The History of the Public Health Movement in the United States

It seems NYC was always more or less the center of the Public Health Movement in the U.S.

Today, Bellevue Hospital and its School of Nursing train a lot of people in Public Health

Looking back, I never knew that Frederick Law Olmstead, the designer of Central Park, was involved-- from a site called Places- Design Observer

Posted 11.15.10 | PERMALINK | PRINT

Essay: Thomas Fisher

Frederick Law Olmsted and the Campaign for Public Health

Frederick Law Olmsted. [courtesy of The New York Public Library]

Landscape architects have long studied and admired Frederick Law Olmsted, often considered the founder of the field in the United States. But Olmsted had another career, distinctly different from landscape architecture and rarely studied by landscape historians. For two years during the Civil War, he served as the general secretary of the United States Sanitary Commission, which was dedicated to improving the sanitation of the Union Army's military camps and the health of Union soldiers. This might seem like a detour in Olmsted's career, an admirable but nevertheless tangential interlude in his progress as a landscape architect. But when we examine Olmsted's Sanitary Commission work in light of the history of public health, it is clear that here — just as with his foundational work in public parks — Olmsted has set an example that landscape architects might follow in the future. To see where the field might venture in the 21st century, in other words, it is illuminating to chart an often-overlooked path that Olmsted pioneered in the mid-19th century.

But let's look first at the state of public health in the period just before the Civil War. Commencing in Germany in the 1840s, the public health movement arose out of concerns about the typhoid and typhus epidemics that had begun to endanger Europe's industrial slums, and the cholera epidemic that had hit London years earlier. The German physician Rudolf Virchow, one of the founders of the social medicine movement, was among the first to see the connection between poor sanitation and disease. In the United States, in 1847, the American Medical Association, after studying the unhygienic conditions in American cities, and aware of Virchow's work, called for improvements to sanitation systems and living quarters in order to avoid an epidemic; sanitary commissions were established in several states, where they advocated for measures such as the better venting of domestic water closets to disperse the noxious odors then considered to be a leading cause of disease.

This belief that diseases were caused by bad "vapors" — the miasma theory of disease, which had held sway since the Middle Ages — was disproved in 1854, when the British physician John Snow traced an outbreak of cholera in London to a polluted water well. Snow's discovery is widely viewed as the beginning of the science of epidemiology and of the modern germ theory of disease. While the miasma theory rightly saw the connection between disease and sanitation, it became clear, in the wake of Snow's work, that the mechanism of disease transport was not bad air but viral or bacterial microorganisms.

Public Intellectual
Olmsted, then living in New York City and working as managing editor of Putnam's Monthly, was well aware of this transformation in our understanding of ill health. He traversed daily the packed streets and passed by the crowded tenements of Lower Manhattan on his way to and from his office. He saw the effects of what came to be called the Great Fire of 1845, which destroyed 300 buildings in New York and prompted the city to enact the nation's first comprehensive building code in 1850. And he heard the debates going on in the 1850s about the health effects of poor sanitation in tenements; this culminated in New York passing the nation's first tenement law in 1867 to control unhealthy housing conditions, and which regulated, among other things, the placement and drainage of outdoor latrines.

Left: Crowded conditions inside a New York tenement house, 1883. [via Library of Congress] Right: Rudolf Virchow (seated) attends an operation, 1904. [via Wikimedia]

    
In 1857, several events propelled Olmsted away from his role as an editor and public intellectual, which required that he report and reflect on these conditions, to a new role, which required that he play a central part in changing them. In the summer of 1857 his publishing venture failed (although his vision for Putnam's Monthly would live on in the Atlantic Monthly and Harper's Magazine, both founded that year). That same summer Manhattan erupted in riots, as street gangs in overcrowded neighborhoods clashed with police; and the first public health convention convened in Philadelphia. Also that same year, Olmsted became the superintendent of Central Park, then being planned, and less than a year later, in April 1858, the Greensward Plan that he and the architect Calvert Vaux had prepared won the design competition for the Park.
     
Echoing the miasma theory, still in popular circulation, Olmsted argued that great public parks, such as his proposed Greensward, would function as the "lungs of the city" — green open spaces where city dwellers could breathe clean air. More accurate, in hindsight, was the emphasis Olmsted and Vaux placed on good sanitation — on well-drained land, well-circulating waterways and well-designed sanitary facilities — which reflected their knowledge of the sanitary movement and the connection the nascent field of public health had made between polluted water and disease.
     
Olmsted served as the chief architect of Central Park up until 1861, when political tensions with the Park's comptroller and board of commissioners led him to resign the position. Meanwhile, the reform-minded Unitarian minister, Henry Whitney Bellows, had been observing and admiring Olmsted's managerial skills in overseeing the construction of Central Park. Bellows, along with a group of prominent physicians, was advocating for the formation of an American Sanitary Commission, patterned after one formed in Britain, with the intent of improving the sanitation of the Union Army camps. Bellows asked Olmsted if he would serve as the general secretary and chief executive officer of the new Commission, which had been authorized by the War Department and created by legislation signed by President Abraham Lincoln in June 1861, two months after the start of the Civil War. Olmsted agreed.

Design of Prospect Park, by Olmsted and Vaux, ca. 1868. [via New York City Department of Parks and Recreation]

Public Servant
Amazingly, the federal government, at first, resisted the requests of the Sanitary Commission to be allowed to enter the military camps with the intent of improving living quarters. Some in the government worried that the Commission's efforts would distract the military from the campaign then underway — a hesitancy that underscores that public health, as a discipline, had not yet had much impact on either the broader public or even on the military establishment. Evidence for the military's lack of awareness was all too evident, from the rudimentary army hospitals then in operation to the archaic operations of the government's military bureau. And military attitudes reflected the wider contemporary acceptance of chronic illness as a part of everyday urban life. Periodic epidemics of smallpox and yellow fever got people's attention, but in the mid 19th century crowded housing and bad sanitation made killers of more common ailments such as tuberculosis, malaria, and respiratory and digestive diseases.
    
A turning point — a growing awareness of the harmful effects of poor sanitation — came in the wake of the Union army's horrible defeat at the First Battle of Bull Run, in July 1861, in Manassas, Virginia. Beyond the military reasons for this defeat — including the inexperience of the new troops — the Sanitary Commission showed how the soldier's poor living environs had contributed to the rout, and the U.S. government finally gave Olmsted and his medical colleagues access to the camps. In his report in September 1861, on Bull Run, Olmsted showed how "excessive fatigue . . . heat, and . . . want of food and drink" led to the "demoralization" of the troops. Such observations may seem far removed from his experience in the design of public landscapes, but Olmsted viewed the field broadly, not separating the quality of a person's life from the quality of the physical or natural environment. The Sanitary Commission inspected and made recommendations not just about the soldiers' exhaustion levels but also about design issues such as the location of camps, the provision of drainage and waste disposal, the ventilation of tents, and the storage and preparation of food.
   
Olmsted directed the Sanitary Commission through mid-1863, at which point conflicts with colleagues and his executive committee, combined with exhaustion from overwork, led him to resign. The Commission continued through the end of the Civil War, along the lines Olmsted had established for it, and it became the core of the American Red Cross, founded 20 years later. Olmsted resumed his extraordinary career in landscape architecture, for which he is best known. Yet it now seems clear that with Olmsted's resignation from the Sanitary Commission a potentially vital connection was severed — the connection between physical design and public health. The disconnection would remain in place for more than a century — and only very recently have the ties begun to be restored.

Headquarters of the U.S. Sanitary Commission, near Gettysburg, Pennsylvania, ca. 1863. [courtesy of the New York Public Library]

EpidemiologyThis disconnection was not the fault of Olmsted; nor can we attribute it to landscape architecture as a field. In the decades after the Civil War, public health, as a discipline, began to move in a very different direction, focusing less on the physical, on sanitary conditions, and more on the medical, on epidemiology. To be sure, this new emphasis resulted in part from the very success of the sanitation movement in the latter half of the 19th century, when dramatic improvements in city building standards led to the elimination of many of the sources of diseases that had once been widespread. Indoor plumbing and water closets eventually became required in housing, as did sewers that separated storm and wastewater. And when New York City passed the Tenement Housing Act of 1901, features we now consider essential to basic livability, such as daylight, natural ventilation, sanitation and security, became available to even the poorest people.

Public health entered an epidemiological phase after the Civil War for another reason as well: the growing efficacy of the medical and pharmaceutical fields in ameliorating chronic diseases and epidemic outbreaks. Through the development of new drugs, the public health community managed to control once serious threats ranging from smallpox and measles to polio and diphtheria. And through the application of environmental chemicals, diseases such as malaria and yellow fever virtually disappeared from North America. Improved living standards certainly helped to curb such diseases, but the physical environment became, at best, a secondary concern for public health.
     
That has changed in recent years. The public health community continues successfully to curb the incidence of the diseases that respond to drug or chemical interventions. But today we face public health challenges very different in nature from those of earlier generations.

Today millions of people on the planet, especially in the rapidly growing cities of the developing world, endure living conditions much worse than what Olmsted witnessed in Lower Manhattan, and almost a billion lack easy access to clean water. We confront as well — perhaps for the first time in history — the public health challenges of prosperity. We now identify diseases like cancer, heart failure, diabetes, emphysema and even obesity as "lifestyle diseases," resulting from individual and social behaviors, from personal choices and cultural patterns; indeed the Centers for Disease Control have been studying "urban sprawl and public health" for several years now. [1] We understand the problem: the increasingly sedentary, high-calorie lifestyle that's become common in wealthier countries has made obesity an epidemic, with all of the attendant malignancies and infarctions that come with it. Here, the causes lie even closer, no farther than the car-dominated cities we build, and the corn-syrup-laced beverages and high-fat foods we produce and market so aggressively.

Ocean Parkway Bicycle Path, designed by Olmsted and Vaux, ca. 1894. [via New York City Department of Parks and Recreation]

Landscape Architecture and Public Health
And so, almost a century and a half after Olmsted left the U.S. Sanitary Commission, we find ourselves, once again, in an era when the larger issues of public health intersect the practices of landscape architecture, architecture and urbanism. And we might well wonder: What would Olmsted do, were he alive today, and facing such paradoxical threats, arising from scarcity in some places and from abundance in others? We might hazard a few guesses, as guides to what we might do now.

First, he would write and speak out about these issues. Olmsted achieved lasting fame as a landscape architect, but he began his career as a public intellectual, and he remained one to the very end of his career. As we can see from his collected papers, Olmsted wrote well and persuasively, and we need to do the same today. Landscape architecture, like all of the design disciplines, has become extremely dependent upon what others — clients mostly, but also communities — deem important; for this reason landscape architects more often than not implement the visions or policies of others. In an era of great change, such as ours, we need to adapt the methods Olmsted used in another turbulent time: defining the discourse, identifying the problems, and proposing the strategies and policies needed to resolve them. Some of that can happen through design, but nothing can replace the power of persuasive writing and speaking. We need more often to put aside the mouse, and take to the keyboard.

Second, Olmsted would partner with a wider range of disciplines than designers typically do now. At the Sanitary Commission, Olmsted's colleagues included an architect, Alfred Bloor, and an engineer, Bridgham Curtis, but they also included physicians, theologians, philanthropists and financial analysts. Olmsted needed such radically interdisciplinary teams to do the varied work required of the Commission, and the same is true today. The causes of homegrown lifestyle diseases and of global pandemics are complex and interwoven; it will take many disciplines, working together, to devise solutions. And of course Olmsted's example suggests that the landscape architect can function not only as an expert in how we inhabit and steward the land, but also as a manager of diverse teams of people. Olmsted knew something about sanitation — but just as important, he knew how to organize and operate a complex commission and oversee the work of a large multidisciplinary staff. This may in fact be among the more important skills landscape architects can offer today, as the field studies how settlement patterns, transportation modes, water quality, etc., relate to the ramifying problems of public health in an urbanizing world.
     
Finally, Olmsted would bring a sense of high professional purpose to the work; throughout his life he pursued larger social goals, regardless of cost, as opposed to the politically expedient or personally beneficial course. His conflicts with the Board of Commissioners at Central Park or with the Executive Committee of the Sanitary Commission arose out of his insistence that they authorize the money necessary to do the job right. (To a lesser extent, the conflicts also followed from his resistance to playing political favorites, something that, particularly in the case of Central Park, alienated him from the New York political bosses.) Surely a similar politics is at least partly responsible for the environments we have created for ourselves. The low-density development that contributes to our obesity, the air and water pollution that contributes to our cancer rates, and the systemic impoverishment that contributes to our pandemics — all are traceable to political decisions and cultures that favor property owners, developers, and landlords, and the banks and shareholders who benefit as well. We will never confront our contemporary public health problems in any meaningful way unless we question the prevailing power structures — unless we make a powerful case for long-range social good and challenge those who skew the rules in favor of short-term gain for an increasingly remote elite. It will take professionalism and political will, but the price of ignoring our contemporary public health crises — pandemics that will endanger billions, chronic diseases that damage lives and by extension the whole society — will be steep, and we will all pay it.

Frederick Law Olmsted's career as a landscape architect foretold where the field would go for its first century and a half in America. His career as the leader of the Sanitary Commission may foretell where the field needs to go in the next century. The health of all of us may depend on it.

Notes
 

1. See Howard Frumkin, MD, "Urban Sprawl and Public Health," Public Health Reports, May–June 2002, Centers for Disease Control, vol. 117.

References

Frederick Law Olmsted, The Passion of a Public Artist, Melvin Kalfus, New York University Press, New York, 1990.

The Papers of Frederick Law Olmsted, Volume IV: Defending the Union, The Civil War and the U.S. Sanitary Commission 1861-1863, Jane Tuner Censer, editor. The John Hopkins University Press, Baltimore, 1986.

"Report on the Demoralization of the Volunteers," Ibid. p. 153-194.

A Clearing in the Distance: Frederick Law Olmsted and America in the 19th Century. Witold Rybczynski. Touchstone, New York, 1999.