Lemuel Shattuck conducted a comprehensive survey of sanitation conditions and practices, and outlined the potential for improving health status by enforcing a sanitary code. His report led to early communal action to protect the public health and created the political support necessary to create a local board of health in Massachusetts. This movement spread to other localities.

The strong role of sanitary engineers such as C. E-A Winslow in the early decades of public health in this country is often overlooked in our current attention to individual health improvement efforts. Winslow was an early leader in public health and a prolific writer on the need for community-wide action to improve health.