While home visiting family for Christmas this year, my husband discovered a gem while poking through one of the old glass-lined book cases which were original to the house. “Look at this!” he exclaimed, and handed me a two-inch-thick volume covered in blue-faded linen. Imagine my surprise as I noted the title: “How to Live: Rules for Healthful Living Based on Modern Science” by Irving Fisher and Eugene Lyman Fisk, MD. The copyright was 1916, yet aside from the now-defunct phrasing, the initial topics discussed and premise as presented in the book's forward could have been written in a modern medical journal.
The book was written during a time of changing morbidity and mortality in the United States. With the advent of the industrial revolution, the 19th century saw a shift in the population from country to city. Several waves of immigration likewise added to the overcrowding of U.S. cities that lacked the infrastructure to provide proper housing, safe public water supplies and waste-disposal systems. These conditions resulted in repeated outbreaks of cholera, dysentery, TB, typhoid fever, influenza, yellow fever and malaria. In 1900, the top three causes of death were pneumonia, TB and diarrheal illness, however the incidence of a number of infectious diseases were already in the process of decline thanks to local, state and federal efforts toward improvements in sanitation and hygiene, as well as childhood vaccination programs.
It was in this setting that the Progressive Movement, a socio-political movement of personal and societal improvement, was perhaps at its height. It was also the setting which would couple an economist and social campaigner with a physician to create a handbook which would outline opportunities to practice preventive medicine and guide health recommendations for athletes, universities and corporations of the time period.
In the forward to “How to Live,” former President William Howard Taft, a then-business associate of the authors, states “While it is true that to the public mind there is a more lurid and spectacular menace in such diseases as small-pox, yellow fever and plague, medical men and public health workers are beginning to realize that, with the warfare against such maladies well organized, it is now time to give attention to the heavy loss from lowered physical efficiency and chronic, preventable disease, a loss exceeding in magnitude that sustained from the more widely feared communicable diseases."
This brings us to 2016 when, in contrast to 1916, the top three causes of death were heart disease, cancer and chronic lower respiratory diseases. Chronic diseases are responsible for 7 in 10 deaths among Americans each year, and the vast majority of our health care costs.
The book goes on to address many venues which avail themselves for intervention. The authors discuss the environment which surrounds the individual and how that interaction affects health. For example, there are chapters on air, food, poisons, activity (rest/exercise) and general hygiene. There is particular recommendation against tobacco as a chief contaminant of inhaled air. Generally speaking, many of the recommendations contained within the book's pages mirror our current recommendations of avoiding tobacco, eating in moderate amounts and choosing minimally-processed foods, as well as moderating alcohol intake.
Not all the contained recommendations would find support in the 21st century, though. I have never once counseled a patient to brush their teeth in the nude to promote air circulation around the body, nor exercise similarly clad -- or unclad, as the case may be. In particular, some beliefs which gained acceptance during the Progressive Movement and supported by the authors would be considered exclusionary at best and racist at worst. It was with dismay that I saw the last chapter is one dedicated to Eugenics and the desire for select breeding to improve the “vitality” of the population.
What I learned from this retrospective is that issues affecting health have long been recognized as the result of complex, interconnected factors ranging from individual to societal levels. This is not a new concept and here we are 100 years later with different perspectives, interventions and delivery systems, yet still grappling with the same issues. The journey continues, now augmented by new vision and diverse representation. How will our next chapter be written?
Donna Tuccero is associate program director of the Duke Family Medicine Residency Program. Email donna.tuccero@dm.duke.edu with questions.
Editor’s note: A member of the Duke Family Medicine Residency Program leadership team guest blogs every month. Blogs represent the opinion of the author, not the Duke Family Medicine Residency Program, the Department of Community and Family Medicine or Duke University.