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(Permission
to reproduce this article appearing in KU Med, Issue No. 1, 2005,
was given by Randy Attwood, Director, University Relations, KU Medical
Center.)
Pushing the Frontier of Public Health
From swatting flies to reforming laws, medical
dean Samuel J. Crumbine put Kansas at the forefront of the nation's
health matters.
By Allen Greiner, MD
When Abraham Flexner released his report on the state
of medical schools in 1910, it became a blueprint for modern medical
education reform. Backed by the Carnegie Foundation and the American
Medical Association, the report was also highly critical of the
fledgling University of Kansas School of Medicine's organization
and clinical instruction. Stinging from the report, the next year
the Board of Regents sought a dean for the School who would provide
leadership and restore the school's reputation. William Allen White,
Pulitzer-prize winning newspaperman and a member of the Board of
Regents, was dispatched to convince the one man the regents wanted
to take the position. That man was Samuel J. Crumbine, secretary
of the State Board of Health.
Crumbine had shown impressive health leadership in
the years preceding his work with the medical school. His career
as a state official and as a public health educator gives crucial
insight into how public health became a powerful force in shaping
the health of our nation throughout the 20th century. His skills
and reputation were just what the struggling medical school was
seeking.
 From July 1902 through June 1904, the
Kansas State Board of Health had no acting executive secretary.
Kansas was without public health leadership to organize responses
to disease outbreaks, nuisances, or sanitary complaints. Public
health had never been a high priority for Kansans or state government
leaders. Secretaries appointed during the last two decades of the
19th century had always maintained private medical practices in
addition to their state duties. It was never clear how much power
these secretaries had over state public health affairs. In 1899,
the outgoing secretary H.Z.Gill refused to take orders from the
governor and attempted to conduct public health business from a
desk in the corridor of the State Capitol. When the new secretary,
William Swan, unexpectedly drowned in a Topeka lake in 1902, there
was little concern that a vacant office would cause a public health
crisis. County health officers were expected to continue reporting
outbreaks and making inspections without a central authority to
coordinate and advise on their activities. Finally, in July 1904,
Crumbine left his Dodge City private practice to accept the job
as secretary ofthe state Board of Health. Crumbine was faced with
the unenviable task of creating a viable government institution
from the ground up. He was more than equal to the challenge. Within
three years, he had created a highly effective Board of Health and
was well on the way to establishing Kansas as a national leader
in public health.
He immediately improved organization of his county
health officers and helped pass pure food and drug laws. He initiated
major campaigns to "swat the fly," eliminate common towels and drinking
cups from public places, and reduce public expectoration. However,
his most lasting legacy has been downplayed and neglected. Crumbine
was able to make public health education a focus for public and
professional audiences across Kansas and the nation. His educational
emphasis allowed him to have widespread impact on the health and
lives of innumerable citizens. His interest in medicine began early.
On the frontier's edge
Crumbine was born in Venango County, Pennsylvania, on September
17,1862. Raised by grandparents, he worked as a pharmacist's apprentice
in Sugar Grove, Pennsylvania, before enrolling at the Cincinnati
College of Medicine and Surgery. His childhood fascination with
bottles in the window of the Old Corner Drug Store in Mercer, Pennsylvania,
had led him to his apprenticeship and to medical school. When he
ran short of tuition funds, he took a job with a Cincinnati pharmacy
and purchased a portion of a drugstore in Kansas, near Dodge City.
During summer vacations and holiday breaks from school, Crumbine
traveled to Kansas and ran his pharmacy, dispensing medical advice
in a state that had no medical licensure laws at that time. Using
funds from his various pharmaceutical enterprises, he completed
his medical degree. In 1885, he married a Cincinnati native, moved
to Kansas, and set up a general practice in Dodge City where he
worked for the next 19 years. It was here he experienced the final
wild years of Dodge City as the "cowboy capital" on the edge of
the frontier.
When Crumbine first arrived in Dodge City as a medical
student, Bat Masterson had just replaced Wyatt Earp as town marshal.
Crumbine's medical practice initially served both gunfighters and
peacekeepers. It was not until the middle 1890s, when drought forced
cattlemen to move their stockyards farther west, that the gambling,
drinking, and red-light districts serving the cowboys moved as well.
Crumbine was well respected in the Dodge City community and went
through much soul-searching before he moved on to Topeka. He would
face a whole host of challenges entirely novel to most country doctors.
"The State Board of Health has heretofore held a
rather insubordinate position among the departments of the state
institutions," Crumbine wrote in a 1904 letter to Gov. E.W. Hoch,
"but I take it that the health and life of the people of this splendid
commonwealth are quite as important a matter as one could well think
of, and it is my desire and my effort has been directed toward the
accomplishment of making the State Board of Health of real service
and value to the physicians and people of the state, and it is along
these lines that I desire to make some suggestions."
Taking on Topeka
Crumbine saw a need for stronger government backing of the Board
of Health. Using new scientific discoveries that clarified the causes
of many public health diseases, he was able to convince the governor
to bolster support for his work. He soon had a ballooning budget
and expanded legal authority.
 Crumbine was most keenly interested in the idea of disease
prevention. His years as a country doctor had convinced him that
"an ounce of prevention is worth a pound of cure." His first public
health success came from application of preventive and bacteriologic
ideas. While practicing in Dodge City, Crumbine convinced the Fred
Harvey diner chain to stop selling milk served out of open jugs
and pitchers. Soon the Dodge City diner and all the others across
the state had milk served in individual bottles. This was a clear
example of how new discoveries related to the germ theory of disease
were opening broad vistas for potential interventions on the part
of public health officials. Officials knew they could use this new
information on disease specificity and employ methods that would
reduce transmission of contagious diseases caused by bacteria, parasites
and unknown filterable agents (later known as viruses).
Crumbine was a pioneer in the practice of taking
new scientific knowledge about disease to the physicians and citizens
he served. He knew this information would empower people to change
behaviors that put them at risk for contracting or disseminating
disease. His work helped shape the movement responsible for society's
modern infatuation with ideas about cleanliness, germs and health.
Crumbine began his official public health career
while still practicing full time in Dodge City. A political friend
appointed him to the State Board of Health in 1900, his reward for
treating the man's child for a life-threatening illness. Formal
training in public health was unknown to the U.S. during this era.
Crumbine relied on reading materials and medical experience to make
decisions. He achieved major success dealing with a smallpox outbreak
in Pratt, Kansas, in 1902, using modified quarantine methods and
aggressive immunization to squelch the epidemic. His fellow Board
of Health appointees were so impressed they nominated him to replace
the Executive Secretary, William Swan, who had died that same year.
Crumbine took two years to decide if he wanted to leave Dodge City
and accept the position in Topeka. He moved his family and took
an office in the state capitol in July 1904.
Crumbine's early months in office were filled with
paperwork and organizing the network of county health officers who
were his connection to public health events at the local level.
He found this group disconnected from the state board and under-informed
about infectious disease. He also felt these officers were missing
opportunities to take newfound knowledge to the people and effect
sanitary and hygienic practices. Determined to correct this problem,
he began a two-pronged attack on ignorance. Using printed bulletins
and campaigns focused at citizens, he convinced many Kansans of
the need for reform in both laws and personal behavior. He sold
a gospel of cleanliness to the people and physicians through germ
theory doctrine. Germs became the enemy and public health the conqueror.
Flies, cups and reform
His first major initiative involved passing laws on pure food and
drugs. He knew that regulations aimed at establishing food and drug
purity would significantly cut down on contamination by reducing
bacteria and foreign substances in these ingested items. The public
seemed very eager to support Crumbine's work on food and drug purity.The
economic hardships of the 1890s and the subsequent rise of the Populist
political party had created much backing for reforms.The first decade
of the 20th century produced initiatives to remove corruption from
government, break up trusts and improve condltions in slums and
for underprivileged children. Several reformist authors, including
Jane Addams, Jacob Riis, and Upton Sinclair were very influential
during this era. Sinclair's The Jungle directed public attention
toward sanitation and food, revealing the shocking filth and contamination
prevalent in Chicago meat-packing houses. Crumbine capitalized on
both the emotions aroused by this expose and those already present
in the reform sensitive citizenry to promote his food and drug regulations.
 His second campaign involved
the common housefly. Marine Hospital Service researchers, from the
military unit that would eventually become the U.S. Public Health
Service, reported that flies carried disease-causing bacteria to
food items. Crumbine discovered these studies and decided to promote
them under the slogan "Swat the fly." His campaign slogan spread
internationally and he succeeded in turning the housefly into one
of public health's biggest villains. Common citizens eagerly adopted
fly control strategies in attempts to banish diseases such as typhoid
fever, tuberculosis, dlphtheria, anthrax, smallpox and childhood
diarrhea.
One Kansas schoolteacher presented Crumbine with
a homemade tool composed of a yardstick and a square piece of wire
screen. Crumbine dubbed it the "fly swatter." Although there are
medieval woodcuts showing simlar insect killing implements, Crumbine's
swatter was likely the first one to use wire screen.
Other citizens and communities outlawed manure piles,
made flypaper, hung screens and chased flies with the new fly swatters
in an effort to banish flies from their homes and towns. Crumbine's
educational success in spreadlng fly vector theory was impressive.
It showed the potential influence public health education could
have on public behavior and belief systems. For many citizens, the
fly represented an attractive way to become devoted to cleaning
up cities and conquering germs.
Crumbine's next major project involved control of
tuberculosis. He decided that the common drinking cup, frequently
attached to the water coolers in train cars, was a major health
hazard. He had common cups outlawed in 1909. Soon after this legislation
passed, a Kansas native living in Boston, Hugh Moore, arrived at
the statehouse in Topeka. He showed Crumbine some of his newly invented,
disposable, cone-shaped paper cups.These "dixie cups" were soon
replacing common drinking cups across the nation and Moore would
go on to be chairman of the board of directors of the Dixie Cup
Company.
Crumbine's additional work on tuberculosis included
a campaign for a ban on public expectoration. He had a Kansas brick
maker print his slogan "Don't spit on the sidewalk' on every third
brick that was manufactured.
Improving the state's supplies of drinking water
was an ongoing interest of Crumbine's. Throughout his tenure as
secretary of the Board, he performed studies and established regulations,
which would prevent consumption of unsafe water. He accompanied
Marshall Barber, KU professor in bacteriology, on a canoe trip down
the Kansas river to test the theory that contaminated water purified
itself every seven miles downstream. Their test tube samples showed
pathogenic bacteria all along the 23 miles from Topeka to Lawrence.
The Board of Health had demanded that all surface water be filtered
before consumption by 1910. Crumbine showed that bacteria from human
wastes could be grown in most surface water supplies. One-quarter
of subsurface aquifers and wells were found to be contaminated in
a 1913 study of rural water supplies. The efforts to improve water
were complemented by improvements in the area of sewage treatment.
Kansas ranked fourth nationally in the number of towns with sewage
treatment plants by 1914. When Crumbine attempted to clean up the
Missouri River in 1915, only Kansas was able to enforce sewage treatment
on upstream sites. Iowa, Nebraska and Missouri were all helpless
due to poor state level sanitary regulation.
KU's figurehead dean
 By 1911, Crumbine's work had become
so well respected that he was asked to become dean of the KU School
of Medicine. After the Flexner report, Crumbine's presence was needed
to shore up the school's meager reputation. He accepted with the
understanding that he would continue with his full-time duties on
the Board of Health and Associate Dean Mervin T. Sudler would actually
run the school. Crumbine was already a well known national public
health figure by 1911 and he used his connections and legislative
influence to strengthen the School through state laws requiring
county commissioners to send the crippled and poor to the School's
hospital for treatment. Crumbine was in some ways a figurehead dean,
but he had shown impressive health leadership in the years preceding
his work with the medical school.
Although funding squabbles with the legislature continued
unabated through Crumbine's term as dean, the school did improve
its entrance requirements, training methods and overall quality
of graduates. Crumbine resigned in 1915.
Crumbine's involvement with the KU School of Medicine
inspired new developments in the education of public health professionals.
He realized that just as he had successfully educated the citizens
of Kansas in regard to infectious disease spread, he could also
instruct the health officers and public health nurses of the state.
He set up the nation's first postgraduate course for county health
officers at the Kansas City medical school campus in 1911. No other
state was attempting to educate those responsible for public health
at the local level as aggressively as Kansas. Yearly courses for
public health nurses would soon follow. The nurses' and doctors'
courses were both held one week out of the year in Kansas City and
charged no tuition. Crumbine's educational influence would eventually
spread the gospel of public health to every corner of the state.
Life after Kansas
Crumbine initiated several important campaigns for children's health
during his later years as Board Secretary. His "save the baby"campaign
of 1914 reduced infant mortality by focusing attention on clean
milk, clean mothers, visiting nurses, and child welfare. A division
of Child Hygiene was created and the Kansas system was soon being
emulated by states from Rhode Island to Michigan.
 Crumbine continued with his campaigns
and educational programs until he was forced to resign in 1923.
The newly elected Gov. Jonathan Davis was angered by Crumbine's
refusal to replace Board of Health staff with political appointees.The
governor appointed an entirely new board in hope of ousting Crumbine,
but the coup was ultimately unsuccessful. The entire state rallied
around Crumbine. There was unprecedented bipartisan support for
Kansas' best known physician. Simultaneously, there were several
overtures for Crumbine's services at the national level. President
Herbert Hoover urged him to take the reins of the American Child
Health Association. Crumbine decided the political battles of Kansas
were less pressing than the health of the nation's children. By
June of that year, he was off to New York City to take up his duties
on a national level.
The public health apparatus Crumbine left behind
was markedly different from what he had inherited in 1904. His efforts
were renowned. He was the subject of a two-part article in The
New Yorker in 1948. Public health issues had been promoted to
the forefront of every citizen's agenda. Crumbine's emphasis on
ducation was responsible. He had found a voice to take the new science
of bacteriology and make it resonate in the hearts of laypersons
and health providers alike. He set standards and created systems
that remain the foundation of public protections we still enjoy
today.
Allen Greiner; MD, is an assistant professor of
family medicine and has a faculty appointment in the department
of history and philosophy of medicine.
The images in this article were provided by the
Clendening History of Medicine Library, University of Kansas Medical
Center. Page 22 illustration was first published in The New
Yorker, July 17, 1948.
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