CHAPTER 1

"To Push Back the Shadowupon the Dial of Time"

The Astonishing New Facts of Life and Death

At the end of 1921, New York City hosted an extraordinaryevent. Mayor John F. Hylan declared November 13–19 "HealthWeek." Two floors of New York's premier exhibition hall, the Grand CentralPalace (right next to Grand Central Terminal), were given over to what wasbilled as "the largest health exposition ever attempted." Thousands attendedthe exposition. To help draw in crowds, organizers offered a "Health Clown"and "Health Characters." There was a Harbor of Child Health, where the ChildHealth Family resided. "Happy," a member of that family, appeared as a sailor.Baseball great Babe Ruth and heavyweight boxing champion Jack Dempseywere on hand to sign autographs (though it's hard to see how either could haveserved as a model for healthy living, even in those days). Visitors had a chanceto gawk at "fat men and women" who for the past three weeks had participatedin a weight-loss competition. The winner of the "perfect baby contest" was announced(William Yarnias, eighteen months old). And of course no healthexposition would be complete without a finalist in the quest for the perfectwoman's foot—to demonstrate, as the reporter for the New York Times put it,"that the world is as romantic as in the days of Cinderella and the Prince." Thehonor went to Miss Elizabeth Doyle, nurse.

The United States Public Health Bureau and other New York City departmentsparticipated, as did social service, charity, and business organizations.There was a plan to set up educational displays and activities throughout thecity: "diet squads," blood pressure machines, and nutritional demonstrations,including animals. Proceeds from ticket sales were to be used to fund publichealth organizations and activities at the local, national, and international levels.

But none of this was the big news. "Health Week" was actually just themiddle segment of an entire "Health Fortnight." It had been preceded by aninternational conference, called the "Health Institute," and it was followed bythe Fiftieth Annual Meeting of the American Public Health Association. Thebig news came at that meeting.

The APHA had been founded in New York City in 1872. It was the first publichealth organization in America, at a time when the very concept of "publichealth," with its emphasis on sanitation, preventive medicine, and collectiveresponsibility, was a novelty. In November of 1921, at the Hotel Astor, the associationwas celebrating its fiftieth anniversary. The Jubilee meeting broughttogether some of the most distinguished figures in the field. On the programwere dozens of speeches, including some with such deadening titles as "Sanitationof Bath-Houses at Public Bathing Beaches," "Proper Size of Sand for RapidSand Filters," and "The Prevention and Cure of Rickets by Sunlight." But twocaught the attention of the press. Dr. Mazÿck P. Ravenel gave the PresidentialAddress, titled "The American Public Health Association, Past, Present, Future."Like other top officials of the association, the president was partly interestedin boosting the achievements of his organization—and why not? This was acelebration, after all. But he also used the occasion to give a capsule history ofmedicine over the previous half-century, speaking above all of Louis Pasteurand Robert Koch. Each achievement he listed—the discovery of a pathogenicmicroorganism (staphylococcus, streptococcus, pneumococcus, the Asiaticcholera spirillum, the tuberculosis and diphtheria bacilli)—represented a victory,imminent or current, over an illness that had threatened populations forcenturies.

One passage in his speech was particularly striking. Telling his audienceabout the journals the APHA had published during its fifty-year history, Dr.Ravenel was moved to say this:

In comparing the earlier volumes with those of to-day, one is struck by the factthat the most important topics discussed in the early years are scarcely evermentioned now. The first volume, published in 1873, is given up largely to yellowfever and cholera. One finds it hard to believe that cholera was at that timewidespread in the United States, and that it existed in more than two hundredtowns and cities of the Mississippi Valley.

The other presentation that found its way into the newspapers was the keynotespeech at the opening banquet. Dr. Stephen Smith was a founder of theassociation, and on the evening of November 16, 1921, his topic was "A HalfCentury of Public Health." While Ravenel and others celebrated the concreteachievements of medicine and public health over the previous, extraordinaryhalf-century, Smith looked at the larger ramifications. Let's say you believedthat European and American medicine had practically obliterated the ravagesof infectious disease. What did that mean for you? It's a simple question, andDr. Smith had a simple answer: a longer life—a much longer life.

Smith spoke specifically of the drop in the death rate, making an astonishingobservation. "The steady fall of the death-rate," he said, "until it has nearlyreached the vanishing point, suggests the possibility of its passing that point.What a tremendous result!" "Vanishing point"—meaning immortality? Well,almost. "We have too long been content with the false code of the Mosaic law,"he said a little later, "that limits life to three-score years and ten, with a possibilityof reaching four-score years." Thanks to modern science, however, weknow what the limit should be. "Biology teaches that the normal and potentiallife of man is one hundred years; that every child born is adapted in physicalconstruction and function to live a century."

In honor of the Jubilee celebration, the APHA published a volume of essays,titled A Half Century of Public Health. Included in that volume was an expandedversion of Smith's Jubilee speech, in which the association's elder statesman explainedthe scientific basis for his extravagant claim. It was this: the normal lifespan of any vertebrate, he believed (drawing on the work of famed British paleontologistRichard Owen), is five times the number of years it takes for that vertebrate'sbones to develop fully. Human bones take twenty years to develop, sothe normal human life span is a century. What the past fifty years have shown,he maintained in the speech, is that "all deaths occurring at an earlier age aredue to conditions existing which are not compatible with the construction andfunctions of the human organisms." And so he proposed that, to mark the anniversary,the APHA should dedicate itself to raising "the standard for the lengthof life" by thirty years. Maybe he wasn't talking literally about immortality; hewas talking about "life that suggests immortality."

No one could have been a better spokesman for this cause. Smith was almost99 years old when he gave this speech. An editorial in the New York Times,titled "All in a Lifetime," picked up the veteran doctor's fondness for Biblicalreference. "What preventive medicine and sanitation have done in the span ofthat one life to push back the shadow upon the dial of time—as the shadowreceded on the dial of King Hezekiah of old—so that there is prospect for alonger enjoyment of that birthright, is one of the brightest chapters of science,"and all thanks to the scientific advances that Smith and Ravenel had mentionedin their speeches. Dr. Smith "happily illustrates" his own theory of longevity,the editor said.

The editor jumped the gun on this point, as it turned out, for StephenSmith died the following August, about a half-year short of his biologically allottedcentury. Still, his achievement was impressive, and the press celebratedhim, both before and after his ill-timed demise. How had he made it to suchan advanced age? He had plenty of advice for whoever would listen: lots ofmilk, not too much meat, plenty of sleep, no spirits or stimulants. He evenrecommended short skirts for women—not, heaven forbid, because he foundthem eye-catching (which in 1921, with hemlines almost up to the knee, theycertainly were), but because he thought they were less likely than long skirts tocarry dirt and bacteria from the street into the home.

At the first annual meeting after Smith's death, the APHA adopted a resolutionto honor its founder. It noted that, in many parts of the world, over theprevious seventy-five years, fifteen years had been added to the average life. Itnoted, too (though without statistics to support the claim), that the gains inthe most recent twenty years had outstripped those of the previous fifty, addingthat these gains were continuing "at an accelerated rate." It reiterated the claimthat modern science had overturned "the scriptural ideal of three score yearsand ten." And finally it issued the prediction "that within the next fifty years asmuch as twenty years may be added to the expectancy of life which now prevailsthroughout the United States." The resolution pledged the efforts of theassociation to the attainment of this goal, slightly more modest though it wasthan the one Dr. Smith had issued at the Jubilee meeting.

Unhappily, both Dr. Smith and the association were wide of the mark, andby a fair amount. According to much more recent figures, expectation of lifeat birth in 1922 was indeed approaching 60, but fifty years later, in 1972, it hadrisen only to slightly over 70 (71.1, to be precise, averaged for both genders):a single decade instead of two or three. How disconsolate Dr. Smith and theAPHA members would have been, with their fondness for scriptural allusion,to know that "three score years and ten" was pretty much what the averageAmerican would get (at birth) a half-century in the future.

Still, as more recent figures also show, the assessment of the fifty years leadingup to the Jubilee was essentially correct. Beginning around 1880, life for theaverage American—physical life—changed dramatically for the better. Peoplein the United States began to live longer, and fewer died in childhood. The paceof change was especially pronounced between 1880 and 1930, though it was notprecisely moving "at an accelerated rate," as the APHA resolution in 1922 hadheld; it began to slow about ten years after the resolution was passed.

Nowhere was the transformation in human life more eloquently and forcefullyexpressed than in an essay written for the same Jubilee volume by Dr.Charles V. Chapin (1856–1941), one of the most influential figures in the historyof public health. Chapin had spent virtually his whole career in Providence,Rhode Island, where he served as superintendent of health from 1884 until hisretirement in 1932. He looked back at the movement he had led, describing itsvarious phases and his own participation in those phases. The essay is considereda classic, succinct history of the Public Health Movement in Americancities. In the concluding section, Chapin announced the movement's achievements.The section is worth quoting at length, because it's difficult to imaginea more eloquent and stirring testimony to the transformation that Americansociety had undergone in a mere half-century. Chapin restricts his discussionto the public health work of cities and states.

Thus have cities and states sought to control disease. The yellow fever nightmarewill terrify no more. There has been practically no cholera since 1873.Smallpox, which in former epidemics sometimes attacked half the population,is a negligible cause of death. Typhus fever is a very rare disease. Plague has notbeen able to gain a foothold....

Typhoid fever is a vanishing disease. The diarrheal diseases caused four timesas many deaths fifty years ago as now. Scarlet fever mortality has fallen ninetyper cent. Diphtheria has decreased nearly as much, and the mortality from pulmonarytuberculosis has been cut in two. Infant mortality in our better citieshas dropped fifty per cent. Not all this, it is true, is due to conscious communityeffort, but is in part, dependent upon economic and other unknown causes.Nevertheless, if only one half of this life-saving is to be credited to health workthe dividend on the money and energy employed indicates good business.

Figures do not measure the terror of epidemics, nor the tears of the motherat her baby's grave, nor the sorrow of the widow whose helpmate has beensnatched away in the prime of life. To have prevented these not once, but a milliontimes, justifies our half century of public health work.

This was all good news. Dazzling news, if you had been around for over fiftyyears and could remember an era when the conditions that Dr. Chapin andothers were now describing were not present—when life on average was significantlyshorter, when many children died in infancy, when the next outbreakof infectious disease could occur without apparent cause at any moment. Dr.Smith had emphasized personal responsibility as the key to a long life. Chapinemphasized the network: collective, public action directed by (in this case) municipalauthorities. Both were right: collective action was essential, but so wasindividual responsibility, as we'll see.

What Statistics Show today

Were the celebrants at the Jubilee right?

Let's consider just two rudimentary measures of a population's health: expectationof life at birth and infant mortality, using only averages and leavingout variations based on gender, ethnic group, geography, income, and educationallevel. Expectation of life at birth is the average number of years peoplewho are born in a particular year can expect to live. Infant mortality is thenumber of children born in a particular year (usually reckoned per thousand)who die before their first birthday. According to figures from the 1990s, thetrend in life expectancy and infant mortality from the late eighteenth centuryto the early twentieth century looks something like this: modest improvement(greater life expectancy, lower infant mortality) through the early nineteenthcentury, a setback from about 1840 until about 1870, "sporadic" improvementuntil about 1880, and then truly dramatic improvement.

Expectation of life at birth rose from 38.3 in 1850, to 39.4 in 1880, to about54.1 in 1920. The largest jump over a single decade (for years ending in zero)between 1850 and the end of the twentieth century occurred from 1880 to 1890.That jump was 5.8 years. The largest jump over a twenty-year period (for yearsending in zero) from 1850 till well into the twentieth century occurred between1880 and 1900. It was 8.4 years.

Infant mortality fell from 229 per thousand in 1850, to 225 per thousand in1880, to 86 per thousand in 1920. By the end of the twentieth century, it stoodat 7 per thousand. The largest decline over a single decade (for years ending inzero) between 1850 and the end of the twentieth century occurred from 1880 to1890. It was 64.7 per thousand. The largest decline over a twenty-year period(years ending in zero) during the same century-and-a-half occurred between1880 and 1900. It was 96.1 per thousand.

In sum, the averages tell us this: starting sometime around 1880, whetheryou lived in the city or the country, whether you were rich or poor, well educatedor illiterate, male or female, white or nonwhite, you were likely to livelonger—even significantly longer—than your parents; you were more likely—even significantly more likely—to survive infancy than your parents had been;and, finally, your children were more likely—even significantly more likely—tosurvive infancy than you yourself had been. Those are essentially the transformationsin American life that Stephen Smith and others were vaunting in late1921 at the meeting of the American Public Health Association.

So the question is, how did the public come to know the good news? Wetoday know that ordinary people in 1921 had a solid foundation for the beliefthat they themselves stood a good chance of living to a substantially more advancedage than their parents and grandparents, and for the belief that theirchildren were much more likely than children of previous generations to surviveto adulthood. But what were the sources of these beliefs in that era?

There appear to be three principal sources. One is vital statistics producedin the era we're discussing. The second is the public health campaign, which I'lldescribe in the next chapter. The third is path-breaking scientific research inthe early twentieth century that promised either to extend human life for morepeople to conventionally recognized limits or to extend human life generallyspeaking beyond all conventionally recognized limits. I'll describe this, too, inthe next chapter.