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BMJ readers choose the “sanitary revolution” as greatest medical advance since 1840

BMJ 2007; 334 doi: (Published 18 January 2007) Cite this as: BMJ 2007;334:111
  1. Annabel Ferriman
  1. 1BMJ

    More than 11 300 readers of the BMJ chose the introduction of clean water and sewage disposal—“the sanitary revolution”—as the most important medical milestone since 1840, when the BMJ was first published. Readers were given 10 days to vote on a shortlist of 15 milestones, and sanitation topped the poll, followed closely by the discovery of antibiotics and the development of anaesthesia.

    The work of the 19th century lawyer Edwin Chadwick, who pioneered the introduction of piped water to people's homes and sewers rinsed by water, attracted 15.8% of the votes, while antibiotics took 15%, and anaesthesia took 14%. The next two most popular were the introduction of vaccines, with 12%, and the discovery of the structure of DNA (9%).

    A total of 11 341 people voted on the shortlist, which was chosen by a panel of experts from a list nominated by readers. Almost a third of the voters were doctors, while a fifth were members of the general public, and one in seven were students. Another tenth were academic researchers. Almost two fifths of the voters were from the United Kingdom, and a fifth were from the United States.

    Johan Mackenbach, professor of public health at Erasmus MC Medical Center, Rotterdam, who championed the cause of sanitation, said, “I'm delighted that sanitation is recognised by so many people as such an important milestone. The general lesson which still holds is that passive protection against health hazards is often the best way to improve population health.

    “The original champions of the sanitary revolution were John Snow, who showed that cholera was spread by water, and Edwin Chadwick, who came up with the idea of sewage disposal and piping water into homes.

    “Inadequate sanitation is still a major problem in the developing world. In 2001, unsafe water, sanitation, and hygiene accounted for over 1.5 million deaths from diarrhoeal disease in low and middle-income countries. Clearly, sanitation still plays a vital role in improving public health now and in the future.”

    In his essay on sanitation in the BMJ's Medical Milestones supplement (BMJ 2007 doi: 10.1136/bmj.39044.508646.94) Professor Mackenbach pointed out that Chadwick's work was based on a misconception, as Chadwick thought that infectious diseases were spread not through water but through air contaminated as a result of poor urban drainage.

    Professor Mackenbach said that Chadwick, who designed the 1834 Poor Law Amendment Act, was not motivated primarily by an altruistic desire to improve the lot of ordinary people; his main concern was that infectious diseases were killing off male breadwinners and that this was proving a heavy burden on the public purse.

    The winner of the BMJ poll was announced at a ceremony at the BMA headquarters in London, chaired by Jon Snow, the broadcaster and presenter of Channel 4 News.

    Fiona Godlee, the BMJ's editor, said: “The response to our poll has been overwhelming. It is deeply heartening to see science and medicine provoke such passion and debate. Selecting just one winner was always going to be difficult, but I'm delighted that the BMJ has helped to remind everyone of the great contribution that medicine and science has made to our lives now and in the future.”

    The Medical Milestones supplement containing the champion's essays on the top 15 advances is distributed with this week's BMJ and is available on More details of the voting are also available at

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