Lower death rates from diseases such as cholera, typhoid, and tuberculosis were only partially the consequence of bacteriologically inspired state preventive measures, and the disease burden from acute infectious disease began to decline rapidly. The provision of clean, properly filtered water supplies and effective sewage systems reflected growing municipal pride and the middle-class desire for cleanliness. It made epidemics such as the outbreak of cholera that killed over eight thousand people in Hamburg, Germany, in little over six weeks in the autumn of 1892 increasingly rare. Just as important were improvements in personal hygiene, which again reflected general social trends as well as the growing "medicalization" of society in western Europe and the United States. Such developments reinforced the stigmatization of poor and oppressed minorities as carriers of infection, since they were now blamed for ignoring official exhortations to maintain high standards of cleanliness, even though their living conditions and personal circumstances frequently made it difficult for them to do so. Particular attention was focused on working-class women, who were held responsible by official and medical opinion for any lack of hygiene in the home (Evans, 1987).
The development of tuberculin by Koch in 1890 made possible the compulsory screening of populations even for asymptomatic tuberculosis. This was increasingly implemented after 1900, in conjunction with the forcible removal of carriers to sanatoria, although this was more effective in isolating people than in curing them. Educational measures also helped reduce the spread of the disease. The development and compulsory administration in many countries of a preventive vaccine against tuberculosis from the 1920s aroused resistance among the medical community, not least because by creating a positive tuberculin reaction in noncarriers, it made it impossible to detect those who truly had the disease, except where symptoms were obvious. These measures had some effect in reducing the impact of the disease. However, although the precise causes of the retreat of tuberculosis remain a matter of controversy among historians, the long-term decline of the disease from the middle of the nineteenth century was probably more the result of improvements in housing, hygiene, environmental sanitation, and living standards than of direct medical intervention. The introduction of antibiotics such as streptomycin after World War II proved effective in reducing to insignificant levels mortality from a disease that had been the most frequent cause of death or disability among Americans aged fifteen to forty-five (Dubos and Dubos).
Similarly, official responses to syphilis centered, especially in Europe, on the forcible confinement of prostitutes to state-licensed brothels or locked hospital wards, where they were subjected to compulsory medical examination. Before World War I, New York, California, and other states had introduced compulsory reporting of cases of venereal disease, and official concern for the health of U.S. troops led to the jailing of prostitutes. Measures such as these had no discernible effect on infection rates, which rose sharply during the war. They also represented a serious restriction on the civil liberties of an already stigmatized group of women, while the men who were their customers, and equally active in the sexual transmission of disease, were regarded as irresponsible at worst, and were not subjected to similar measures. The development of Salvarsan (arsphenamine) by Paul Ehrlich in 1910 introduced the possibility of an effective treatment for syphilis. But here again there was resistance, both within the medical community and from outside, from those who considered that an increase in sexual promiscuity would be a result. This view became even more widespread following the use of penicillin on a large scale during World War II (Brandt).
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