Summary of : A History of Public Health

Summary of :

A History of Public Health

Compiler :

Miracle Brite Waani                                        15111101262

Faculty of Public Health

Sam Ratulangi University

2017

INTRODUCTION

History provides a perspective to develop an understanding of health problems of communities and how to cope with them. We see through the eyes of the past how societies conceptualized and dealt with disease. All societies must face the realities of disease and death, and development concepts and methods to manage them. These coping strategies form part of a worldview associated with a set of cultural or scientific beliefs, which in turn help to determine the curative and preventive approaches to health.

PREHISTORIC SOCIETIES

Earth is considered to be 4.5 billion years old, with the earliest stone tools dating from 2.5 million years BCE representing the presence of antecedents of man. Homo erectus lived from 1.5 million to 500,000 years ago and Homo sapiens Neanderthalensis at about 110,000 BCE. The Paleolithic Age is the earliest stage of man’s development where organized societal structures are known to have existed. These social structures consisted of people living in bands which survived by hunting and gathering food. There is evidence of use of fire going back some 230,000 years, and increasing sophistication of stone tools, jewelry, cave paintings, and religious symbols during this period. Modern man evolved from

Homo sapiens, probably originating in Africa and the Middle East about 90,000 years ago, and appearing in Europe during the Ice Age period from 40,000–35,000 BCE. During this time, man spread over all major land masses following the retreating glaciers of the last Ice Age at 11,000–8000 BCE.

THE ANCIENT WORLD

Development of agriculture served growing populationsunable to exist solely from hunting, stimulating the organization of more complex societies able to share in production and in irrigation systems. Division of labor, trade, commerce, and government were associated with development of urban societies. Growth of population and communal living led to improved standards of living but also created new health hazards including spread of diseases. As in our time, these challenges required community action to prevent disease and promote survival.

Ancient cities in India were planned with building codes, street paving,

and covered sewer drains built of bricks and mortar. Indian medicine originated in herbalism associated with the mythical gods. Between 800 and 200 BCE, Ayurvedic medicine developed and with it, medical schools and public hospitals. Between 800 BCE and 400 CE, major texts of medicine and surgery were written. Primarily focused in the Indus Valley, the golden age of ancient Indian medicine began in approximately 800 BCE. Personal hygiene, sanitation, and water supply

engineering were emphasized in the laws of Manu. Pioneering

physicians, supported by Buddhist kings, developed the use of drugs and surgery, and established schools of medicine and public hospitals as part of state medicine. Indian medicine played a leading role throughout Asia, as did Greek medicine in Europe and the Arab countries. With the Mogul invasion of 600 CE, state support declined, and with it, Indian medicine.

THE EARLY MEDIEVAL PERIOD (FIFTH  TO TENTH CENTURIES CE)

The Roman Empire disappeared as an organized entity following the sacking of Rome in the fifth century CE. The eastern empire survived in Constantinople, with a highly centralized government. Later conquered by the Muslims, it provided continuity for Greek and Roman teachings in

health. The western empire integrated Christian and pagan cultures, looking at disease as punishment for sin. Possession by the devil and witchcraft were accepted as causes of disease. Prayer, penitence, and exorcising witches were

accepted means of dealing with health problems. The ensuing period of history was dominated in health, as in all other spheres of human life, by the Christian doctrine institutionalized by the Church. The secular political structure was

dominated by feudalism and serfdom, associated with a strong military landowning class in Europe. Church interpretation of disease was related to original or acquired sin. Man’s destiny was to suffer on Earth and hope for a better life in heaven. The appropriate intervention in this philosophy was to provide comfort and care through the charity of church institutions. The idea of prevention was seen as interfering with the will of God. Monasteries with well-developed sanitary facilities were located on major travel routes and provided hospices for travelers. The monasteries were the sole centers of

learning and for medical care. They emphasized the tradition of care of the sick and the poor as a charitable duty of the righteous and initiated hospitals. These institutions provided care and support for the poor, as well as efforts to cope with epidemic and endemic disease.

THE LATE MEDIEVAL PERIOD (ELEVENTH TO FIFTEENTH CENTURIES)

In the later feudal period, ancient Hebraic and Greco Roman concepts of health were preserved and flourished in the Muslim Empire. The twelfth-century Jewish philosopher-physician Moses Maimonides, trained in Cordova and expelled to Cairo, helped synthesize Roman, Greek, and Arabic medicine with Mosaic concepts of communicable disease isolation and sanitation. Monastery hospitals were established between the eighth and twelfth centuries to provide charity and care to ease the suffering of the sick and dying. Monastery hospitals were described in the eleventh century in Russia. Monasteries provided centers of literacy, medical care, and the ethic of caring for the sick patient as an act of

charity. The monastery hospitals were gradually supplanted by municipal, voluntary, and guild hospitals developed in the twelfth to sixteenth centuries. By the fifteenth century, Britain had 750 hospitals. Medical care insurance was provided by guilds to its members and their families. Hospitals employed doctors, and the wealthy had access to private doctors

The fourteenth century saw a devastation of the population of Europe by plague, wars, and the breakdown of feudal society. It also set the stage for the agricultural revolution and later the industrial revolution. The period fol-

lowing the Black Death was innovative and dynamic. Lack of farm labor led to innovations in agriculture. Enclosures of common grazing land reduced spread of disease among animals, increased field crop productivity, and improved sheep farming, leading to development of the wool and textile industries and the search for energy sources, industrialization, and international markets

THE RENAISSANCE (1500–1750)

Commerce, industry, trade, merchant fleets, and voyages of discovery to seek new markets led to the development of a moneyed middle class and wealthy cities. In this period, mines, foundries, and industrial plants flourished, creating

new goods and wealth. Partly as a result of the trade generated and the increased movement of goods and people, vast epidemics of syphilis, typhus, smallpox, measles, and the plague continued to spread across Europe. Malaria was still

widespread throughout Europe. Rickets, scarlet fever, and scurvy, particularly among sailors, were rampant. Pollution and crowding in industrial areas resulted in centuries-long epidemics of environmental disease, particularly among

the urban working class. A virulent form of syphilis, allegedly brought back

from America by the crews of Columbus, spread rapidly throughout Europe between 1495 and 1503, when it was first described by Fracastorus. Control measures tried in various cities included examination and registration of

prostitutes, closure of communal bath houses, isolation in special hospitals, reporting of disease, and expulsion of sick prostitutes or strangers. The disease gradually decreased in virulence, but it remains a major public health problem Eighteenth-Century Reforms The period of enlightenment and reason was led by philosophers Locke, Diderot, Voltaire, Rousseau, and others. These men produced a new approach to science and knowledge derived from observations and systematic testing of ideas as opposed to instinctive or innate knowledge

as the basis for human progress. The idea of the rights of man contributed to the American and French revolutions, but also to a widening belief that society was obliged to serve all rather than just the privileged. This had a profound impact on approaches to health and societal issues.

Applied Epidemiology

Scurvy (the Black Death of the Sea) was a major health

problem among sailors during long voyages. In 1498, Vasco da Gama lost 55 crewmen to scurvy during his voyages, and in 1535, Jacques Cartier’s crew suffered severely from scurvy on his voyage of discovery to Canada. During the sixteenth century, Dutch sailors knew of the value of fresh vegetables and citrus fruit in preventing scurvy

Jenner and Vaccination

Smallpox, a devastating and disfiguring epidemic disease, ravaged all parts of the world and was known since the third century BCE. Described first by Rhazes in the tenth century, the disease was confused with measles and was widespread in Asia, the Middle East, and Europe during the Middle Ages. It was a designated cause of death in the Bills of Mortality in 1629 in London. Epidemics of smallpox occurred throughout the seventeenth to eighteenth and into the nineteenth centuries primarily as a disease of childhood, with mortality rates of 25 to 40 percent or more and disfiguring sequelae.

FOUNDATIONS OF HEALTH STATISTICS AND EPIDEMIOLOGY

Registration of births and deaths forms the basis of demography. Epidemiology as a discipline borrows from demography, sociology, and statistics. The basis of scientific reasoning in these fields emerged in the early seven-

teenth century with inductive reasoning enunciated by Francis Bacon and applied by Robert Boyle in chemistry, Isaac Newton in physics, William Petty in economics, and John Graunt in demography. Bacon’s writing inspired a whole generation of scientists in different fields and led to the founding of the Royal Society.

SOCIAL REFORM AND THE SANITARY MOVEMENT (1830–1875)

Following the English civil war in 1646, veterans of the Parliamentary Army called on the government to provide free schools and free medical care throughout the country as part of democratic reform. However, they failed to sustain interest or gain support for their revolutionary ideas amidst postwar religious conflicts and restoration of the monarchy. In Russia, the role of the state in health was promoted following initiatives of Peter the Great to introduce west-

ern medicine to the country. During the rule of Catherine the Great, under the supervision of Count Orlov, an epidemic of plague in Moscow (1771–1772) was suppressed by incentive payments to bring the sick for care. In 1784, a Russian physician, I. L. Danilevsky, defended a doctoral dissertation on “Government power — the best doctor.” In the eighteenth and nineteenth centuries, reform

movements promoted health initiatives by government. While these movements were suppressed (the Decembrists, 1825–1830) and liberal reform steps reversed, their ideas influenced later reforms in Russia. Max von Pettenkoffer in 1873 studied the high mortality rates of Munich, comparing them to rapidly declining

rates in London. His public lectures on the value of health to a city led to sanitary reforms, as were being achieved in Berlin at the same time under Virchow’s leadership. Pettenkoffer introduced laboratory analysis to public health practice and established the first academic chair in hygiene and public health, emphasizing the scientific basis for public health. He is considered to be the first professor

of experimental hygiene. Pettenkoffer promoted the concept of the value of a healthy city, stressing that health is the result of a number of factors and public health is a community concern, and that measures taken to help those in need benefit the entire community.

Germ Versus Miasma Theories

Until the early and middle parts of the nineteenth century, the causation of disease was hotly debated. The miasma theory, holding that disease was the result of environmental emanations or miasmas, went back to Greek and Roman medicine, and Hippocrates (Air, Water, and Places). Miasmists believed that disease was caused by infectious mists or noxious vapors emanating from filth

in the towns and that the method of prevention of infectious diseases was to clean the streets of garbage, sewage, animal carcasses, and wastes that were features of urban living. This provided the basis for the Sanitary Movement, with great benefit to improving health conditions. The miasma theory had strong proponents well into the later part of the nineteenth century.

HOSPITAL REFORM

Hospitals developed by monasteries as charitable services were supplanted by voluntary or municipal hospitals mainly for the poor during and after the Renaissance. Reforms in hospital care evolved along with the sanitary revolution. In eighteenth-century Europe, hospitals operated by religious orders of nuns and by municipal or charitable organizations were dangerous cesspools of pestilence because of lack of knowledge about and practice of infection control, concentration of patients with highly communicable diseases, and transmission of disease by medical and other staff. Reforms in hospitals in England were stimulated by the reports of John Howard in the late eighteenth century, becoming part of wider social reform in the early part of the nineteenth century. Professional reform in hospital organization and care started in the latter half of the nineteenth century under the influence of Florence Nightingale, Oliver Wendel Holmes, and Ignaz Semmelweiss. Clinical epidemiologic studies of “antiseptic principles” provided a new, scientific approach to improvement in health care.

THE BACTERIOLOGIC REVOLUTION

In the third quarter of the nine teenth century, the sanitary movement rapidly spread through the cities of Europe with demonstrable success in reducing disease in areas served by sewage drains, improved water supplies, street paving, and waste removal.

Vector-Borne Disease

Studies of disease transmission defined the importance of carriers (i.e., those who can transmit a disease without showing clinical symptoms) in transmission of diphtheria, typhoid, and meningitis. This promoted studies of diseases borne by intermediate hosts or vectors. Parasitic diseases of animals and man were investigated in many centers during the nineteenth century, including Guinea worm disease, tapeworms, filariasis, and veterinary parasitic diseases such as Texas cattle fever. David Bruce demonstrated transmission of nagana (animal African trypanosomiasis), a disease of cattle and horses in Zululand, South Africa, in 1894–1895, caused by a trypanosome parasite transmitted by the tsetse fly, leading to environmental methods of control of disease transmission.

MICROBIOLOGY AND IMMUNOLOGY

Ilya Ilyich Mechnikov in Russia in 1883 described phagocytosis, a process in which white cells in the blood surround and destroy bacteria, and his elaboration of the processes of inflammation and humoral and cellular response led to a joint Nobel Prize in 1908 with Paul Ehrlich. Other investigators searched for the bactericidal or immunological properties of blood that enabled cellfree blood or serum to destroy bacteria. This work greatly strengthened the scientific bases for bacteriology and immunology.

Pasteur’s co-workers, Emile Roux and Alexandre Yersin, isolated and grew the causative organism for diphtheria and suggested that the organism produced a poison or toxin which caused the lethal effects of the disease. In 1890, Karl Fraenkel in Berlin published his work showing that inoculating guinea pigs with attenuated diphtheria organism could produce immunity.

Advances in Treatment of Infectious Diseases

Since World War II, advances in immunology as applied to public health led to the control and in some cases potential eradication of diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella, and more recently hepatitis B and Haemophilus influenza type b. The future in this field is promising and will play a central role in public health well into the twenty-first century. Treatment of infectious diseases has also played a vital part in reducing the toll of disease and limiting its spread. In 1909, Paul Ehrlich, awarded the Nobel Prize in 1908 jointly with Methchnikov, seeking a “magic bullet,” discovered an effective antimicrobial agent for syphilis (Salvarsan). Later more important antimicrobial antibiotics

were discovered in the 1920s, followed by the sulfa drugs in the 1930s, and the antibiotics and penicillin and streptomycin in the 1940s by Alexander Fleming and Selman Waksman (Nobel Prizes, 1945 and 1952). These and later generations of antibiotics have proven powerful tools in the treatment of infectious diseases

MATERNAL AND CHILD HEALTH

Preventive care for the special health needs of women and children developed as public concerns in the late nineteenth century. Public awareness of severe conditions of women’s and children’s labor grew to include the effects on health of poverty, poor living conditions and general hygiene, home deliveries, lack of prenatal care, and poor nutrition. Preventive care as a service separate from curative medical services for women and children was initiated in the unsanitary urban slums of industrial cities in nineteenth century France in the form of milk stations ( gouttes de lait ). One village in France instituted an incentive payment to mothers whose babies lived to 1 year; this resulted in a decline in infant mortality from 300 per 1000 to 200 per 1000 within a few years. The plan was later expanded to a complete child welfare effort, especially promoting breast-feeding and a clean supply of milk to children, which had dramatic effects in reducing infant deaths.

NUTRITION IN PUBLIC HEALTH

As infectious disease control and later maternal and child health became public health issues in the eighteenth to nineteenth centuries, nutrition gained recognition from the work of pioneers such as James Lind (see preceding section entitled “Applied Epidemiology”). In 1882, Kanehiro Takaki, surgeon-general of the Japanese navy, reduced incidence of beriberi among naval crews by adding meat and vegetables to their diet of rice. In 1900, Christiaan Eijkman, a Dutch medical officer in the East Indies, found that inmates of prison camps who ate polished rice developed beriberi, while those eating whole rice did not. He also produced beriberi experimentally in fowls on a diet of polished rice, thus establishing the etiology of the disease as a deficiency condition and fulfilling a nutritional epidemiologic hypothesis. Eijkman was awarded the Nobel Prize in

physiology or medicine in 1929. In the United States, the pioneering Pure Food and Drug Act was passed in 1906, stimulated by journalistic exposures of conditions in the food industry and Upton Sinclair’s famous 1906 novel The Jungle. The legislation established federal authority in food and labeling standards, originally for interstate commerce, but later for the entire country. This provided for a federal regulatory agency and regulations for food standards. The Food and Drug Administration (FDA) has pioneered nutritional standards now used throughout the world. In the early part of the twentieth century, the U.S.

Department of Agriculture (USDA) supported “land grant colleges” and rural counties to establish an extension service to promote agricultural improvement and good nutrition in poor agricultural areas of the country. These services, along with local women’s organizations, helped create a mass movement to improve good nutrition, canning surplus foods, house gardening, home poultry production, home nursing, furniture refinishing, and other skills that helped farm families survive the years of economic depression and drought, promoting better nutrition

through education and community participation.

MILITARY MEDICINE

Professional armies evolved with urban civilizations and developed in the ancient world from about 4000 BCE. Since organized conflict began, armies have had to deal with the health of soldiers as well as treatment of the wounded. Injunctions on military and civilian camp siting and sanitation were c

learly spelled out in the Bible (Old Testament). Roman armies excelled at con-

struction of camps with care and concern for hygienic conditions, food, and medical services for the soldiers. Throughout history, examples of defeat of armies by disease and lack of support services prove the need for serious attention to the health and care of the soldier. Studies of casualties of war in major conflicts contribute not only to military medicine but to knowledge of the care of civilian populations in natural or man-made disasters.

INTERNATIONALIZATION OF HEALTH

Cooperation in health has been a part of international diplomacy from the first international conference on cholera in 1851 in Cairo to the health organization of the League of Nations after World War I, and into modern

times. Following World War II, international health began to promote widespread application of public health technology, such as immunization, to developing countries. The World Health Organization (WHO) was founded in 1946 with a charter defining health as “the complete state of physical, social and mental well-being, and not merely the absence of disease.” The tradition of international cooperation is continued by organizations such as WHO, the International Red

Cross/Red Crescent (IRC), United Nations Children’s Fund (UNICEF), and many others. Under the leadership of WHO, eradication of smallpox by 1977 was achieved through united action, showing that major threats to health could be controlled through international cooperation. The potential for eradication of polio further demonstrates this principle. The global spread of disease has taken enormous tolls of human life with global proportions and the threat continues in the twenty-first century. Globalization of public health threats can emerge and spread rapidly, as seen with the HIV pandemic since the 1980s and SARS in 2003. More recently, concerns have grown for potentially devastating pandemic influenza, such as the H5N1 virus strain known as avian influenza. Chronic diseases, the commonest causes of mortality and disability in the industrialized

countries in the latter half of the twentieth century, are now also predominant in most developing countries with growing middle-class communities. Tobacco use, obesity, diabetes, heart disease, and cancer are among the leading

causes of morbidity and mortality in the contemporary world.

THE EPIDEMIOLOGIC TRANSITION

As societies evolve, so do patterns of disease. These changes are partly the result of public health and medical care but just as surely are due to improved standards of living, nutrition, housing, and economic security, as well as changes in fertility and other family and social factors.As disease patterns change, so do appropriate strategies for intervention. During the first half of the twentieth century, infectious diseases predominated as causes of death even in the developed countries. Since World War II, a major shift in epidemiologic patterns has taken place in the industrialized countries, with the decline in infectious diseases and an increase in the noninfectious diseases as causes of death. Increases in longevity have occurred primarily from declining infant and child mortality, improved nutrition, control of vaccine-preventable diseases, and the advent

of antibiotics for treatment of acute infectious diseases. The rising incidence of cardiovascular diseases and cancer affects primarily older people, leading to a growing emphasis in epidemiologic investigations on causative risk factors for these noninfectious diseases. Studies of the distribution of noninfectious diseases in specific groups go back many centuries when the Romans reported excess death rates among specific occupational groups. These studies were updated by Ramazzini in the early eighteenth century. As noted earlier, in eighteenth century London, Percival Potts documented that cancer of the scrotum was more common among chimney sweeps than in the general population. Nutritional epidemiologic

studies, from Lind on scurvy among sailors in 1747 to Goldberger on pellagra in the southern United States in 1914, focused on nutritional causes of noninfectious diseases in public health.

ACHIEVEMENTS OF PUBLIC HEALTH IN THE TWENTIETH CENTURY

The foundations of public health organization were laid in the second half of the nineteenth and first half of the twentieth centuries. Water sanitation, waste removal, and food control developed at municipal and higher levels of government, establishment of organized local public health offices with state and federal grants, and improved vaccination technology all contributed to the control of communicable diseases. Organized public health services implemented the regulatory and service components of public health in developed countries, with national standards for food and drug safety, state licensing, and discipline in the health professions. At the beginning of the twentieth century, there were few effective medical treatments for disease, but improved public health sta

ndards resulted in reduced mortality and increased longevity. As medical technology improved following World War II with antibiotics, antihypertensives, and antipsychotic therapeutic agents, the focus was on curative medical care, with a widening chasm between public health and medicine. In our time, a new interest in the commonality between the two is emerging as new methods of organizing

and financing health care develop, to contain the rising costs of health care and increase utilization of preventive medicine. National and state efforts to promote public health during the twentieth century widened in scope of activities

and financing programs. This required linkage between governmental and nongovernmental activities for effective public health services. Dramatic scientific innovations brought vaccines and antibiotics which along with improved nutrition and living standards, helped to control infectious disease as the major cause of death. In the developed countries, the advent of national or voluntary health insurance on a wide scale opened access to health care to high percentages of the population.

CREATING AND MANAGING HEALTH SYSTEMS

Provision of medical care to the entire population is one of the great challenges of public health. Governments of all political stripes are active in the field of health policy, as insurers, providers, or regulators of health care. As will

be discussed in subsequent chapters, nations have many reasons to ensure health for all, just as they promote universal education and literacy. National interests in the late nineteenth and early twentieth centuries were defined to include having healthy populations, especially for workers and soldiers, and for national prestige. Responsibility for the health of a nation included measures for prevention

of disease, but also financing and prepayment for medical and hospital care. National policies gradually took on measures to promote health, structures to evaluate health of the nation, and modification of policies to keep up with

changing needs. The health of a population requires access to medical and hospital services as well as preventive care, a healthy environment, and a health promotion and policy orientation. Greek and Roman cities appointed doctors to provide

free care for the poor and the slaves. Medieval guilds provided free medical services to their members. In 1883, Germany introduced compulsory national health insurance to ensure healthy workers and army recruits, which would provide a political advantage. In 1911, Britain’s Chancellor of the Exchequer, Lloyd George, instituted the National Insurance Act, providing compulsory

health insurance for workers and their families. In 1918, following the October Revolution, the Soviet Union created a comprehensive state-operated health system with an emphasis on prevention, providing free comprehensive care in all parts of the country

SUMMARY

The history of public health is directly related to the evolution of thinking about health. Ancient societies in one way or another realized the connection between sanitation and health and the role of personal hygiene, nutrition, and

fitness. The sanctity of human life ( Pikuah Nefesh ) established an overriding human responsibility to save life derived from Mosaic Law from 1500 BCE. The scientific and ethical basis of medicine was also based on the teachings of Hippocrates in the fourth century BCE. Sanitation, hygiene, good nutrition, and physical fitness all had roots in ancient societies including obligations of the society to provide care for the poor. These ethical foundations support efforts to preserve life even at the expense of other religious or civil ordinances. Social and religious systems linked disease to sin and punishment by higher powers, viewed investigation or intervention by society (except for relief of pain and suffering) as interference with God’s will. Childbirth was associated with pain, disease, and frequent death as a general concept of “in sorrow shall you bring forth children.”Health care was seen as a religious charitable responsibility to ease the suffering of sinners.

Acceptance of the right to health for all by the founders of the United Nations and the WHO added a universal element to the mission of public health. This concept was embodied in the constitution of the WHO and given more

concrete form in the Health for All concept of Alma-Ata, which emphasized the right of health care for everyone and the responsibility of governments to ensure that right. This concept also articulates the primary importance of prevention and primary care, which became a vital issue in competition for resources between public health and hospital-oriented health care.

The lessons of history are important in public health. Basic issues of public health need to be revived because new challenges for health appear and old ones re-emerge. The philosophical and ethical basis of modern public health is a belief in the inherent worth of the individual and his or her human right to a safe and healthful environment.