Warren Winkelstein

Florence Nightingale : Founder of Modern Nursing and Hospital Epidemiology

Florence Nightingale is revered as the founder of modern nursing. Her substantial contributions to health statistics are less well known. She first gained fame by leading a team of 38 nurses to staff an overseas hospital of the British army during the Crimean War. Newspaper reports of unsanitary conditions at the military hospital had aroused the public, and the Secretary of War responded by appointing a team of nurses to address the situation. The Secretary was a friend of Nightingale’s and knew her leadership skills. Nightingale and her team arrived in Turkey in November 1854. They found hospital conditions were far worse than reported. The wards were vastly overcrowded, patients were covered with rags soiled with dried blood and excrement, the water supply was contaminated, and the food inedible. Sewage discharged onto floors of wards and dead animals rotted in the courtyards. According to Nightingale, the hospital case-fatality rate during the first months after her arrival was 32%. Although Nightingale did not accept the concept of bacterial infection, she deplored crowding and unsanitary conditions. She put her nurses to work sanitizing the wards and bathing and clothing patients. Nightingale addressed the more basic problems of providing decent food and water, ventilating the wards, and curbing rampant corruption that was decimating medical supplies. She had to overcome an inept and hostile military bureaucracy, which she did in part by paying for remediation from private sources, including her own funds. She also kept careful statistics. Within 6 months, the hospital case fatality had dropped to 2%. When Nightingale returned to London 3 years later, she was a national hero. However, within a few more years she had become an invalid herself (suffering at age 40 from what may have been chronic fatigue syndrome). Although she lived as a recluse for the next 50 years, she continued to exert substantial influence on nursing and public health through letters, books, conference presentations, and personal persuasion. She was skilled in mathematics and far ahead of her time in understanding the importance of health data. She argued (unsuccessfully) that Parliament should extend the 1860 census to collect data on sickness and disability, and she advocated for the creation of a Chair in Applied Statistics at Oxford University. The Royal Statistical Society acknowledged her contributions to health data by electing Florence Nightingale to membership—the first woman to be so honored—and the American Statistical Association made her an Honorary Member.

Adolphe quetelet: statistician and more.

Who was Adolphe Quetelet? Born in Belgium in 1796, Quetelet early revealed a talent for the sciences in combination with a deep interest in the humanities, including the performing arts, painting, and poetry. After receiving his doctorate in mathematics from the University of Ghent at age 23, he went to Paris to study probability theory with Laplace, Fourier, and Poisson. Returning to Brussels, he founded the Royal Astronomical Observatory in 1828, which he directed for several years. During his career, he made important contributions to a wide range of disciplines: meteorology, astronomy, mathematics, statistics, demography, sociology, criminology, and the history of science. Quetelet explored relationships not only among celestial bodies but within human and social bodies, ie, societies. He took many anthropometric measurements and pioneered the statistical investigation of social behaviors, studying their distributions and averages. He systematically collected data on births, deaths, and crimes and contributed to the methods of population censuses. In a famous 1835 essay, Quetelet introduced the notion of the homme moyen (“average man”), combining the social and physical characteristics of populations. Such patterns, he argued, could be explained by “the general causes for which society exists and maintains itself.” He believed that the “science of man” should investigate the “social body,” and not the “particularities distinguishing the individuals composing it.” Quetelet’s influential work was amplified by the English school of social biometrics in the early 20th century. He believed that statistical laws explained social phenomena, and that as civilization developed, the “average man” would be ever more closely approximated. This vision ignited heated debates about free will versus social determinism in the new disciplines of sociology and political economy. A cosmopolitan citizen–scientist, Quetelet actively fostered cooperation across the scientific community. He organized the first international statistical meetings and journals and was active in several Belgian and Europe-wide scientific societies. He became a private tutor to Prince Albert, Queen Victoria’s consort; his perspectives may have influenced Prince Albert’s political views. He frequently gave lectures aimed at general audiences, and kept a roster of 2,500 correspondents. With Malthus, he discussed population trends; with Goethe, he debated philosophical issues; and with US President Garfield, he consulted about improving the US census. Quetelet died in 1874, 5 days shy of his 78th birthday. Despite Quetelet’s numerous contributions to physical and social sciences—all relevant to public health and epidemiology—he is not generally considered among the founders of the field. He left his mark on public health, nonetheless. In proposing a body mass index (weight kg /height m ), Quetelet provided a way to quantify the relationship between a person’s life course weight and height, starting from the premise that “the transverse growth of man is less than the vertical.” His measure was so insightful and practical that it endures to this day as the most widely used indicator of obesity, a leading cause of disease and death in human populations. From Institute of Social Medicine, State University of Rio de Janeiro, Rio de Janeiro, Brazil and School of Public Health, University of California – Berkeley, Berkeley, CA. Copyright

Lemuel Shattuck: architect of American public health.

On the 100th anniversary of Lemuel Shattuck’s 1850 Report of the Sanitary Commission of Massachusetts, Winslow praised the Report as “the most outstanding single ‘Book of Prophesy’ in the history of public health.” What was this report, and what made it so important? Lemuel Shattuck was born in 1793 in Ashby, Massachusetts. His first career was as a teacher, and he moved westward with the wave of migration in 1817. Afflicted with poor health, he returned to the family home in Concord in 1822, where he became active in civic affairs. He had the strong conviction that collection of data could enhance the ability of government to respond to social ills. He wrote A History of Concord (which included statistical analyses based on church and municipal records), reorganized the local school system to provide a quantitative evaluation of student achievement, and founded the American Statistical Association. After moving to Boston in 1835, he opened a bookshop, was elected to the Massachusetts legislature, and campaigned for a census of Boston. The census was conducted in 1845 and was so successful that Shattuck was called to Washington, DC to help organize the 1850 US census. There he introduced procedures that revolutionized the national census. Lemuel Shattuck’s crowning achievement, however, was as Chair of a Commission authorized by the Massachusetts Legislature to conduct a “sanitary survey of the State” and make recommendations for the “promotion of public and personal health.” Shattuck planned, implemented, and wrote the Commission’s Report. This Report was divided into 4 parts. The first 2 dealt with the history and status of the “sanitary movement,” locally and worldwide. The third provided the statistical evidence underpinning 50 recommendations for the organization and implementation of public health agencies, both at the state and local levels. These recommendations included infrastructure for collecting public health data. The fourth part presented arguments supporting the recommendations, and included a model state public health law. The model law was enacted by the Massachusetts Legislature in 1866 and widely emulated by other States. Most of the 50 recommendations of the Shattuck Report are now standard components of American public health practice. Shattuck was not just a “prophet” of American public health, but its most influential architect.