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Channel Posts
SANITARIANS FULLY RECOGNISED THE IMPORTANCE OF NUTRITION BUT DID NOT BELIEVE THAT THE GOVERNMENT HAD ANY ROLE IN THE MATTER (apart from food safety)
Dr Southwood Smith, an experienced doctor, knew fully well about the crucial importance of nutrition to the immune system ("state of susceptibility"). He had a full chapter on nutrition in his 1847 book, "The Philosophy of Health". https://www.gutenberg.org/files/60937/60937-h/60937-h.htm. In his 1858 lecture, Smith made it VERY CLEAR that nutrition had played a huge role in increased life expectancy: "Agriculture took a surprising start, multiplying a hundredfold the production of fresh vegetable food, and increasing, perhaps, in a still more remarkable degree, the amount of fresh animal food, by the extension of the comparatively new art of collecting, storing, and preserving fodder for cattle in winter." https://www.google.com.au/books/edition/Transactions_of_the_National_Association/Nv9JAAAAMAAJ?hl=en&gbpv=0
But the Sanitarians did not believe that the government had any role in nutrition.
Even on housing, they merely noted its importance: apart from some regulations on quality of housing, they did not want the government to do anything about the issue.
In other words, the mental model of the Sanitarians was as complete as possible, but they LIMITED government involvement only to a few things.
| 2 |  No text... | 3 |
| 3 |  Although I've come across the housing issue earlier in the writings of the Sanitarians, I did not explicitly link it with the Sanitarians until I read Southwood Smith's specific admonition against assuming that sewerage and clean water would fix epidemics.
Even though they did not understand the value of isolation of the sick, the seemed to intuitively understand the need for people to have some distance from each other (improved isolation) - which was pivotal for the reduction of diseases like smallpox and pertussis.
They were wrong to not also include nutrition as a key pillar. Thus, measles CAN'T be reduced merely by better housing. Isolation CAN'T work with it (nor with diseases like influenza). It requires nutrition to get rid of measles.
Note: the image of the model house is from Chadwick's 1842 report (page 397) https://archive.org/details/b21307313/page/396/mode/2up | 4 |
| 4 |  No text... | 3 |
| 5 | CORRECTING MY MISUNDERSTANDING ABOUT THE SANITARIANS:
Southwood Smith's work on epidemics is actually quite good. He insisted that sewerage and clean water supply would NOT eliminate all diseases. Instead, he wanted better housing and reduced over-crowding, as well - thus dealing also with airborne diseases.
"the most perfect drainage, combined with the most ample supply of water, will not alone secure for the public health all which it is practicable to accomplish. There must also be provision for the better construction of the houses of the poor; for the prevention of overcrowding; for street ventilation and cleansing, and for the exclusion from the neighbourhood of human dwellings of filth-creating animals and of noxious trades. When all this is done, as it might be done, and as it would be done were there a general perception of the crying evils it would remedy, Epidemics would disappear, the more formidable of them immediately, and all of them, I believe, in the end." (https://www.gutenberg.org/files/61029/61029-h/61029-h.htm)
OVERCROWDING was the key word in relation to airborne diseases (and this word had arisen from the time of Charles Maclean).
Thus, Chadwick and Southwood Smith were firm proponents of housing reform. Chadwick’s 1842 report included a “statement of the requisites of cottage architecture” - and they were deeply involved in a project to build model houses.
In other words, while a sewerage system (and clean streets) was the main focus of the two main Sanitarians, they had two other legs of reform: clean water and housing. (Note: I've shown at great length how John Snow came late to the table - the private sector and Chadwick had already started - and implemented - water reforms.)
I'll now need to integrate these three ideas in the PH textbook - as being derived from the Sanitarians.
But there's ONE MORE THING! Smith clearly discussed host factors - long before Rene Dubos. He hypothesised about an IMMUNE SYSTEM ("state of susceptibility") long before others came to the scene.
https://wellcomecollection.org/works/ejhynsjj/items?canvas=13 | 3 |
| 6 |  One of the blunders by public health founders was the belief that sanitation would cure almost all diseases.
In reality, sanitation (and clean water) could ONLY reduce water borne diseases. It could have no possible effect on airborne infectious diseases - which were ONLY amenable to nutrition (and isolation in a few cases like smallpox and pertussis).
The CBA for sanitation and clean water almost certainly over-counted expected benefits.
https://chatgpt.com/share/6a9d3936-0c20-83ec-8acb-5d45c3a63d1f | 14 |
| 7 |  One way to show the DRAMATIC increase in nutritional status in England after 1900 is to visualise nutritional sufficiency as a conical bucket.
The portion B of the bucket (from 1700 to 1900) holds a volume of nutrition not too different to the entire volume of nutrition in portion A.
In addition, specific nutrients like Vitamin A were found mainly after 1910.
By merely "filling up" total calories by 10% and vitamins by perhaps 50% after 1900, a dramatic upsurge in mortality ensued. Of course, better housing (people were much richer by 1940, than in 1900) added to the effect.
Sanitation could not possibly have played a very prominent role since it only affected a few of the many infectious diseases. Diseases not carried via water (such as TB, measles, scarlet fever, smallpox) are largely immune to sanitary improvements. | 12 |
| 8 | In this context, it is important to note that internationally, in dire emergencies, the MINIMUM food requirement for a human is set at 2,100 calories.
https://iris.who.int/server/api/core/bitstreams/c6f336b9-0c36-4431-80fd-840c05344817/content
This means that with the average British citizen consuming 3,300 calories in ~1940, they had achieved SUBSTANTIAL FOOD FOR EVERYONE.
Most importantly for my thesis, pasteurization of milk had made this MOST VITAL FOOD widely available to children (mainly by making it cheap and affordable).
Complete nutritional sufficiency was probably achieved in England only by ~1960, but even by 1940, food was sufficient to contribute significantly to life expectancy improvements.
As I've also noted, photographs of children and of the poor show a sharp decline in dire poverty by 1940.
We know that VIRTUALLY NO MEDICAL ADVANCE had occurred prior to 1940, therefore almost the entire contribution to life expectancy till that time can be attributed to food (and improved housing and clothing/ shoes) - and from 1890, a portion of it to sanitation and water. | 12 |
| 9 |  No text... | 12 |
| 10 |  I do need to prove my thesis that nutritional sufficiency dramatically increased in England in the first half of the 20th century.
Here are two charts, taken from a 2010 paper and a 1936 book:
https://nber.org/system/files/working_papers/w15875/w15875.pdf
and
https://fao.org/fileadmin/templates/library/docs/613_OR7.pdf
My thesis has two parts (a) total calorific intake in England increased sharply, (b) nutrient deficiencies were dramatically reduced (via pasteurized milk).
I think it is quite self-evident that a society which could eat 2230 calories per day in 1700 and 3250 calories by 1934 (i.e. 46% more!) PLUS had high quality milk for children was going to have very low child mortality and hence overall mortality.
THIS INCREASE IN FOOD + ITS QUALITY, IS WHAT EXPLAINS OVER 50% OF THE INCREASE IN LIFE EXPECTANCY IN THE WEST. Just food. | 11 |
| 11 |  No text... | 15 |
| 12 | To date I've not tried to accurately fit real life expectancy data with the main causes, merely used tables and arithmetical calculations. This is my first attempt to do so, for the UK.
This chart broadly validates other calculations made in the book, but it seems to me that there is a bigger component for "everything else".
Of course, these lines are purely subjective, based on information that's inside my head - and others might make slightly different lines based on their own understandings.
EXPLANATION FOR THE LARGE BUMP IN NUTRITION from 1910: I've identified a particularly large bump in nutrition in early 20th century - since photographic and other evidence suggests significant elimination of dire poverty in the UK during this period (ability to buy food, healthier food such as pasteurised milk, and mass-scale production of food). That's the period when diseases like measles were virtually entirely eliminated, and TB etc. brought under great control. (Housing played a key role in TB and many other infectious diseases.)
VIRTUALLY NO MEDICAL CONTRIBUTION PRE-1900:
There is virtually no positive medical contribution before 1900 (killings probably exceeded lives saved), and a small increase since the 1940s with antibiotics and vaccines; then it picks up pace, but by now it is stagnating: it is virtually impossible at this stage to further increase life expectancy with medical advance. | 14 |
| 13 |  I'd amend to: Not attempting to punish evil is equivalent to authorizing it.
The problem is that the outcome "to punish" is VERY UNLIKELY IN THIS ULTRA-EVIL WORLD. All one can do is to try. 99.99% of the corrupt thugs that rule this world will escape any attempts to punish them. That doesn't mean one should not try. | 17 |
| 14 | The concluding chapter on life expectancy is the opportunity to summarise key findings from the book about various factors that determine human health.
The estimates continue to be rubbery - because it is close to impossible to perfectly unpack the causes of long term changes in mortality. However, these estimates are probably in the right ballpark. We know, for instance, that almost all improvements in infectious disease occurred long before "medical advance" (e.g. vaccines), and in fact, vaccines hugely delayed the eradication of smallpox.
We also know that there has been very little improvement in mortality rates for non-infectious diseases. Medical science is fighting an uphill battle in the West - having reached severely diminishing returns.
The ultimate resource in all this has been human inventiveness. Political and economic freedom enabled people to challenge authority, invent new things, and create new resources and markets. Those ideas and inventions (not medical) contributed to almost all improvements in life expectancy. Medical science did a bit as well, but at least till the end of the 19th century, it killed more than it saved. | 20 |
| 15 |  The concluding chapter on life expectancy is the opportunity to summarise key findings from the book about various factors that determine human health.
The estimates continue to be rubbery - because it is close to impossible to perfectly unpack the causes of long term changes in mortality. However, these estimates are probably in the right ballpark. We know, for instance, that almost all improvements in infectious disease occurred long before "medical advance" (e.g. vaccines), and in fact, vaccines hugely delayed the eradication of smallpox.
We also know that there has been very little improvement in mortality rates for non-infectious diseases. Medical science is fighting an uphill battle in the West - having reached severely diminishing returns.
The ultimate resource in all this has been human inventiveness. Political and economic freedom enabled people to challenge authority, invent new things, and create new resources and markets. Those ideas and inventions (not medical) contributed to almost all impro | 19 |
| 16 |  I've finished a preliminary cut of chapter 36 and will now move to ch.37 (in which I will conclude the discussion on the drivers of life expectancy). https://sanjeev.sabhlokcity.com/Misc/Textbook-SPH-draft_Part2.pdf | 20 |
| 17 |  Here's a further refinement of the NTD data problem.
The NTD count is hugely problematic. They try to add up the delivered NTDs and stillbirths. But an unknown number of ill-formed babies ARE NATURALLY ABORTED.
And since ultrasound became more widely available, ill-formed babies are consciously aborted - but these are not always added up.
In other words, even to know whether NTDs are diminishing from the use of folic acid, is close to impossible. A lot of guesswork prevails in this area of "science". | 19 |
| 18 |  I HAVE A LAW, THAT CAN BE CALLED SABHLOK'S LAW:
"freedom comes closest to being measured objectively through its effect on the physical flow of people from a lower to higher levels of freedom. We can predict this flow with almost the same precision with which we predict the flow of water which flows, instead, from a higher to a lower level."
NO COUNTRY HAS EVER BREACHED THIS LAW. Nor will.
Around 250-300,000 Chinese FLEE CHINA each year. Around 2-6 MILLION people immigrate into USA each year.
Q.E.D.
China is a HELL HOLE. (And of course, India).
https://www.macrotrends.net/global-metrics/countries/chn/china/net-migration | 20 |
| 19 |  Chapter 36 is turning out to be much more work than I had initially thought.
Much ado about nothing, is what it is. The net effect of fortification (voluntary or even mandatory) on life expectancy is SO MINOR it is literally impossible to count it (maybe a few weeks + or -). But there is a HUGE industry (doctors, chemists, public health "experts", health economists) who earn their living by analysing fortification. Almost all of them funded by taxpayers.
Even as my main conclusion remains unchanged (i.e. VERY LITTLE EFFECT ON LIFE EXPECTANCY), I need to outline the topic sufficiently in the textbook.
Topics with a red line are under process, the ones in green are mostly done. ... I do want to finish this chapter and move on within the next day or two.
https://sanjeev.sabhlokcity.com/Misc/Textbook-SPH-draft_Part2.pdf | 18 |
| 20 |  Bentham's focus was unambiguous: on the SAFETY of food. Wiley went further, by adding a "purity" test - something possible only in natural foods.
While pure food is safe, not all safe food needs to be "pure". To that extent Wiley was over-ruled by American legislators. I don't think we will ever go back to a Pure Food Act. Innovations in food can't be stopped in the name of safety.
What we need is a system by which SAFETY is paramount - and that is the main reason to oppose mandatory fortification, which can be unsafe for some. | 16 |
