National Nurses United

2 www.NationalNursesUnited.org History: Founders of Public Health, Sanitation Movement, and Infection Prevention The significance of environmental conditions in infection prevention was recognized relatively late in the history of organized health care. Formal acknowledgement of this concept in the budding field of health science marked the beginning of public health as we know it today. Historical records point to the years between 1854 and the late 1880's as a key period for the development of infection prevention and public health. In 1854, a cholera outbreak was devastating London. A physician named John Snow used epidemiological mapping of the residences of cholera victims to identify potential common sources. Snow discovered that the source of the outbreak was a particular city water pump on Broad Street that was used by many residents of the hardest hit neighborhood. With this data, he promoted the idea that disease could be prevented through envi- ronmental modification. If the pump associated with the outbreak was decommissioned, he theorized, the cholera outbreak would in turn be extinguished. Removing the handle of the water pump did indeed help end the out- break. 1854 is the same year that the founder of modern nurs- ing, Florence Nightingale, assumed her position as a lead nurse in a British Army hospital during the Crimean war. While in this position, Nightingale collected and eval- uated statistical data that demonstrated an association between the unsanitary conditions in the hospital and the high mortality rates of patients. Soldiers were brought to the hospital to be treated for war-related injuries yet died en masse of diarrheal infections and sepsis. Once she assessed that the causes of disease were associated with sanitary conditions of the hospital, Nightingale imple- mented changes in hospital policies and practices that improved these conditions accordingly. The incidence of deadly infection dramatically decreased as a result. In 1859, Nightingale published her first book, Notes on Nursing: What it is and What it is Not. The work drew upon her experience in Crimea and promoted her Environmental Theory. This theory stated that healing and disease share a correlative relationship with hygiene and sanitation practices, and it is the nurse's primary role to ensure that disease is prevented and health promoted by conscientiously managing the patient environment. Notably, Nightingale's publication attributes improved health outcomes to physical alterations in hospitals, such as improving ventilation and waste management practices. In the preface of Notes, she also acknowledges that sociopolitical and engineering aspects of the healing environment are just as influential to human health. She remarks, "Bad sanitary, bad architectural, and bad administrative arrangements often make it impossible to nurse." This work is considered to be the foundation of modern nursing practice and still resonates in the essence of nursing today. Snow and Nightingale's theories regarding sanitation and hygiene were considered radical in a time where trusted healers thought disease to be an unpreventable fact of life or to originate from "bad air" or divine punishment for immorality. These world-changing ideas provided the foundation for the fields of public health and preventa- tive medicine. In the decades following the hygiene and sanitation movement, scientists such as Luis Pasteur, Joseph Lister and Robert Koch developed germ theory. Germ Theory explained what Snow and Nightingale had concluded— that communicable diseases are transmitted by micro- organisms and manifest at the microscopic level. The rationale for hand sanitization, and soon after antiseptic surgical technique, began to explain disease transmission and manifestation at the human host level before human immunology was understood. These discoveries saved many lives in the pre-antibiotic era, which ended with Alexander Fleming's discovery of penicillin in the 1940s. The discovery and mastery of antibiotics and vaccines in the mid 20th century led to massive declines in mor- bidity and mortality from infectious diseases around the world. Subsequently, research and health care provision focused more and more heavily on medical treatment and vaccination programs, leaving aside the preventative sanitation practices and other measures that Snow and Nightingale had found so impactful. For a short while, much of society felt that medicine had mastered infec- tious diseases, despite early predictions of antimicrobial drug shortcomings and unintended negative effects. Until the end of the 20th century, widespread antimi- crobial use and vaccine distribution were considered by many to be the most effective and cost-efficient ways to reduce infectious disease burden. Though personal hygiene, sanitation, and decontamination remain important concepts in modern medicine, considerably more emphasis, money, and energy has been spent in research and development of pharmaceuticals than on these preventative measures. We see evidence today, in emerging and re-emerging diseases, ongoing epidemics despite medication availability, factors stunting develop- ment of new classes of antimicrobial drugs, acceleration of disease transmission due to globalization and climate change, and with the shadow of a post-antibiotic era looming larger, that the neglect of environmental control and infection prevention measures comes with a cost. Antibiotic resistance rates have been rapidly increasing worldwide. The U.S. Centers for Disease Control and Pre- vention (CDC) and World Health Organization (WHO) have both deemed antibiotic resistance a pressing crisis that could have "catastrophic consequences" for health. Most health care-acquired infections in the U.S. are antibiotic resistant and result in at least 99,000 deaths annually.

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