Non-communicable disease

That would be whatever has rotted Robert Kennedy Junior's brain. It seems he rejects the so-called Germ Theory of Disease. To be sure, infectious disease is no longer the leading cause of death in the United States, or even a major contributor.

 

 

 

(I happened to have a chart handy that's a few years old, but this hasn't changed in a major way since 2010. There was a blip, obviously, during the height of the Covid 19 pandemic.) As you can see, about half of all deaths in the U.S. in 1900 were directly attributable to infectious diseases; now it's just that tiny sliver labeled "pneumonia or influenza. (The situation is different in low income countries, where tuberculosis, malaria, HIV and water-borne disease continue to kill a lot of people, including children.) However, as all sane people know, the reason that infectious disease is no longer a major cause of death in the U.S. is because we know about it, we understand it, we have the tools to deal with it, and we use them. Yes, vaccination and antibiotics are important, but just as important are public health and sanitation measures to stop contagious disease at the population level. So I'm going to start with that today.

Two of the leading causes of death in 1900, gastrointestinal infections and tuberculosis, were major killers of children, and a major underlying cause of these deaths was cow’s milk. The U.S. population originally was predominantly rural, but by 1900 the majority of the population in the northeast lived in cities, and by 1910 the same was true in the west and Midwest. Cow’s milk had to come into cities like New York from farms tens of miles away, at a time when there was no refrigeration, and it was often contaminated with pathogens that killed the children who drank it.

Louis Pasteur, along with the German Robert Koch, developed our understanding of how microbes cause disease. He invented pasteurization in 1865, but even 25 years later milk was not normally pasteurized. Then a German immigrant in New York City, a wealthy merchant named Nathan Strauss, learned about pasteurization. In 1892 he used his own money to establish a pasteurization plant in Manhattan’s East Village, and in 1893 he established “milk depots” in low income neighborhoods to sell pasteurized milk below cost. He also established a second plant to provide pasteurized milk to an orphanage on Randall’s Island, where the mortality rate was something like 15% a year. The death rate immediately dropped substantially.

Strauss’s efforts attracted the attention of scientists and physicians, and incited a campaign to outlaw the sale of unpasteurized milk. This came to the attention of president Theodore Roosevelt, who in 1907 appointed a commission to study the matter. The report came back the following year with the conclusion that pasteurization would save many lives. As the reaction to public health mandates more recently might lead you to predict, the campaign to mandate pasteurization provoked a furious backlash, including from most milk producers. Why they thought it was good business to kill their customers I cannot say. Many in the general public also opposed the ban on raw milk, claiming that pasteurization negatively affected nutrition and taste. Nevertheless Chicago did ban the sale of raw milk in 1909, but New York didn’t get around to it until a typhoid epidemic in 1913. Nearly all major cities followed suit in the next few years, and the infant and child mortality rate plummeted.[1]

A second major causes of infectious disease and child mortality was contaminated drinking water. Cholera is an intestinal infection caused by the bacterium Vibrio cholera, which is spread through water or food contaminated by feces. The disease causes severe diarrhea that can last for several days. Depending on the bacterial strain, the fatality rate from untreated cholera can range from 5% to 50%. It was a common deadly disease in 19th Century cities.

Remember that before 1854, it was generally believed that cholera and other diseases were caused by “bad air” or “miasma,” created by rotting organic matter, a theory accepted from the time of Hippocrates, and apparently believed today by Robert Kennedy Jr. In 1854 a cholera outbreak occurred in the Soho district of London. Physician John Snow mapped deaths from the outbreak and discovered that they mostly occurred among people whose nearest source of water was a pump on Broad Street. He persuaded the local council to remove the pump handle and the outbreak ended.

It was found that the water from the Broad Street well was contaminated with sewage from a cesspit. Snow also mapped outbreaks among people who received mechanically pumped water from commercial operators, and was able to associate them with water from the Thames that was contaminated with sewage. Pasteur and Koch had yet to develop the germ theory of disease, so Snow and his contemporaries had no idea of the causal mechanism. Nevertheless the idea that drinking water contaminated by sewage was a cause of cholera gradually came to be accepted.

By 1900, cities were building infrastructure to separate drinking water from sewage. But city water didn’t become fully safe until the development of chlorination. Once the germ theory of disease was understood, it became possible to experiment with chemical additives that would kill pathogens in water, and small amounts of chlorine were found to be effective. In 1899, Jersey City contracted for the construction of a new water system that would be free of contamination. The project was completed in 1904 but in a lawsuit concluded in 1908, the judge found that the Jersey City Water Company was not consistently delivering pure water. The company’s sanitary adviser, physician John Leal, contracted for the construction of a plant to add chlorine to the Jersey City water supply. In a second trial, the judge concluded that the experiment was successful and that the water was now “pure and wholesome.” Cities rapidly adopted chlorination and by 1918 more than 1,000 North American cities were chlorinating their water. The result was a dramatic decline in deaths from waterborne disease. 

To be continued . . . . 

---

[1]Today, federal law bans interstate sale of raw milk, but state laws vary. Eleven states allow raw cow’s milk to be sold in retail stores without restriction, but others allow sales only directly at the farm, while 20 prohibit it entirely. I do not believe there is any validity to claims that it is nutritionally superior, but it is less dangerous than it was in 1900, because of refrigeration, because it is likely to be fresh, and because cattle today are unlikely to be infected with pathogens that can pass into their milk. However, it would not be possible to safely produce, distribute and store raw milk at the scale necessary to meet consumer demand. In fact milk keeps on store shelves almost indefinitely because it is pasteurized and sealed.