Associations between typhoid mortality and municipal finances of water and sewerage systems in eighteen urban centers in the United States, 1888-1932

Abstract

The global burden of typhoid fever remains high, concentrated in underserved communities with poor water and sanitation services. Yet, typhoid was eliminated from much of the developed world in the twentieth century, with the installation of water and sanitation systems and the introduction of vaccines and antimicrobials. In the United States, this period was known as the “epidemiological transition,” observed as widespread reductions in overall mortality. The transition coincided with increases in local government power and finances. This thesis studied the public health advancements at the turn of the twentieth century in the U.S., and their effect on typhoid mortality. In particular, this work considered the effects of municipal investments in water and sewerage systems on typhoid mortality from 1902-1931 in eighteen urban centers across the U.S. The decline in typhoid-related mortality at the turn of the twentieth century corresponded to the installation of water and sewerage systems in the U.S. This reflected the epidemiological transition of the time period. Decade-wise mortality declines in typhoid mirrored the long-term influence of clean water technology as well. Notably, typhoid mortality rates were linked to city-specific improvements in water and sewerage systems, with significant increases in municipal finances corresponding to decreases in mortality. In particular, the per capita economic indicators of debt and cumulative outlay most strongly associated with mortality rates, reflective of the importance of municipal bond markets in the U.S. in financing water systems. Increased municipal spending on water and sewerage systems likely increased the capacities of such systems, leading to decreases in typhoid mortality. Trends in typhoid mortality were found to be city-specific. Consideration of these past successes may inform the development of cost-effective control and prevention programs in present-day endemic regions, and add to current research on historic typhoid mortality in the U.S.