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HISTORY OF PUBLIC HEALTH

Shaila Kumar
Public Health Trainee
University of West of England, Bristol

The history of public health has been a flourishing field in the last three decades. Yet despite a spate of excellent monographs about various epidemic diseases and many good collections about health and disease in Africa, Asia, the Middle East, Latin America, as well as Europe and North America, the most recent textbook on the history of public health is four decades old. George Rosen's venerable, A History of Public Health, was first published in 1958.

Public Health in Ancient Rome

Public health was developed by the Romans as they believed that cleanliness would lead to good health. The Romans made links between causes of disease and methods of prevention. as a consequence they developed a large system of Public Health works around their empire.
The Romans believed that Prevention of illness was more important than cure of illness. Roman Philosophy was based along the lines of searching for a reason then establishing a preventative measure to minimise the risk attached. As a practical people they used observations of the environment to determine what was causing ill health. This form of empirical observation led the Romans to realise that death rates were higher in and around marshes and swamps.
The cure would then be based upon logic. As the Romans believed that Gods held the key to longevity of life they initially built Temples to the gods near large swamps to pacify them and reduce the deaths. Alternatives to this were the drainage of swamps and they also ensured that the army and important people lived away from these areas.
Such empirical observations led the Romans to believe that ill health could be associated with, amongst other things, bad air, bad water, swamps, sewage, debris and lack of personal cleanliness. In some places, Rome included, it is impossible to avoid all of these unless something is physically done to alter the environment. The Romans, being technologically adequate, resolved to provide clean water through aqueducts, to remove the bulk of sewage through the building of sewers and to develop a system of public toilets throughout their towns and city's. Personal hygiene was encouraged through the building of large public baths (The City of Bath being an obvious British example of these).

Public Health in Ancient Greek

The Ancient Greek would not have been too unfamiliar with some of the health and fitness regimes that are used by people today. The word 'Regimen' was used by the Greeks to describe peoples lifestyles: from which can be derived the word regimented (as in organised). The Greek philosophy of 'Regimen' covered what people ate, drank, the types and amount of exercise that they took and how much sleep they had.
These ideas were very thorough: it demonstrates that the Greeks knew that lifestyle could affect the quality of life, as evidenced by their development and championing of the Olympics. Such is the quality of the remaining evidence that we can even see that doctors advice differed for those who were rich: and could therefore afford to spend time and money on relaxing, and those who worked or were poorer: and therefore couldn't maintain as healthy a lifestyle as possible many of which are still visible in places today.

Origins of Public Health

In some ways, public health is a modern concept, although it has roots in antiquity. From the beginnings of human civilization, it was recognized that polluted water and lack of proper waste disposal spread vector-borne diseases. Early religions attempted to regulate behavior that specifically related to health, from types of food eaten, to regulating certain indulgent behaviors, such as drinking alcohol or sexual relations. The establishment of governments placed responsibility on leaders to develop public health policies and programs in order to gain some understanding of the causes of disease and thus ensure social stability prosperity, and maintain order.

Early public health interventions

By Roman times, it was well understood that proper diversion of human waste was a necessary tenet of public health in urban areas. The Chinese developed the practice of variolation following a smallpox epidemic around 1000 BC. An individual without the disease could gain some measure of immunity against it by inhaling the dried crusts that formed around lesions of infected individuals. Also, children were protected by inoculating a scratch on their forearms with the pus from a lesion. This practice was not documented in the West until the early-1700s, and was used on a very limited basis. The practice of vaccination did not become prevalent until the 1820s, following the work of Edward Jenner to treat smallpox.
During the 14th century Black Death in Europe, it was believed that removing bodies of the dead would further prevent the spread of the bacterial infection. This did little to stem the plague, however, which was most likely spread by rodent-borne fleas. Burning parts of cities resulted in much greater benefit, since it destroyed the rodent infestations. The development of quarantine in the medieval period helped mitigate the effects of other infectious diseases. However, according to Michel Foucault, the plague model of governmentality was later controverted by the cholera model. A Cholera pandemic devastated Europe between 1829 and 1851, and was first fought by the use of what Foucault called "social medicine", which focused on flux, circulation of air, location of cemeteries, etc. All those concerns, born of the miasma theory of disease, were mixed with urbanistic concerns for the management of populations, which Foucault designated as the concept of "biopower". The German conceptualized this in the Polizeiwissenschaft ("Science of police").
Public Health in UK
In the UK, the origins of the public health movement are traditionally traced back to Victorian times. In the 18th Century due to the migration of people from farms and villages in the country to towns during the industrial revolution (for work in the newly formed factories and industries), the population in British towns rose dramatically. In 1700 there were only seven towns outside London with a population of over 10,000 (Clarke & Slack, 1976) but with the great influx of workers and their families into the rapidly industrialised towns during the 1800's, this number increased massively and the problems of over-population became disastrous. Ashton and Seymour (1998) describe the findings of Dr Duncan, Liverpool's first medical officer of health who wrote of one third of the population of Liverpool living in cellars of back to back houses with earth floors, no ventilation or sanitation and as many as sixteen people in one room. Of course the infra-structure of these communities had not been built to withstand such a population explosion and in the early 19th century 'the problems of environmental degradation, disease and human misery reached massive proportions and were in evidence across large tracts of Britain' (Webster, 1990).

Eventually public hysteria grew due to the cholera epidemic of 1831-32 and the high mortality rates from other communicable diseases like dysentery and TB. Ashton (1999), cites an annual death rate in Liverpool about that time as 36 in 1,000, the highest in the country. Only one report had enough significance to force concern about these conditions into action to improve them. This was 'the Report on the Sanitary Conditions of the Labouring population of Great Britain' by Edwin Chadwick in 1842.

Originally Chadwick, a lawyer, was appointed to report on the organisation of the Poor Laws but Webster (1990) states that his intentions to 'create model institutions adapted to the needs of specific groups of the distressed' were never met and instead the Victorians created the 'huge workhouses which subjected their inmates to the worst degradation and humiliation' (Webster, 1990).

Because of his work on this report his thinking about the reasons for the plight of the poor began to change and like many health professionals trying to tackle inequalities in health today, he became convinced that their suffering was due to the dreadful conditions in which many of them lived. His report led the way for the era now called 'the sanitary movement' where water supply, drainage and sewage systems were improved radically and the Public Health Act of 1848 was installed. The act also instigated the setting up of a General Board of Health to oversee these reforms.

The science of epidemiology was founded by John Snow's identification of polluted public water well as the source of an 1854 cholera outbreak in London. Dr. Snow believed in the germ theory of disease as opposed to the prevailing miasma theory. Although miasma theory correctly teaches that disease is a result of poor sanitation, it was based upon the prevailing theory of spontaneous generation. Germ theory developed slowly: despite Anton van Leeuwenhoek's observations of Microorganisms, (which are now known to cause many of the most common infectious diseases) in the year 1680 , the modern era of public health did not begin until the 1880s, with Robert Koch's germ theory and Louis Pasteur's production of artificial vaccines. As the prevalence of infectious diseases in the developed world decreased through the 20th century, public health began to put more focus on chronic diseases such as cancer and heart disease.
Public health, though often insufficiently appreciated by the other specialties of medicine, has since the nineteenth century helped to bridge the traditional gulf that exists between individual medicine and the greater society in which it functions. Thus it is Public Health, with its emphasis on populations rather than individual patients, that has provided medicine its ultimate rationale. And throughout the history of public health since the Renaissance, there has been a tension between the restriction of individual liberties and the greater interests of the community or the state.
The plague has always fascinated historians, but leprosy during the centuries of its great prevalence, from about 1100 to 1500, also deserves more attention, if for no other reason than it was the model for disease as stigma well into our own time.
In the early modern world, after about 1500, the West grew in wealth and world dominance, but it did not grow healthier. Infections that took a terrible toll on previously isolated societies, so-called virgin populations, became domesticated as world travel increased and urbanization progressed. Diseases that had been epidemic became endemic in urban centres. The strength of the state was assessed by the size of its population; one way of assessing that strength was to count numbers of people.

Basic terms in public Health

Addiction

Contested term used to describe compulsive drug taking. First in use to denote a disease requiring psychiatric treatment in the early 20th century, replacing older language of "habit", "inebriety", "morphinomania". Primarily focused on alcohol and drugs initially. Recent discussion of nicotine addiction symbolises ownership by public health as well as by psychiatry.

Community Health

Community health workers were organised in the countries of the developing world after Alma Ata’s (1978) focus on primary health care (PHC) and WHO’s Health for All by the Year 2000 gave public health a higher profile at the international level. Conceptual and practical confusion between PHC and public health, as in the UK, with tensions between general practitioners (GPs) and public health personnel.

Community Medicine

Concept developed by social medicine academics in the UK to provide training in health administration and epidemiology for the effective administration of health services. Critics argued that, when implemented in the 1970s, the loss of the medical officer of health meant that the relationship with the local community was lost. Distinct from community health (see above).

Epidemiology

The science of disease in populations. In the 19th century, the epidemiology of infectious disease and vital statistics were central parts of the public health curriculum. After the Second World War, epidemiology expanded its remit within public health to include chronic disease and the concept of "relative risk" was born.

Disease

The health of the public was undermined by epidemic infectious diseases like cholera, which ravaged industrialising countries in the 19th century. After the Second World War, the greater prevalence of chronic, degenerative disease began to characterise high and middle income populations. New and re-emerging infectious disease became a global health problem at the close of the 20th century.

Eugenics

The science of improving the quality of the human race, especially by selective breeding. Prominent in the early 20th century. Contrasted the declining fertility of the middle class with the high fertility of the "residuum" in large towns. Positive and negative versions, which attracted a wide range of political and social reform opinion.

Germ theory/ bacteriology

The bacteriological revolution ascribed the origins of infectious disease to specific organisms. Pasteur demonstrated the existence of bacteria that communicated disease and Koch identified the causative agent of tuberculosis. Germ theory identified the underlying cause of disease as the entry of micro-organisms in the body. For public health this meant a change of focus from environmental to individual solutions.

Health Education

The individual focus in turn of the century public health led to increased reliance on educating individuals, often mothers. The revival of individual arguments for prevention and lifestyle in the 1970s saw further emphasis on health education, often carried out through mass media "single issue" campaigns. Their efficacy in changing behaviour was questioned.

Health Promotion

Term used to describe positive strategy for improving health based on framework laid out in international documents such as WHO’s Health for All (1981) and the Ottawa Charter (1986). Implies intersectoral cooperation, marketing techniques for health, broader environmental emphasis. Often confused with health education.

Hygiene

Originally meant practices and principles for maintaining health—that is, moderation, cleanliness. Now interchangeable with "sanitary", its meaning is restricted to prevention of infection. In previous centuries the term was more expansive, encompassing ideas of moral and racial contamination. Social or racial hygiene described interventions like forced sterilisation of the "unfit".

Inoculation/ Vaccination

Deliberate introduction of smallpox matter through the skin or mucous membrane, to confer immunity, introduced from the Middle East into England in 1717. Jenner published the account of his first experiment with vaccination in 1798. Important, but controversial public health procedure, with history of working class opposition because of inequities and safety issues.

Maternity and Child Welfare

Maternal and child welfare was central to the individualised public health of the turn of the 19th century. Many countries established child welfare clinics. In the UK the role of the health visitor was important, advising mothers and monitoring infant health, an intrusion that was often resented.

Medical Police

Promoted from late 18th century by physician Johann Peter Frank. A state administered system of health inspectors with powers to quarantine, disinfect, and cleanse. Aimed to support aims of absolutist rulers to boost population numbers, ensuring fit labour force and military conscripts. Policing model remained important in 19th century, as with British medical officer of health.

New Public Health

Term subject to confusion, used to denote different versions of recent public health. Lifestyle public health of 1970s, with reference to Lalonde Report, emphasised individual responsibility for prevention of ill health. Limitations of this approach led to new public health of the 1980s focusing on environmental concerns and health inequality. More recent changes stress role of clinical prevention and genetics.

Occupational Health

Occupational diseases more prevalent because of the industrial revolution. European states introduced legislation to regulate the health and safety of factory work in the 19th century. Systems of factory inspection developed in Britain and Prussia. Occupational health an important driving force behind social insurance systems, but tended to remain separate from mainstream public health.

Sanitary Movement

Sanitary movement launched in European countries in the 1820s. Inspired in Britain by Benthamism, and emphasised the need for "experts" in the service of government. Sanitarianism aimed to reduce environmental pollution in the interests of human health. Preventable disease was dependent on environmental factors such as impure air and water supply.

Social Medicine

Term used in some countries to denote health as a democratic right with disease caused by socioeconomic factors, but also used with biological explanations of same. Post Second World War academic discipline aiming to link the planning of health and social services to the needs of the population. Failed to influence medical education or public health practice, but retained symbolic importance.

Urbanisation

Britain underwent rapid urbanisation from the 18th century. Migration to industrial centres was not met by infrastructure development, creating dire conditions of overcrowding, poor housing, and sanitation. The impact of epidemic disease and poor health status of the urban proletariat established enduring link between urban life and ill health.

Vital Statistics

Initially christenings and burials were recorded in Bills of Mortality, which sought to monitor plague deaths in 17th century London. The 1830s saw more extensive compilation of statistics of births and deaths in countries like France and the UK, where the work of William Farr at the General Register Office provided data for sanitary reformers.
Modern Public Health
In America, public health worker Dr. Sara Josephine Baker lowered the infant mortality rate using preventative methods. She established many programs to help the poor in New York City keep their infants healthy. Dr. Baker led teams of nurses into the crowded neighbourhoods of Hell's Kitchen and taught mothers how to dress, feed, and bathe their babies. After WWI many states and countries followed her example in order to lower infant mortality rates.
During the 20th century, the dramatic increase in average life span is widely credited to public health achievements, such as vaccination programs and control of infectious diseases, effective safety policies such as motor-vehicle and occupational safety, improved family planning, fluoridation of drinking water, anti-smoking measures, and programs designed to decrease chronic disease.

Jonas Salk developed a vaccine against polio in 1955, reducing the number of U.S. cases from 58,000 in 1952 to just 5,000 in 1957.
Meanwhile, the developing world remained plagued by largely preventable infectious diseases, exacerbated by malnutrition and poverty. Front-page headlines continue to present society with public health issues on a daily basis: emerging infectious diseases such as SARS, making its way from China to Canada and the United States; prescription drug benefits under public programs such as Medicare; the increase of HIV-AIDS among young heterosexual women and its spread in South Africa; the increase of childhood obesity and the concomitant increase in type II diabetes among children; the impact of adolescent pregnancy; and the ongoing social, economic and health disasters related to the 2005 Tsunami and Hurricane Katrina in 2006. These are all ongoing public health challenges.
Since the 1980s, the growing field of population health has broadened the focus of public health from individual behaviors and risk factors to population-level issues such as inequality, poverty, and education. Modern public health is often concerned with addressing determinants of health across a population, rather than advocating for individual behaviour change. There is a recognition that our health is affected by many factors including where we live, genetics, our income, our educational status and our social relationships - these are known as "social determinants of health." A social gradient in health runs through society, with those that are poorest generally suffering the worst health. However even those in the middle classes will generally have worse health outcomes than those of a higher social stratum (WHO, 2003). The new public health seeks to address these health inequalities by advocating for population-based policies that improve the health of the whole population in an equitable fashion.
The burden of treating conditions caused by unemployment, poverty, unfit housing and environmental pollution have been calculated to account for between 16-22% of the clinical budget of the British National Health Service.
UK Public health functions include:
• Health surveillance, monitoring and analysis • Investigation of disease outbreaks, epidemics and risk to health • Establishing, designing and managing health promotion and disease prevention programmes • Enabling and empowering communities to promote health and reduce inequalities • Creating and sustaining cross-Government and intersectoral partnerships to improve health and reduce inequalities •Ensuring compliance with regulations and laws to protect and promote health • Developing and maintaining a well-educated and trained, multi-disciplinary public health workforce • Ensuring the effective performance of NHS services to meet goals in improving health, preventing disease and reducing inequalities • Research, development, evaluation and innovation • Quality assuring the public health function

Medical Profession

The predecessors of today's directors of public health were the medical officers of health (MoH) appointed by the Board the first being Dr William Duncan who was appointed as MoH to the city of Liverpool in 1847. However, Dr Duncan and those medical officers of health who followed him, were employed by the local authority and only after a NHS reorganisation in 1974 did the medical officer of health and those community services that he (and it was normally a 'he') was responsible for like health visiting and maternal and child health, combine with hospital services and come under the auspices of the health authority. These 'Specialists in Community Medicine' in the 1970's were often 'preoccupied with inequalities in health services' (Crown, 1999) and it was not until a landmark report by Donald Acheson in 1988 that the public health function of health services was specifically addressed again. Also around this time a movement motivated in part by the WHO 'Health for All' strategy (1985) widened the perspective of public health to include once again environmental issues as well as the physical, social and psychological aspects of public health.

Acheson (1988) not only advocated a change in title for medics working in this area from 'Specialists in Community Medicine' back to Consultants in Public Health Medicine, but also clarified what public health medicine was about. His definition of public health being the 'science and art of preventing disease, prolonging life and promoting health through the organised efforts of society' is accepted today as definitive.

Other professions have also played a part in the development of public health in this country, but do not seem so widely acknowledged or accepted as expert as the medical profession. Environmental health officers in the 1800's played a massive role in enforcing by-laws to ensure clean water, streets and good sanitation in collaboration with the then medical officers of health, but stayed with the local authority after the 1974 reorganisation separating and thus diminishing the partnership of environmental health and medicine. Health visitors, the 'Lady Sanitary Visitors' of the 1800's although frequently designated as 'public health nurses' have often had their role marginalised by 'organisational barriers' (Cowley, 1995). All those involved in improving housing in Victorian times also played a major part in improving public health. Poor housing and poor health seem almost synonymous, Nightingale (Lowry, 1991) stated that 'the connection between health and the dwellings of the population is one of the most important that exists' and recently Acheson (1998) agreed by identifying that 'poor quality housing is associated with poor health and that dampness is associated with increased prevalence of allergic and inflammatory lung disease such as asthma, independent of smoking and other socio-economic conditions'.

It is heartening, therefore, to learn that the government is committed to widening the role of other health professionals in public health work and extending and strengthening collaboration between health services and local authorities where public health in the UK originated.

Public Health Clarified

What does Achesons' definition tell us about the meaning of public health? If community nurses are to be involved in public health work some understanding of its meaning is needed. Perhaps the key term is 'the organised efforts of society', implying some 'collective responsibility for health and prevention' (Beaglehole & Bonita, 1997). This can mean the partnerships and collaborative approaches the government is so keen on to promote health, like the 'health action zones' or 'health living centres'. Another key issue identified by Beaglehole and Bonita (1997) when clarifying the meaning of public health is that a population perspective must be taken.

Nurses involved in public health work need to focus on the health of local communities, groups and populations, not on individuals or families. When trying to identify the health needs of local communities', approaches using both 'art and science' come in. Beaglehole and Bonitas (1997) suggest both a qualitative (art) and quantitative (science) approach can be taken in identifying health needs. The foundation stone of the quantitative approach to public
Health is seen as epidemiology and it has certainly shaped much of public health action throughout the last 150 years.

Historically Snow's work on cholera during 1848-54 and more recently the classic cohort study by Richard Doll and colleagues (1994), where an association was found between cigarette smoking and disease, particularly lung cancer, have both had long term consequences for the population as a whole. However, with users of the health service being urged to participate in identifying health needs a more qualitative approach is being taken and is being more readily accepted e.g. focus group work. Another key feature of public health is the acknowledgement that health is much more than the biological determinants communities are born with or acquire, but that it is the socio-economic and environmental factors that affect communities health which need to be tackled.

Although health visitors and school health nurses are particularly mentioned in 'Saving Lives' (DoH, 1999) all community nurses can expect some involvement at some time in the public health agenda into the next millennium.

This for the most parts will be dependent on local initiatives and local need but could involve:

• Helping local groups and communities identify their own health needs.

• Meeting specific health needs of local communities e.g. accident prevention or reducing coronary heart disease.

• Working in partnership with other agencies to meet identified local health needs.

Initiating or maintaining programmes to meet specific local targets.
Although the purely medical approach to public health work is being questioned and public health is increasingly seen as multidisciplinary, community nurses specifically, have been identified to initiate and to implement aspects of public health policy. The question is are we up to the challenge?

References

? Fee E, Acheson R. A history of education in public health. Health that mocks the doctors’ rules. Oxford: Oxford University Press, 1991.

? Hamlin C. Public health and social justice in the age of Chadwick: Britain, 1800–1854. Cambridge: Cambridge University Press, 1998.

? Harrison M. Public Health in British India. Anglo-Indian Preventive Medicine, 1859–1914. Cambridge: Cambridge University Press, 1994.
? Lewis J. What Price Community Medicine? The Philosophy, Practice and Politics of Public Health since 1919. Brighton: Harvester/Wheatsheaf, 1986.

? Petersen A, Lupton D. The New Public Health. Health and Self in the Age of Risk. London: Sage, 1996.

? Porter D, ed. The History of Public Health and the Modern State. Amsterdam: Rodopi, 1994.

? Webster C, ed. Caring for health. History and diversity. 3rd edn. Buckingham:Open University Press, 2001.

? Weindling P, ed. The social history of occupational health. Beckenham: Croom Helm, 1985.

? Worboys M. Spreading germs: disease theories and medical practice in Britain, 1865–1900. Cambridge: Cambridge University Press, 2000.

? Acheson, D. (1988) Committee of Inquiry into the future Development of the Public Health function. HMSO, London.

? Acheson, D. (1988) Independent Inquiry into Inequalities in health. The Stationery Office, London.

? Ashton, J., Seymour, H. (1988) The New Public Health. Open University Press, Milton Keynes.

? Ashton, J. (1999) 'Past and present public health in Liverpool' Griffiths, S. and Hunter, D.J. (Eds). (1999) Perspectives in Public Health. Radcliffe Medical Press

? Clark, P., Slack, P. (1976) English Towns in Transition 1500-1700. Oxford University Press, London.

? Crown, J. (1999) 'The practice of public health medicine: past, present, future.' In DoH (1997) The New NHS, modern, dependable. The Stationery Office, London.

? Griffiths, S. and Hunter, DJ (Eds) (1999) Perspectives in Public Health. Radcliffe Medical Press, Oxford.

? Webster, C. (1990) The Victorian Public Health legacy: A Challenge to the Future. The Public Health Alliance, Birmingham.

? WHO (1985) Health For All in Europe by the Year 2000, Regional Targets. WHO, Copenhagen.

First Published November 2007

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