Water and Filth: Reevaluating the First Era of Sanitary Typhoid Intervention (1840-1940)

Abstract

While typhoid fever remains an important cause of illness in many low- and middle-income countries, important insights can be learned by exploring the historical experience with typhoid fever in industrialized countries. We used archival research to examine British and American attempts to control typhoid via sanitary interventions from the 1840s to 1940s. First, we assess how varying perceptions of typhoid and conflicts of interest led to a nonlinear evolution of control attempts in Oxford, United Kingdom. Our qualitative analysis shows how professional rivalries and tensions between Oxford's university and citizens ("gown and town"), as well as competing theories of typhoid proliferation stalled sanitary reform until the provision of cheap external credit created cross-party alliances at the municipal level. Second, we use historical mortality data to evaluate and quantify the impact of individual sanitary measures on typhoid transmission in major US cities. Together a historiographic and epidemiological study of past interventions provides insights for the planning of future sanitary programs.

Keywords: public health history; sanitary reform; typhoid control; typhoid mortality.

Figure 1.

Historical typhoid mortality and morbidity data in Oxford, United Kingdom. Source: Oxford Medical Officer of Health Annual Reports, Oxfordshire History Center.

Figure 2.

Observed time series and long-term typhoid transmission rates with water supply interventions and yearly investments in water supply systems are shown for each of the 4 cities. In the plots on the left, the observed time series of weekly deaths reportedly due to typhoid (gray lines) and the yearly typhoid deaths per 100 000 population (red lines) is shown for each city from 1889 through 1931. In the plots on the right, the estimated long-term typhoid transmission (gray lines), single water supply system interventions or events (dashed vertical lines: red denotes filtration, diagonal blue lines denote chlorination, diagonal green lines denote reversal of water flow, and purple dashed lines denote other intervention/event), and yearly water supply system investments (colored dots: dark green denotes receipts, orange denotes expenses, purple denotes outlays, pink denotes total value divided by 10, and light green denotes funded debt divided by 10) are shown for each city.