Infectious disease remains a major cause of school absenteeism. One Wisconsin study found that three-fourths of absences among schoolchildren were due to viral illnesses.1 Hand hygiene is a simple intervention that has proven effective at reducing illness among schoolchildren.2 However, a study found that only 28% of female and 8% of male students washed their hands with soap after using the bathroom.3 To promote handwashing, the Centers for Disease Control launched the Healthy Schools Healthy People campaign in 2003.4 The campaign, which still exists today, is part of a long line of school-based hygiene initiatives.Among the most famous predecessors in America was the Modern Health Crusade (MHC), launched in 1915 by the National Tuberculosis Association (NTA) to curb tuberculosis (TB) by instilling lifelong health habits in children through daily “chores,” public recognition, and competition. Using Michigan as a case study, this article argues that the MHC normalized hygiene with structured incentives and maintained adherence through surveillance. This article traces the MHC’s origins, examines its reinforcement mechanisms in Michigan classrooms, and concludes with lessons for today’s pediatricians, educators, and policymakers designing 21st-century school health initiatives.The MHC began as an offshoot of the NTA’s popular Christmas Seal fundraiser, during which the association sold one-penny decorative stickers used to seal Christmas cards. Charles DeForest, the director of Christmas Seal sales, developed a campaign framing children’s involvement in fundraising as a “crusade” against tuberculosis. Children who sold 10 Christmas Seals received certificates for their efforts. The idea proved tremendously popular, with over 100 000 certificates being issued that year.5 Building on this enthusiasm, DeForest expanded the initiative into a health education curriculum that was implemented in schools. Instead of fundraising, schoolchildren strived to complete “chore cards,” featuring daily hygiene chores, such as brushing their teeth and washing their hands.6 Pupils earned points for completing chores and advanced through medieval-themed ranks from Page to Knight Banneret while receiving decorative pins and buttons. By 1919, over 3 million children were enrolled in the MHC.5A 1922 chore card, shown below, outlined 11 'daily health rules' (Figure 1).6 Some students were surprised by these high standards. An eighth grader admitted, “I never thought of keeping things out of my mouth…. I did not wash my hands. Lots of times I didn’t clean my fingernails.”7 Yet the game structure proved compelling. One Michigan teacher wrote: “So many of the parents tell me how the children ask to be washed now where before they avoided it. And one little girl walked half a mile back home one morning to clean her teeth.”8The MHC also relied on social pressure to enforce adherence. Teachers conducted public daily inspections to monitor students. The MTA offered the following guidance: The children should sit in position with their hands on their desks and their handkerchiefs in sight…. You should pass down the aisles and inspect each child…. The minimum standard should require clean faces, teeth, hands, and nails and clean handkerchiefs. The children who meet the requirements should be complimented, and those who fail should be given helpful suggestions.9Progress was displayed on a public “Roll of Health Knighthood,” which offered positive reinforcement and public embarrassment. And as if upholding personal hygiene wasn’t hard enough, in 1923 the program expanded its scope to include moral chores, mandating truthfulness and cheerful behavior (Figure 2).10The implementation of the MHC in Michigan, with its seemingly objective evaluation of chores, was tainted by the era’s racism, despite evidence of the program’s positive impact in Black communities. One teacher in Albion, Michigan, discontinued the program in a classroom of Black students, citing “dishonesty” in chore reporting.11 However, the MHC, brought to Atlanta’s public schools by Carrie Dukes, an African American reformer, with support from Black school officials, taught students not only about the importance of health and personal hygiene but successfully motivated students to organize neighborhood clean-ups. Students also composed rhymes for the program that appeared in “The Crusaders Corner” column of the Atlanta Independent, an African American newspaper.12 The varied implementation of the MHC for Black students across different communities stresses the importance of designing public health interventions with an equity lens to ensure they do not unintentionally widen existing health disparities.The MHC demonstrates how game-like incentives in a token economy can shape student behavior. Its posters and scorecards were the mass media of the era. Today, digital social platforms serve a similar role in shaping norms and are already being used by school nurses to promote wellness with annual events such as Global Handwashing Day.13 A century later, the MHC reminds us that habits children learn together can transform public health and that equity must be considered when designing public health efforts.I’d like to thank Janette Greenwood, PhD, and Amy Richter, PhD, for their guidance and revision of a version of this article during my time at Clark University.
Dillon Prus (Thu,) studied this question.