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The history of consumer protection against household poisons presents a key case study of the uniquely American struggle to balance public health and safety with the interests of business. By the late 19th century, package designs, warning labels, and state statutes had formed an uneven patchwork of protective mechanisms against accidental poisonings. As household chemicals proliferated in the early 20th century, physicians concerned with childhood poisonings pressured the federal government to enact legislation mandating warning labels on packaging for these substances. Manufacturers of household chemicals agreed to labeling requirements for caustic poisons but resisted broader regulation. Accidental poisonings of children continued to increase until the enactment of broad labeling and packaging legislation in the 1960s and 1970s. This history suggests that voluntary agreements between government agencies and manufacturers are inadequate to protect consumers against household poisonings and that, in the United States, protective household chemical regulation proceeds in a reactive rather than a precautionary manner.

To inform choices about the future of epidemiology, the present condition of epidemiology is examined, in terms of its evolution through three eras, each demarcated by its own paradigm: (1) the era of sanitary statistics with its paradigm, miasma; (2) the era of infectious disease epidemiology with its paradigm, the germ theory; and (3) the era of chronic disease epidemiology with its paradigm, the black box. The historical context in which these eras arose is briefly described. In each era, the public health was at the center of the concerns of the founders and early protagonists of the prevailing paradigm. Around this intellectual development we weave a further theme. We argue that in the present era, the public health has become less central a concern. At the same time, in epidemiology today the dominant black box paradigm is of declining utility and is likely soon to be superseded.

Stigma is not new to public health, nor is it unique to HIV/AIDS. History provides an unfortunate abundance of examples of “prejudice, discounting, discrediting, and discrimination”1 directed toward persons who are ill or perceived to be ill. Leprosy was viewed as divine punishment for moral misconduct in centuries past, and persons infected with Mycobacterium leprae were forcibly excluded from both civil and religious society.2 Those who became ill with cholera in the early years of our American republic were publicly decried as intemperate, lazy, and vice ridden.3 Even after the germ theory became widely accepted, discrediting divine wrath, miasma, and other incorrect theories of disease, negative attitudes lingered. For example, some persons with syphilis were “innocent”; others were not. Often, physicians were reluctant to treat patients in the latter category, considering them immoral and hence unworthy of care.4

An innovation often occurs in several arenas almost simultaneously, after being preceded by a long preparatory period when information and experience are accrued to the point at which opinion is influenced to change. Nevertheless, the introduction of an innovation is usually accompanied by resistance and hostility. This article traces the development of the concept and practice of antisepsis in health care, with emphasis on the contributions of three individuals who were contemporaries practicing in different health care fields, but who apparently were uninfluenced by each others' work. Semmelweis, a Hungarian obstetrician, recognized the importance of person-to-person transmission of infectious agents and effected dramatic reductions in puerperal mortality by requiring antiseptic handwashing. Lister, a Scottish surgeon, was the first physician to apply the germ theory to clinical practice and developed the techniques of antiseptic surgery and wound care, resulting in dramatic reductions in surgical mortality. Nightingale, a British nurse, initiated sanitary reforms in hospitals, schools, and military camps in England and abroad, incorporating high levels of environmental and personal hygiene. These reforms were also succeeded by dramatic reductions in mortality. In light of historical and current evidence of efficacy and the evidence of continued inadequacies in practice, it seems reasonable to speculate that further reductions in nosocomial infection rates are possible by a more careful application among individual practitioners of the basic principles of antisepsis.

ENGLAND is the home of public health engineering. In that country such activities date back prior to the germ theory of disease and also antedate substantial accomplishments in this field elsewhere. Administrative practice has had much to do there with the history of public health engineering. This is particularly true in view of the fact that the Local Government Board of England had for a great many years jurisdiction over problems relating to sewerage, sewage disposal and river pollution, and over their bearing upon water supplv projects and the disposal of industrial wastes. In 1919 this jurisdiction was transferred to the Ministry of Health.

There is no more interesting chapter in the history of sanitary science than that devoted to the development of our ideas regarding the cause and transmission of typhoid fever. Confused as the disease was until about the middle of the hast century with typhus fever, the differentiation of the two left the cause of typhoid fever still unknown. Real work in connection with its transmission thus began with the recognition of the disease as a clinical entity. It was early evident in the study of typhoid fever that filth, particularly filth from human bodies had a large share in the causation of outbreaks. It was likewise recognized that water and milk polluted with human filth sometimes caused widespread epidemics of the disease. These facts seem to have been accepted by most of the early students of typhoid, but most of the sanitarians of the middle of the last century denied the contagiousness of the disease. Murchison formulated a theory of the causation of typhoid to fit these beliefs. He taught that the disease was pythogenic, or bred in filth, that the virus was spontaneously generated in decomposing organic matter and was given off in an effluvium of malaria. He later modified this theory by ackowledging the contagious element in the disease, but still contended that the contagion from a case had to develop or breed in filth before infecting others. Murchison's ideas were generally accepted by the sanitary world and prevailed until the year 1873 when Budd* published his wonderful series of observations on the spread of the disease and his conclusions from them. Budd's work, begun long before the days of the germ theory or even Listerism, was continued with the publication of occasional papers on the subject, from 1850 to the time of the publication of his complete monograph in 1873. In many respects this monograph on typhoid fever is the most remarkable document ever produced on the subject. Working as a practitioner in the rural districts of England, with only his own personal observations and reason to guide him, he produced a work which lacks but little of telling the whole story of the transmission of typhoid fever even today. Budd's conclusions, which he supports by full and complete epidemiological evidence, are as follows: 1. That typhoid fever is, in its essence, a contagious, or self-propagating

FIFTY years ago sanitary engineering in this country scarcely existed, even in name. The larger cities were provided with public water supplies and there was a general desire among sanitarians to supply water free from filth. Sewers in combination with storm water drains.had been built in the larger communities to a limited extent for several decades. Some of the more progressive engineers were watching the activities of the Rivers Pollution Commissions in England andc at Paris, Berlin and a number of other places abroad. The germ theory of disease had not been established. The laboratory man spoke of chemical tests in terms unappreciated by the engineer and of comparatively little aid to him. Bacteriology had not sprung into being. In brief, the historyof the past fifty years tells practically all of the substantial accomplishments of the sanitary engineer in advancing the publichealth movement on this continent. I shall outline briefly what the engineer has accomplished along sanitary lines in the field of water supply, water purification, sewerage, sewage disposal, control of streams and the collection and disposal of solid wastes.

The cleaning of city streets is necessary for several reasons which may be summarized as the preservation of the public health, the physical comfort and convenience of the people, and a regard for decent cleanliness and good appearance. Of these, the preservation of the public health must be considered of first importance. Filthy streets have long been held by sanitary authorities to be a prolific cause of disease. But our views as to the exact way in which street filth causes or propagates disease have, in the light of more recent investigations and conclusions, undergone a notable change. The prevailing idea in the past, among sanitarians and physicians as well as in the public mind, has been that filth and organic matter in the process of decay gives off poisonous gases or exhalations capable of conveying if not of creating various diseases in the bodies of those exposed to it. Thus, it was held that the effluvia from sewers entering dwellings through untrapped pipes and fixtures was the direct cause of much sickness. More recent investigations and the development of the germ theory of diseases led to the conclusion that a large number, if not all of the infectious or contagious diseases that affect mankind are caused, directly or indirectly, by specific organisms which propagate and multiply in the blood, and that these organisms or their germs are carried into the body not by gaseous exhalations, but only by solid or fluid matter with which the germs are incorporated or to.which they are attached. We, therefore, hear little now, from those qualified to express an opinion, about the deadly character of sewer gas, and other like emanations. The smells and effluvia from filth and decaying matter, while they may affect the general health and lower the vitality, and thus make those exposed to them more susceptible to attack, are no longer regarded as in themselves able to create or to convey specific diseases. The organisms that cause these diseases must reach the blood through physical contact or by conveyance in connection with solid or fluid matter introduced into the alimentary or respiratory systems.