal the intricate, far-reaching way these standards are woven into the world we have built around us.<\/p>\n\n\n\n