In 1920, Public Health is defined as: "the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health."

Germ Theory’s Effect on Hospital Architecture

By the late 1800s, germ/antiseptic theory, popularized by the British Surgeon Joseph Lister, was taking hold and influencing the ways hospitals were architected and visualized in public consciousness.

"Hospital architecture was long designed for maximum cleaning and cleanliness (rounded corners, no ledges or cracks, minimal ornament, hard materials, and few spatial subdivisions)" 

Hospital Architects responded to germ theory with larger, taller buildings, growing in stories while attempting to maintain natural light. Placements of beds and windows, arrangements of flues and ventilators, and the proper design of heating systems were all implemented in the hopes of controlling hospital diseases, classified as septic diseases. Antiseptic (carbolic acid), intense heat, and chemical disinfectants were used to treat possible germs spread through soil, air, and water. There were proponents of vertically oriented hospitals, and similarly critics who believed that bad air could spread upward between floors. Ultimately, architectural reactions to the mainstream sanitary science were not uniform. Fears of the prevalence of miasmatic (air-born) and septicemic diseases in hospitals, however, led to a widespread and intense proselytization of germ theory by scientists.

Social Consequences and Weaponizing of Germ Theory

"Germ theory became widely proselytized by the medical and public health establishment. It was the responsibility of mothers, and women more generally, to ensure the safety, sanitation and cleanliness of the nation by mothering scientifically" (Goode, 2014).

There were raced and classed implications in the promulgation of sanitary science as the norm. Prescriptions about cleanliness and scientific mothering reduced the value of non-Western knowledge on disease prevention, and were used as excuses to bar Midwives, especially those of color, from practicing.

As lower Manhattan became overcrowded with immigrants, local city health leaders formed rules for sanitation, hygiene, food and water supplies, etc. and started various registration requirements for health care providers. (NYC Midwife History, 2021)

Midwives, by the mid 1900s, were being positioned in opposition to credentialed physicians, who were viewed as clean, sanitary, and safe. A similar dichotomy was constructed between the home and hospital, where hospitals were associated with an ultra-cleanliness that could not be attained in the home. Media, in targeted ads in women’s magazines, played a role in convincing women that superior care could be administered in germ-free hospitals. This promotion of science-backed cleanliness in a largely white, male-dominated medical establishment was supported by racial stereotypes that were used to demean the knowledge of Midwives (Thompson, 2015).

"In 1922, Dr. Lobenstine observed that “the surest way to eliminate the midwife, if such elimination is desirable, is by continually raising the standards demanded of her.”

The credentialing of the Midwifery profession is a practice that remains today, which many view as an attack on “intuitive ways of knowing.” Midwives must continue to prove their worth in a system that values profit over care.

In a for-profit system, created in part by an investment in sanitary science and institutionally backed knowledge, mothers can pay to receive better care. Within the hospital setting, patients have to be able to afford emotional labor and extra space, which Midwives cultivate into their practice as is. In medicalized hospital births, these extras can cost up to 900 dollars a night, uncovered by insurance. As such, natural birthing centers have appealed to women on Medicaid. While the data shows that Midwives save costs to the healthcare system and hospitals through low intervention techniques, a persistent stigma around the care and cleanliness that Midwives can provide, as well as the pervasive idea that pregnancy is a risky condition, have contributed to the valuation of medicalized, hospital births. 

It is an uphill battle, but more patients and hospitals are appreciating the “uniqueness and scope” of Midwifery, and in some cases hospitals seek out Midwives with New York State licensure. (NYC Midwife History, 2021)