Public Health/History

Learning Tasks

 * Explore the history of public health and the origin of basic concepts. What are the main changes and evolutionary steps in Public Health in history?
 * What were the drivers for innovation in the field of public health?

History
See also the history about water supply and sanitation

Until the 18th century


From the beginnings of human civilization, communities promoted health and fought disease at the population level. Definitions of health as well as methods to pursue it differed according to the medical, religious and natural-philosophical ideas groups held, the resources they had, and the changing circumstances in which they lived. Yet few early societies displayed the hygienic stagnation or even apathy often attributed to them. The latter reputation is mainly based on the absence of present-day bioindicators, especially immunological and statistical tools developed in light of the germ theory of disease transmission.

Public health was born neither in Europe nor as a response to the Industrial Revolution. Preventive health interventions are attested almost anywhere historical communities have left their mark. In Southeast Asia, for instance, Ayurvedic medicine and subsequently Buddhism fostered occupational, dietary and sexual regimens that promised balanced bodies, lives and communities, a notion strongly present in Traditional Chinese Medicine as well. Among the Mayans, Aztecs and other early civilizations in the Americas, population centers pursued hygienic programs, including by holding medicinal herbal markets. And among Aboriginal Australians, techniques for preserving and protecting water and food sources, micro-zoning to reduce pollution and fire risks, and screens to protect people against flies were common, even in temporary camps. Western European, Byzantine and Islamicate civilizations, which generally adopted a Hippocratic, Galenic or humoral medical system, fostered preventive programs as well. These were developed on the basis of evaluating the quality of local climates, including topography, wind conditions and exposure to the sun, and the properties and availability of water and food, for both humans and nonhuman animals. Diverse authors of medical, architectural, engineering and military manuals explained how to apply such theories to groups of different origins and under different circumstances. This was crucial, since under Galenism bodily constitutions were thought to be heavily shaped by their material environments, so their balance required specific regimens as they traveled during different seasons and between climate zones.

In complex, pre-industrialized societies, interventions designed to reduce health risks could be the initiative of different stakeholders. For instance, in Greek and Roman antiquity, army generals learned to provide for soldiers' wellbeing, including off the battlefield, where most combatants died prior to the twentieth century. In Christian monasteries across the Eastern Mediterranean and western Europe since at least the fifth century CE, monks and nuns pursued strict but balanced regimens, including nutritious diets, developed explicitly to extend their lives. And royal, princely and papal courts, which were often mobile as well, likewise adapted their behavior to suit environmental conditions in the sites they occupied. They could also choose sites they considered salubrious for their members and sometimes had them modified.

In cities, residents and rulers developed measures to benefit the general population, which faced a broad array of recognized health risks. These provide some of the most sustained evidence for preventive measures in earlier civilizations. In numerous sites the upkeep of infrastructures, including roads, canals and marketplaces, as well as zoning policies, were introduced explicitly to preserve residents' health. Officials such as the muhtasib in the Middle East and the Road master in Italy, fought the combined threats of pollution through sin, ocular intromission and miasma. Craft guilds were important agents of waste disposal and promoted harm reduction through honesty and labor safety among their members. Medical practitioners, including public physicians, collaborated with urban governments in predicting and preparing for calamities and identifying and isolating people perceived as lepers, a disease with strong moral connotations. Neighborhoods were also active in safeguarding local people's health, by monitoring at-risk sites near them and taking appropriate social and legal action against artisanal polluters and neglectful owners of animals. Religious institutions, individuals and charitable organizations in both Islam and Christianity likewise promoted moral and physical wellbeing by endowing urban amenities such as wells, fountains, schools and bridges, also in the service of pilgrims. In western Europe and Byzantium, religious processions commonly took place, which purported to act as both preventive and curative measures for the entire community.

Urban residents and other groups also developed preventive measures in response to calamities such as war, famine, floods and widespread disease. During and after the Black Death (1346–53), for instance, inhabitants of the Eastern Mediterranean and Western Europe reacted to massive population decline in part on the basis of existing medical theories and protocols, for instance concerning meat consumption and burial, and in part by developing new ones. The latter included the establishment of quarantine facilities and health boards, some of which eventually became regular urban (and later national) offices. Subsequent measures for protecting cities and their regions included issuing health passports for travelers, deploying guards to create sanitary cordons for protecting local inhabitants, and gathering morbidity and mortality statistics. Such measures relied in turn on better transportation and communication networks, through which news on human and animal disease was efficiently spread.

After the 18th century
With the onset of the Industrial Revolution, living standards amongst the working population began to worsen, with cramped and unsanitary urban conditions. In the first four decades of the 19th century alone, London's population doubled and even greater growth rates were recorded in the new industrial towns, such as Leeds and Manchester. This rapid urbanization exacerbated the spread of disease in the large conurbations that built up around the workhouses and factories. These settlements were cramped and primitive with no organized sanitation. Disease was inevitable and its incubation in these areas was encouraged by the poor lifestyle of the inhabitants. Unavailable housing led to the rapid growth of slums and the per capita death rate began to rise alarmingly, almost doubling in Birmingham and Liverpool. Thomas Malthus warned of the dangers of overpopulation in 1798. His ideas, as well as those of Jeremy Bentham, became very influential in government circles in the early years of the 19th century. The latter part of the century brought the establishment of the basic pattern of improvements in public health over the next two centuries: a social evil was identified, private philanthropists brought attention to it, and changing public opinion led to government action. The 18th century saw rapid growth in voluntary hospitals in England.

The practice of vaccination began in the 1800s, following the pioneering work of Edward Jenner in treating smallpox. James Lind's discovery of the causes of scurvy amongst sailors and its mitigation via the introduction of fruit on lengthy voyages was published in 1754 and led to the adoption of this idea by the Royal Navy. Efforts were also made to promulgate health matters to the broader public; in 1752 the British physician Sir John Pringle published Observations on the Diseases of the Army in Camp and Garrison, in which he advocated for the importance of adequate ventilation in the military barracks and the provision of latrines for the soldiers.

Public health legislation in England


The first attempts at sanitary reform and the establishment of public health institutions were made in the 1840s. Thomas Southwood Smith, physician at the London Fever Hospital, began to write papers on the importance of public health, and was one of the first physicians brought in to give evidence before the Poor Law Commission in the 1830s, along with Neil Arnott and James Phillips Kay. Smith advised the government on the importance of quarantine and sanitary improvement for limiting the spread of infectious diseases such as cholera and yellow fever.

The Poor Law Commission reported in 1838 that "the expenditures necessary to the adoption and maintenance of measures of prevention would ultimately amount to less than the cost of the disease now constantly engendered". It recommended the implementation of large scale government engineering projects to alleviate the conditions that allowed for the propagation of disease. The Health of Towns Association was formed at Exeter Hall London on 11 December 1844, and vigorously campaigned for the development of public health in the United Kingdom. Its formation followed the 1843 establishment of the Health of Towns Commission, chaired by Sir Edwin Chadwick, which produced a series of reports on poor and insanitary conditions in British cities.

These national and local movements led to the Public Health Act, finally passed in 1848. It aimed to improve the sanitary condition of towns and populous places in England and Wales by placing the supply of water, sewerage, drainage, cleansing and paving under a single local body with the General Board of Health as a central authority. The Act was passed by the Liberal government of Lord John Russell, in response to the urging of Edwin Chadwick. Chadwick's seminal report on The Sanitary Condition of the Labouring Population was published in 1842 and was followed up with a supplementary report a year later. During this time, James Newlands (appointed following the passing of the 1846 Liverpool Sanatory Act championed by the Borough of Liverpool Health of Towns Committee) designed the world's first integrated sewerage system, in Liverpool (1848–1869), with Joseph Bazalgette later creating London's sewerage system (1858–1875).

The Vaccination Act 1853 introduced compulsory smallpox vaccination in England and Wales. By 1871 legislation required a comprehensive system of registration run by appointed vaccination officers.

Further interventions were made by a series of subsequent Public Health Acts, notably the 1875 Act. Reforms included the building of sewers, the regular collection of garbage followed by incineration or disposal in a landfill, the provision of clean water and the draining of standing water to prevent the breeding of mosquitoes.

The Infectious Disease (Notification) Act 1889 mandated the reporting of infectious diseases to the local sanitary authority, which could then pursue measures such as the removal of the patient to hospital and the disinfection of homes and properties.

Public health legislation in other countries
In the United States, the first public health organization based on a state health department and local boards of health was founded in New York City in 1866.

In Germany during The Weimar Republic the country faced many public health catastrophes. The Nazi Party had a goal of modernizing health care with Volksgesundheit, German for people's public health; this modernization was based on the growing field of eugenics and measures prioritizing group health over any care for the health of individuals. The end of World War 2 led to the Nuremberg Code, a set of research ethics concerning human experimentation.

Epidemiology
The science of epidemiology was founded by John Snow's identification of a polluted public water well as the source of an 1854 cholera outbreak in London. Snow believed in the germ theory of disease as opposed to the prevailing miasma theory. By talking to local residents (with the help of Reverend Henry Whitehead), he identified the source of the outbreak as the public water pump on Broad Street (now Broadwick Street). Although Snow's chemical and microscope examination of a water sample from the Broad Street pump did not conclusively prove its danger, his studies of the pattern of the disease were convincing enough to persuade the local council to close the well pump by removing its handle.

Snow later used a dot map to illustrate the cluster of cholera cases around the pump. He also used statistics to illustrate the connection between the quality of the water source and cholera cases. He showed that the Southwark and Vauxhall Waterworks Company was taking water from sewage-polluted sections of the Thames and delivering the water to homes, leading to an increased incidence of cholera. Snow's study was a major event in the history of public health and geography. It is regarded as the founding event of the science of epidemiology.

Control of infectious diseases


With the pioneering work in bacteriology of French chemist Louis Pasteur and German scientist Robert Koch, methods for isolating the bacteria responsible for a given disease and vaccines for remedy were developed at the turn of the 20th century. British physician Ronald Ross identified the mosquito as the carrier of malaria and laid the foundations for combating the disease. Joseph Lister revolutionized surgery by the introduction of antiseptic surgery to eliminate infection. French epidemiologist Paul-Louis Simond proved that plague was carried by fleas on the back of rats, and Cuban scientist Carlos J. Finlay and U.S. Americans Walter Reed and James Carroll demonstrated that mosquitoes carry the virus responsible for yellow fever. Brazilian scientist Carlos Chagas identified a tropical disease and its vector.