
Sanitation conquered disease long before vaccines or antibiotics - jasoncrawford
https://rootsofprogress.org/draining-the-swamp
======
bbeckerman
I always love bringing up [Ignaz
Semmelweiss]([https://wikipedia.org/wiki/Ignaz_Semmelweis](https://wikipedia.org/wiki/Ignaz_Semmelweis)),
the Hungarian physician who advocated for hand washing before germ theory was
established, after observing that pregnant mothers were more likely to become
infected when they were handled by doctors than by midwives. His
fastidiousness made him unpopular though and he was ridiculed as a stickler by
his fellow staff. When he refused to drop this theory, his colleagues
convinced his wife to commit him to a mental hospital, where he died due to
infection from an unsanitary operation.

~~~
firethief
His story gives me hope... Sometimes, it _is_ everyone else who's crazy.

~~~
hatsuseno
If by crazy you mean steadfastly clinging to the status quo due to human
behavior at scale still being programmed by our herd mentality, then yes,
everyone else is crazy. The only hope I derive from it is that there's a
chance we'll overcome that nature at some point. But I'm not that optimistic
about our chances.

------
gumby
Prevention vs treatment, indeed! I anticipate that as antibiotics become less
effective that table manners and food handling hygiene will have a revival.
For example we’ll go back to proper butter knives rather than everyone using
their bread knife in the communal butter dish.

~~~
dfsegoat
Related: First bacteriophage therapies are entering human trials and gaining
steam.

Antibiotics will likely become obsolete when you can target bacteria without
the bystander side effects they have on our cells. They are the perfect
antibacterial smart weapon really.

[https://medcitynews.com/2020/01/adaptive-phage-
gets-10-from-...](https://medcitynews.com/2020/01/adaptive-phage-gets-10-from-
dod-for-antibacterial-phage-therapies/)

~~~
bsder
_IF_ you can identify your specific bacterium and the phage that kills it
before the disease kills you.

Antibiotics will continue to be effective precisely _because_ they are broad
spectrum. A doctor can hit you with an antibiotic before they know exactly
what you have.

I am always happy to see new tools in medicine. However, I suspect phages are
most going to be used initially in persistent, chronic, antibiotic resistant
infections where everything else has failed.

~~~
dfsegoat
You are absolutely right, I failed to note that the increased specificity
means you lose the broad spectrum effect.

I still think in the cases you describe that they could stand to replace e.g.
Vancomycin - BEFORE that fails. The side effect profile for that drug is
horrendous: GI bleed, neuro/sensory damage, liver damage, retinal damage etc..

It seems like a blend of phages with slightly varied activity could also
reproduce the broad spectrum effect, and CRISPR is going to make that pretty
easy I think.

~~~
lxmorj
One approach might be broad spectrum antibiotics when urgent and specific
bacteria undetermined. In parallel, cultures to isolate the problem, then
apply the specific phage to finish the job. Seems like this would prevent or
at least hugely reduce antibiotic resistance from increasing.

------
kstenerud
Sanitation is good, but too much sanitation is not so good. We're only just
beginning to understand our relationship with bacteria, virii and micro-
organisms. While sanitation was a great boon to reducing deadly pathogens,
we're now in the process of swinging the pendulum too far, using antibacterial
products that should really only be used in hospitals, keeping children out of
the dirt (with growing indications that this leads to allergies), and
generally living in fear of anything not institutional-clean. Our immune
systems are beginning to atrophy from lack of "exercise".

Have you ever wondered why lovers touch their lips together, effectively
sharing the bacterial brew in their mouths with another? I can guarantee that
such evolved behavior is not simply coincidental.

~~~
Valgrim
I prefer this much intimate/disgusting/sexier explanation:

"Kissing in humans is postulated to have evolved from the direct mouth-to-
mouth regurgitation of food (kiss-feeding) from parent to offspring or male to
female (courtship feeding) and has been observed in numerous mammals.[59] The
similarity in the methods between kiss-feeding and deep human kisses (e.g.
French kiss) are quite pronounced; in the former, the tongue is used to push
food from the mouth of the mother to the child with the child receiving both
the mother's food and tongue in sucking movements, and the latter is the same
but forgoes the premasticated food. In fact, through observations across
various species and cultures, it can be confirmed that the act of kissing and
premastication has most likely evolved from the similar relationship-based
feeding behaviours."

[https://en.wikipedia.org/wiki/Kiss#Biology_and_evolution](https://en.wikipedia.org/wiki/Kiss#Biology_and_evolution)

------
dredmorbius
A fantastic graphical representation of this is "The Conquest of Pestilence in
New York City", produced by the Department of Health & Mental Hygine, showing
progress from 1800 to 2002:

[http://1.bp.blogspot.com/-uTWEATUzgxk/TXQoTibILtI/AAAAAAAAAA...](http://1.bp.blogspot.com/-uTWEATUzgxk/TXQoTibILtI/AAAAAAAAAAM/eyirotYDmXo/s1600/2004_01_healthstat.jpg)

This tracks _mortality_ (rather than life expectency), but shows clearly the
tremendous progress made from 1850, with a peak mortality rate approaching 50
deaths per thousand peak (from a baseline of ~30 - 40 per mille) to about
12/mm in 1920, and the present rate of about 6/mm.

From 1950-1970, and for a briefer period in the 1980s, progress was _reversed_
with mortality increasing. There's actually been an impressive (though small
realtive to 19th century improvements) reduction since 1990.

Looking at that chart, realise that virtually all the improvement through
about 1950 precedes _most_ of what we consider to be modern medicine: advanced
cancer treatments, antibiotics, most vaccines, transplant surgeries, genetic
therapy, pacemakers, and more. The progress instead comes mostly through
increased sanitation and hygiene, as well as reduced environmental
contaminations and hazards, though it includes both antisceptics and
anesthesia.

We've been paying a _tremendous_ amount in medical advances for a very slight
improvement in outcomes.

~~~
tomarr
Wouldn't you really need a log scale or further interrogation to make that
claim? To me it seems mortality dropped about 40% in last 50 years which is
quite substantial.

~~~
dredmorbius
Absolute vs relative improvements, vs cost of attainment, are two different
questions. The largest overall reductions, and increases in life expectancy,
come from very basic interventions.

The problem w/ efficiency measures generally is that there's progress to some
theoretical maximum, and it comes with diminishing returns.

Breaking down life expectancy gains by demographics, the've moved more for men
than women (since 1920, far more the reverse before), largely due to workplace
risk, violence, and military service), and the poor/minorities rather than
wealthy/majority (access, preventive care, environment, violence, stress).

The upper bound's moved little. Exceptional longevity is profoundly correlated
geographically with poor recordkeeping.

See:

The difference in gains by age, here for England and Wales beginning 1700,
through2013, w/ all ages from 1850:
[https://ourworldindata.org/uploads/2013/05/Life-
expectancy-b...](https://ourworldindata.org/uploads/2013/05/Life-expectancy-
by-age-in-the-UK-1700-to-2013.png)

Note that whilst at-birth increases (1850) from about 40 to 80, a 40 year old
gains only 67 - 82 or so (15 years). It's early-life mortality that's changed
most.

Similar US trends: [https://lh5.googleusercontent.com/qtYQp1x-ZF9iXc-
zVh7Kg2xJBX...](https://lh5.googleusercontent.com/qtYQp1x-ZF9iXc-
zVh7Kg2xJBXGZE3Uzb0l3wEKBiYqrKDU6tRCkZqdoz4lyiwoU5JUUDXyJc0wrsQexprLMzzhdA74rj_m1guuEHvzCnMai2Tn7gQqVn7vktQ)

By gender/race, 1970-2010, US:
[https://www.cdc.gov/nchs/images/databriefs/101-150/db125_fig...](https://www.cdc.gov/nchs/images/databriefs/101-150/db125_fig1.png)

An unusual presentation, showing mortality by age in 1950 vs. 2015. Note the
double factor: reduced infant/early childhood mortality, and somewhat reduced
adult mortality:
[https://siepr.stanford.edu/sites/default/files/styles/page-w...](https://siepr.stanford.edu/sites/default/files/styles/page-
width/public/fuchs-fig1.png?itok=3P-fXpH-)

Discussion:
[http://conversableeconomist.blogspot.com/2018/04/inequality-...](http://conversableeconomist.blogspot.com/2018/04/inequality-
in-us-life-expectancy.html)

Geographic distribution:
[https://localtvwtkr.files.wordpress.com/2017/05/s078658261-3...](https://localtvwtkr.files.wordpress.com/2017/05/s078658261-300.jpg?quality=85&strip=all&strip=all)

There are also hidden costs: mortality is selective pressure, and we've lifted
much of that for about 5 generations. I have concerns. (I'll also note this
generally impacts the wealthy more than poor, within _and_ between countries.)

------
taneq
There’s degrees of “conquered”. Seat belts ‘conquered’ motor vehicle trauma
before airbags did. Each new thing helps fill in the gaps left by the already-
existing things.

~~~
Spooky23
Yes and no.

I'll use an anecdote from my personal life. If you by some misfortune end up
in the hospital for an extended time, you have an ever-increasing risk of
being infected by drug-resistant bacteria. This happened to a loved one, and
it's a tragic thing that will significantly reduce that loved one's lifespan.

Why does this happen? Antibiotics and filth. Antibiotics enable the awful
management practices of this particular hospital. There aren't enough aides,
the rooms and equipment are filthy, even the lunchroom is dirty. I sat
visiting for weeks at a time a different times of day and night and _never_
saw a mop, or a cleaning of surfaces that were soiled. Your average McDonald's
kitchen is cleaner.

The economics of insurance are such that the consequences of these infections
don't damage the bottom line.

For some people, airbags can discourage seatbelt use in the same way.

~~~
scarejunba
Was this in America? Which hospital was it?

~~~
Spooky23
I won’t call out examples because they are common.

Bring up one of the medical quality websites (the feds publish this as well)
and you’ll find plenty of examples in 3 star or lower hospitals. Most
hospitals in NYC are like this.

------
hyfgfh
I'm actually anti-sanitation, we mud people believe it causes allergies!

~~~
oldgradstudent
There's a difference between mud and that other brown stuff.

~~~
socceroos
Unscheduled fecal transplant

------
not2b
Note that the title chosen does not match the title of the article, which is
"Draining the Swamp".

~~~
dang
Obviously we can't use that title or the thread will lose its mind. Since the
submitter's profile indicates that he is the author of the article, or at
least the proprietor of the site, I think it's fair to stick with what he
posted.

~~~
jasoncrawford
The HTML title is deliberately different from the header. The header is a
catchy/literary title; the HTML title is more descriptive of what you'll get
if you click through. So, all is as intended. Thanks.

------
topspin
rootsofprogress.org? Funded by "Emergent Ventures," some affiliate of Marginal
Revolution University... Whose narrative am I looking at here?

Honest question. Anyone know?

~~~
brownbat
Popular economists Tyler Cowen and Alex Tabarrok maybe. And people can agree
or disagree with them on a variety of issues.

But describing "sanitation improves health outcomes" as just somebody's
"narrative" feels a bit like responding to "The sky is blue," by asking "Yes,
but who benefits?"

Sometimes an idea is just an idea.

~~~
manicdee
Sometimes a poorly communicated idea turns into an anti-vax movement. Other
times a poorly communicated idea is used as cover for malfeasance, such as
“war on drugs” which is actually about oppressing an underclass.

~~~
catalogia
The article isn't poorly communicated. It says that vaccines are "extremely
effective", backs that up with citations and numbers, and lauds the scientific
revolution.

------
hprotagonist
[https://observablehq.com/@mbostock/the-impact-of-
vaccines](https://observablehq.com/@mbostock/the-impact-of-vaccines)

That figure is real hard to refute, or square with any other cause of
reduction of measles infections except vaccination.

~~~
DanAndersen
That's true -- though the figure you're linking focuses specifically on
measles cases rather than overall mortality, which is what the OP article is
focusing on.

(as an aside, it's really weird that the (first few) comments here on HN seem
a little adversarial; I wonder if maybe some people looked at the headline
only and assumed it was attempting some sort of anti-vax argument, which the
article isn't doing at all.)

~~~
jasoncrawford
So there is something odd going on with measles. I haven't dug into the data,
but from a couple of data points I've seen, it seems that measles _mortality_
was declining for a long time even while measles _cases_ were not. That is,
there was a decline in the case-fatality rate, without a decline in cases. The
disease was still around but getting less deadly. Then the vaccine actually
reduced the number of cases.

So what was reducing the case-fatality rate? I don't know, but it might have
been nutrition. There's evidence at least that Vitamin A makes measles less
severe/deadly.

~~~
oldgradstudent
> So what was reducing the case-fatality rate?

Sanitation, antibiotics, oral rehydration therapy, machine ventilation,
nutrition, and so on.

It's not the measles itself that was the cause of most fatalities, it was the
pneumonia, diahrrea, and other opportunistic infections that come with it.

------
qwerty456127
People should not settle this dense in the first place. I hope more people are
going to rural areas once StarLink an competitors deploy universal Internet
connection coverage.

~~~
scarejunba
That will be acceptable if we price in carbon externalities into things so
that people who live rurally pay the costs they impose on the world.

~~~
catalogia
There's more to it than just carbon. It's certainly possible to have a carbon
neutral lifestyle in rural areas, however that doesn't account for the habitat
destruction innate to low density rural development.

~~~
zdragnar
Low density rural development can easily fit into existing habitat; I live on
5 acres of forest with maybe 1/2 acre set aside for house, lawn and garden
plots. Aside from gasoline for vehicles, my house is nearly self sufficient
resource-wise. The biggest destruction of habitat is massive fields for
farming.

Of course, when a "developer" comes along, buys up an entire field or three,
and builds a mini-suburban style neighborhood in the middle of nowhere, the
habitat was already lost, but it will do absolutely no favors to any wildlife
that might try to come back... not to mention the absurdity of living on tiny
half to 1 acre lots in a division miles from the nearest village.

~~~
scarejunba
In which case, I suppose pricing for restoration elsewhere will be low cost to
you and high cost to the developer. As it should be. It's all just a matter of
putting the externalities back in.

