Public Health

Concepts and practices

The Greco-Roman world

The Middle Ages

The modern era

Public health and sanitary reform

Development of the health sciences

The twentieth century—international trends

BIBLIOGRAPHY

As far back in time as one can ascertain, men have lived in the organized groups that we call communities and have had to deal in one way or another with health problems arising from their biological attributes and needs and from their social circumstances. The major areas of concern have been the provision of food and water in sufficient supply and of acceptable quality, the control of the physical environment, the prevention or control of epidemic and endemic diseases, the provision of health care, and the relief of physical and social disability.

Out of the need for dealing with the health problems of group living, there has evolved, with increasing clarity over the centuries, a recognition of the signal importance of community action in the promotion of health and the prevention and treatment of disease. This recognition and its consequences for action are summed up in the concept of public health. It has its roots in such rudimentary measures as the rituals and incantations against pestilence of ancient Mesopotamia and in the advanced administrative systems of imperial Rome, the ruthless isolation by the medieval community of the person afflicted with leprosy or plague, the needs of kings and princes to achieve and maintain power through large populations, as well as in the continuing efforts and devotion of numerous men and women who have desired only to better the condition of their fellows.

Concepts and practices

Health and ill health have their biological roots, but the biological processes and phenomena have been and are being influenced, impeded, and facilitated in contexts of changing political, economic, social, and cultural elements. Indeed, the changing character of community health action is due to the circumstance that health problems do not exist in the abstract but have always been linked with the varying conditions of particular groups of people. One may almost say that each period of history has its own ideal of health and its own public health. For example, the concept of health in medieval Europe was limited by the theological concept of sin. This was particularly true in the case of mental health; not until the realm of health was extensively secularized was it even possible to begin to consider mental health in a public health context. In this sense, the concept of public health must of necessity be asymptotic. The goals of public health are not Platonic ideas, absolute and unchanging. They represent in some form the dominant values of a society, and public health activities have been explained or justified on several grounds, such as religion, humanitarianism, or scientific interest. An extremely pervasive consideration, furthermore, has been economic or social utility.

Historical analysis of public health reveals two major components that have been involved in its evolution. One is the development of medical science and technology. Understanding the nature and cause of disease provides a basis for prevention and control. Thus, faced with problems of epidemic disease, communities have acted in terms of some prevailing concept of the nature of disease. On the primitive level of knowledge, such action is generally couched in supernatural terms. For thousands of years epidemics were looked upon as divine judgments on the wickedness of mankind, and it was believed that these punishments were to be avoided by appeasing the wrathful gods. Alongside this theurgical theory of disease, however, there gradually developed the idea that pestilence is due to natural causes involving physical, biological, and social factors, that is, causes that can be studied rationally by the human mind. Beginning with the efforts of the Greeks, men have endeavored to combine speculations, theoretical inferences, observations, and experimental facts into theories that would explain the occurrence of diseases and provide a rationale for their prevention or control.

Effective action, however, depends on a variety of nonscientific elements, which are basically political, economic, and social. Disease may seriously disturb the life of the group. This is particularly true when people fall ill with contagious diseases and thus menace the health of their fellow men, or when individuals become a burden on the community because of illness or disability. To deal with such matters society creates agencies, establishes laws, and institutes procedures to implement laws. Public administration, in a simple form, is found early in human history, and from the beginning public health has been closely linked with governmental activity.

Thus, the administration of public health is in large measure a political act. Any endeavor to understand public health practice must take account of the political dimension, because it lies at the base of the activity. Because public health is an expression of the aims and values of a society and is so closely linked with government, the practice of public health has been influenced not alone by the state of scientific knowledge but equally, if not more so, by prevailing theories of society and the state. The work of Johann Peter Frank in the eighteenth century is inconceivable apart from mercantilism and enlightened absolutism, just as that of Edwin Chadwick in the nineteenth century has its roots in philosophical radicalism and classical economics. Similarly, public health policy in the Soviet Union derives a characteristic stamp from communist doctrine, just as, in the United States, it has been molded by federalism, free enterprise, liberalism, and social reform.

The Greco-Roman world

Evidence of activity related to community health has been found in the earliest civilizations. Bathrooms, drains, and water supply and sewerage systems testify to the achievements of the ancient Cretans, Egyptians, and others. Services today associated with public health are not mentioned frequently in antiquity; nevertheless, there were specific administrative arrangements for such matters as drainage and water supply, for which designated officials were responsible.

An important theoretical contribution of antiquity was the idea developed by the Greeks that disease is due to natural causes, involving the natural environment and especially climate. Ill health developed when there was an imbalance between man and his environment. This view is clearly expressed in the Hippocratic work The Airs, Waters and Places, the first known systematic endeavor to elucidate the causal relations between disease and environmental factors (climate, soil, water, mode of life, and nutrition). For more than two thousand years this basic approach provided the theoretical underpinning for an epidemiological understanding of endemic and epidemic disease. No fundamental change occurred in this respect until late in the nineteenth century, when the sciences of bacteriology and immunology were developed.

When Rome conquered the Mediterranean world and took over the culture of the Greeks, it also accepted Greek ideas on health and disease but adapted them to Roman purposes. The Romans were no theoreticians, but they left their mark on history as engineers and administrators, builders of sewerage systems and baths, and providers of water supplies and other health facilities. Thus the waterworks of Rome were supervised by a board which had at its disposal a permanent staff of workers. Similarly, the maintenance and cleansing of the sewerage system was under the supervision of specially designated officials, who had a staff of public slaves. Equally significant was the organization of medical care. By the second century A.d. there was a public medical service, and hospitals had been created. These were first provided for soldiers, slaves, and public functionaries, later for civilians. Eventually, under the influence of Christianity, motives of charity and benevolence led to the creation of hospitals and related facilities in many localities. The foundation of hospitals for the sick, the disabled, and the indigent in the medieval period derives from Roman institutions.

Public health in Rome can clearly be seen as a social subsystem of the community with an organizational structure, a set of functions in terms of defined objectives, functionaries to carry out the necessary activities, a rationale to explain what was done, and techniques and tools for these purposes. Furthermore, this system had relationships with other parts of the social organization of Rome; the growth of the administrative system can clearly be seen as a consequence of the expansion of the community.

The Middle Ages

The disintegration of the Greco-Roman world led to a decline of urban culture and with it to a decay of public health organization and practice. However, the East Roman, or Byzantine, Empire was to a large extent able to carry on the tradition and culture of the classical world. Here the Greco-Roman legacy was preserved, and from this center it was first transmitted to the Arabs in the East and later to the peoples of Europe. In the West during the earlier medieval period (a.d. 500-1000), communal activities in the interest of health were undertaken under the aegis of the church and particularly the monastic orders; they undoubtedly provided models for the urban communities that began to develop in Europe about the tenth century.

Many of the public health problems of the medieval community were simply due to the circumstance that an increasing population had to be accommodated within a limited space and that for a long time most of the inhabitants maintained a rural mode of life. The problems were in essence those already indicated for antiquity, but to deal with them the medieval municipalities had to create anew the institutions needed for a hygienic mode of life. While the medieval community did not have an organized public health system in the present-day sense, it did have administrative machinery for disease prevention, sanitary supervision, and, in general, protection of community health. The character of this machinery was closely related to the general administration of the medieval municipality. The city or town was run by a council that had charge of finances, organized its provisioning, ordered and supervised public works, and also dealt with health and welfare problems. Physicians were not involved in public health administration but were employed for specific duties, such as the provision of expert counsel in times of pestilence or in medico—legal matters, the diagnosis of leprosy and similar conditions, and the provision of medical care to the indigent, to prisoners, or to other public charges as required.

The institution of quarantine

Medieval man was far from passive when faced by the problem of epidemics. He did what he could to protect himself, but in a manner consistent with the prevailing climate of thought and belief. Thus, his protective ideas were based on an amalgam of medical and religious views. The need to control leprosy was recognized early and led to a mode of public health action that is still with us, namely, the isolation of persons with communicable diseases. When the community believes itself menaced by such individuals it feels justified, acting through its institutions, in subjecting such people to restraints and sanctions in order to protect itself; people suffering from certain communicable diseases have to be reported to the authorities, and in some cases the freedom of the individual may be severely circumscribed. Thus, following policies adopted at the third Lateran Council in 1179, lepers were expelled from the medieval community, deprived of their civil rights, and consigned to a legal and social death. At the same time, places of refuge (leper or lazar houses) were provided for these unfortunate people.

The preventive principle used to combat leprosy was amplified and carried further in dealing with that other great scourge of the Middle Ages, bubonic plague, popularly known as the Black Death. From this preventive endeavor grew a basic contribution to public health practice, namely, the institution of quarantine. Beginning at Venice in 1348, public officials in Italy, southern France, and the neighboring area created a system of sanitary control to combat plague and other infectious diseases, with observation stations, isolation hospitals, and disinfection procedures. Based on more accurate knowledge and organized more rigorously, quarantine is still a part of contemporary public health practice. Other areas of public health to which the Middle Ages made significant contributions were health education and the development of the hospital. Even though medieval hospitals had little in common with the modern institutions, they provided one of the sources from which our hospitals evolved.

The modern era

With minor modifications, the public health pattern created by the medieval urban community continued in use from the sixteenth to the nineteenth century. With the development of national states in Europe, central governments took action increasingly but sporadically; on the whole, public health problems were handled by the local community. During this period, however, basic scientific knowledge was being acquired on which the structure of modern public health would eventually be erected. The great scientific outburst of this period began to make possible the more precise recognition of diseases and a better understanding of their nature. At the same time, ideological form was given to the possibility and importance of applying scientific knowledge to the health needs of the community. Concurrently, a quantitative approach to health problems developed out of the political and economic needs of the modern state. To increase national power and wealth, a large population was considered necessary. It was in relation to this concern that political arithmetic, that is, the collection and analysis of quantitative data bearing on national life, developed. The founder of this approach was William Petty, a seventeenth-century physician and economist; but the first solid contribution to vital statistics was made by his friend John Graunt, whose classic book Natural and Political Observations …Upon the Bills of Mortality appeared in 1662. The application of statistical analysis to community health problems was to prove extraordinarily fruitful for the development of public health.

The consideration of health problems in connection with the aim of maintaining and augmenting a population that could be economically productive and provide fighting men logically implied a health policy for the entire dominion of a monarch or of a nation. This implication was recognized and began to be developed in England and on the Continent during the seventeenth and eighteenth centuries. While a number of thinkers and men of affairs endeavored to deal with public health on a national scale, it was not until the nineteenth century, with the advent of the new industrial and urban civilization, that the problem of organizing the larger community to protect its health became a matter of national concern and led to concrete results. The earlier efforts reached a high point in the work of Johann Peter Frank, whose career spanned the late eighteenth and early nineteenth centuries, and who is best known as a pioneer in public health administration and social medicine.

During the eighteenth century the cultural and economic movements known as the Enlightenment and the industrial revolution provided the seedbeds in which the new ideas, tendencies, and methods that revolutionized public health in the nineteenth century germinated and developed. In Britain, France, the countries of central Europe, and the United States, similar problems were attacked in the name of reason, order, human welfare, economy, and community concern. Among these were alcoholism, infant mortality, epidemics, the care of the insane, the creation or improvement of hospitals and dispensaries, improvement of the physical environment in towns, and the health conditions of specific groups such as soldiers, sailors, scholars, prisoners, miners, metalworkers, and various kinds of artisans. This interest is linked to the development of the health survey. The method was applied to the investigation of regions, communities, institutions, or population groups. Thus, John Howard published his account of the State of the Prisons in 1777 and proposed means to ameliorate social and health conditions which he had found. When applied to regions or communities, these investigations were known as medical topographies. Comprising sanitary surveys, epidemiologic studies, and social investigations, they prepared the way for the more specialized surveys and analyses that were carried out during the nineteenth and twentieth centuries. Today the survey as a tool for studying community health problems is an important component of the public health armamentarium.

Public health and sanitary reform

Modern public health developed out of the sanitary reform movement of the nineteenth century, which began in England, where the impact of the industrial revolution on health was first recognized as a matter of community concern requiring governmental action on a continuing basis. Nevertheless, wherever industrialism developed, whether in France, Germany, or the United States, the consequences were similar and called for similar remedies. The human cost of industrialization and urbanization in terms of ill health and premature death was great, and the sanitary reformers endeavored to reduce it by organizing the community to protect the health of its members. This aim was coupled with a recognition that disease for which the individual could not be held responsible was an important factor in the cost of public assistance and that it would be good economy to undertake community-wide measures for the prevention of disease.

In England

The industrial revolution found England without any effective system of local government or any national agency to deal with the health problems which it created or intensified. At the same time urban communities grew and became more congested, and more and more people became aware of the cities’ novel, powerful, and alarming qualities. It was apparent that endemic or epidemic diseases tended to seek out the poorer districts, but they were not limited to them. This awareness and the consequent desire to reduce or eliminate disease and the destitution which it produced are among the major roots from which the sanitary reform movement sprang.

One of the first products of this reform movement was the Report on the Sanitary Condition of the Labouring Population of Gt. Britain, a fundamental document dealing with modern public health which appeared in 1842. Prepared by Edwin Chadwick, lawyer, administrator, and one of the creators of sanitary reforms, the Report showed that communicable diseases were associated with filthy environmental conditions. In Chadwick’s view, what was needed was an administrative organ to undertake a preventive program by applying engineering knowledge and techniques in an efficient and consistent manner. He also recognized the need for a physician to see that action was taken when necessary and to keep watch on health conditions in the community.

The Public Health Act of 1848, passed by Parliament after six years of agitation, established the General Board of Health. This step was a major landmark in the history of public health, because it created a basis for the further evolution of public health administration in England and led eventually to the establishment of the Ministry of Health in 1919. Moreover, it set an example whose influence was felt far beyond England. The impact of British sanitary reform was nowhere more pervasive than in the United States, where, as in England, one of the basic problems involved in the genesis and development of public health was the need to create an effective administrative mechanism for the supervision and regulation of community health.

In America

Between 1800 and 1830, only five major American cities had boards of health. Even as late as 1875 many large urban communities had no health departments. Beginning in the 1830s, however, increasing immigration and urban growth produced situations that required urgent attention. Inadequate provision for housing, water supply, sewerage, and drainage brought into being a whole brood of evils that expressed themselves in the urban slum. Recurrent epidemics of smallpox, typhoid and typhus, cholera, and yellow fever impressed upon the public the urgent need for effective public health organization.

In 1866 the New York Metropolitan Board of Health was established, an event which marked a turning point in the development of American public health. This example was soon followed by other states and municipalities in establishing effective health departments: Massachusetts, 1869; California, 1870; District of Columbia, 1871; Minnesota, 1872; Virginia, 1872; Michigan, 1873; Maryland, 1874; Alabama, 1875; Wisconsin, 1876; and Illinois, 1877.

As state and local health departments were organized, the idea of a national health agency seemed the logical next step. However, it should be remembered that until practically the end of the nineteenth century the U.S. government had no concern with public health matters. Organization and action for the protection of community health were considered a local responsibility to be carried out by the state or the locality. Thus, the doctrine of state sovereignty continued to hold sway in the health field and handicapped public health action on a national basis for many years. Congress created the National Board of Health in 1879, but it was of little significance and disappeared after 1883. The establishment of a national health agency was not achieved in the United States until 1953, when the Federal Security Administration became the cabinet Department of Health, Education and Welfare, which included the Public Health Service, the Children’s Bureau, and the Food and Drug Administration, as well as other health, welfare, and educational services of the federal government.

Development of the health sciences

This evolution has gone hand in hand with the development of a complicated urban industrial society and has been one of the responses to the need for a more organized, efficient administration of health services. At the same time, the provision of a stable administrative structure has made it easier to incorporate new scientific knowledge into public health practice and to deal with new problems as they occur.

Public health action depends not only on governmental organization and public attitudes but also on the health sciences and their technology. Understanding the nature and cause of disease provides a basis for preventive action and control. This was accomplished for many of the communicable diseases through the development of bacteriology and immunology, the sciences that have exercised the most profound influence on community health from the end of the nineteenth century to the present. It is almost impossible to overemphasize the consequences of this development. Based on the researches of Louis Pasteur and Robert Koch, as well as on the studies of their co-workers and successors, scientists identified the microorganisms responsible for specific diseases and uncovered their mode of action. The way was thus opened for public health action on a more specific, accurate, and rational basis. An example is the prevention and control of diphtheria through the use of antitoxin and toxoid.

Beginning about 1870 there was a continuing downward trend in mortality because of a decline in the frequency of certain diseases: chiefly smallpox, typhoid and typhus, yellow fever, malaria, and tuberculosis. These trends were roughly the same in the municipalities of western Europe and the United States and undoubtedly reflected first the impact of the earlier sanitary reform movement and then that of the bacteriological era. This period also saw an increasing concern with the health of mothers and children, problems of nutrition, health education, occupational health, and the organization and provision of health services on a community basis.

The twentieth century—international trends

The past fifty years have witnessed an unprecedented over-all trend toward the improvement of community health. Yet, this advance has not been uniform either within communities or between various parts of the world. A large group of countries, generally underdeveloped in an economic and technologic sense, and often newly independent, still have problems of preventable disease like those with which the countries of western Europe and the United States had to cope one hundred years ago. Their problems are still the control of infectious diseases, the provision of uncontaminated water supplies and proper sewerage, and the elevation of the standard of living to a minimum acceptable level. In short, the underdeveloped areas of the world confront the twentieth-century public health workers with the same kind of problems that the sanitary reformers faced on a national scale in the nineteenth century.

International health action has grown out of a broadening realization that in a world which for more than a hundred years has been contracting because of technological development and increasingly complex economic and political interdependence, the presence of disease in one area constitutes a continuing danger for many others. To deal with such problems, the World Health Organization was created in 1946, on the basis of experience obtained from earlier governmental and private organizations.

In the economically more advanced countries such as the United States and Great Britain, the actual problems of community health are different. As the diseases of infancy, youth, and early adulthood have been reduced so that people no longer die of them in great numbers, many more individuals live into the older years. As a result, among the current problems are the prevention or control of chronic conditions such as cancer, diabetes mellitus, arthritis, musculoskeletal diseases, and the mental changes associated with aging.

As problems of communicable disease have declined in urgency, community health programs have been altered to include other elements and conditions that may adversely affect the physical, social, and psychological well-being of people. In recent years the widening horizons of public health have brought to our attention problems of chronic disease, but also such problems as accident prevention, mental health, addictive diseases, the organization of medical care, and increasing needs for social services. Also important in the light of current problems is the renewed emphasis on control of the physical environment. Our expanding and changing technology has led to environmental alterations of increasing complexity. The once dominant problems of bacterially contaminated water and food have been replaced to a considerable degree by chemical pollution. In this category is the new and important field of radiation control.

The welfare state

These developments must be seen in the perspective of a world-wide historical evolution that has brought into being the modern state with its concern for individual, family, and community needs in health and welfare. There is probably no more fascinating process in recent history than that through which the laissez-faire “night watchman” state of the nineteenth century has been transformed into the present welfare state. The same broad developments occurred in all the leading industrial countries, although with numerous variations and, above all, differences in tempo due to varying historical traditions and conditions. Today, the principle of state intervention and control in health matters is accepted; the only difference is the greater or lesser efficiency of the intervention and the means by which it is accomplished. Its emergence has resulted from the effects of important political, economic, and social trends. Thus, during this period, the typical trend of political and economic organization has been the continuous and progressive replacement of smaller units by larger ones. Another factor has been the need for national efficiency and the planned utilization of resources. These developments have necessarily led to the widespread acceptance of the need for a strong central authority entrusted with large powers to promote social well-being. This change has brought about an increasing rationalization and bureaucratization of health services, and it explains in part why in our time the social sciences have become an increasingly important element in public health.

The modern concept that a national government is responsible for the health of the people is an extension of the earlier view whereby the local community provided for such needs. As the center of power has moved from the small political unit to the large one, this shift has affected the provision of health services. Although the function of health promotion and protection is today lodged basically in the executive organ of the national community, the individual localities, as well as groups and persons in them, must still take an important part in the preservation of individual and collective health. Thus voluntary health agencies, that is, organizations not supported by tax funds, play an important role on the American health scene.

The relations of the national health service to local health organizations and personnel show wide variations throughout the world. In some countries, such as Great Britain and the Soviet Union, all health services are essentially socialized. In other countries, like the United States, the national health authority deals with international and interstate problems, carries out and stimulates extensive programs of research, encourages state and local health departments through financial support, and provides guidance where needed. Increasingly over the past forty years, the public health worker, in order to deal with the complex problems of contemporary communities, has had to become a highly trained, specialized professional. To provide the required education and training, institutions known as schools of public health have been established.

Public health has moved a long way from its beginnings. More and more, man can consciously plan for better health because available knowledge and resources make it possible in many instances to act with a clear understanding of what he is doing. Many health problems have been solved basically, but knowledge awaits application in practice. In all countries there are problems of community health that require political and social action guided by available knowledge. In this sense, the dynamic and changing character of community health action and the significant trends and issues involved in it must be viewed as an aspect of the process of social change in society.

George Rosen

[See alsoHealth; Illness; Medical Care; Medical Personnel; Vital Statistics; and the biographies ofGraunt; Petty.]

BIBLIOGRAPHY

Fischer, Alfons 1933 Geschichte des deutschen Ge-sundheitswesens. 2 vols. Berlin: Rothacker.

Frazer, William M. 1950 A History of English Public Health: 1834-1939. London: Bailliere.

Graunt, John (1662) 1939 Natural and Political Observations Made Upon the Bills of Mortality. Baltimore: Johns Hopkins Press.

Great Britain, Poor Law Commissioners (1842) 1965 Report on the Sanitary Condition of the Labouring Population of Gt. Britain, by Edwin Chadwick. Edinburgh Univ. Press.

Hanlon, John J.; Rogers, Fred B.; and Rosen, George 1960 A Bookshelf on the History and Philosophy of Public Health. American Journal of Public Health 50:445-458.

Howard, John (1777) 1929 The State of the Prisons. New York: Dutton. -“First published as The State of the Prisons in England and Wales.

Lesky, Erna 1959 Osterreichisches Gesundheitswesen im Zeitalter des aufgeklarten Absolutismus. Archiv fur osterreichische Geschichte 122, part 1.

Parisot, Jacques 1933 Le developpement de I’hygiene en France. Nancy (France): Thomas.

Rosen, George 1958 A History of Public Health. New York: MD Publications.

Siegerist, Henry E. 1956 Landmarks in the History of Hygiene. London School of Hygiene and Tropical Medicine.

Simon, John (1890)1897 English Sanitary Institutions. 2d ed. London: Smith.

Smillie, Wilson G. 1955 Public Health: Its Promise for the Future. New York: Macmillan.

Winslow, Charles E. A. 1943 The Conquest of Epidemic Disease: A Chapter in the History of Ideas. Princeton Univ. Press.

Public Health. For much of American history, protecting local business figured prominently in public‐health efforts. During the Colonial Era, smallpox and yellow fever ravaged seaports, paralyzing business activity. Townspeople fled; shops closed; visitors avoided the stricken cities. To revitalize trade, local authorities often published false reports minimizing the danger. They also quarantined ships, established pesthouses (isolation hospitals), introduced short‐term sanitary reforms, and experimented with smallpox inoculation. A major vindication of inoculation came during a 1721 Boston epidemic that claimed nine‐hundred lives. Cotton Mather championed the procedure, while Boston's most prominent physicians opposed it. Smallpox vaccination, developed by the English physician Edward Jenner, became available by 1800.

During the nineteenth century, outbreaks of cholera, especially in 1832–1833, 1849–1850, and 1866, and other epidemic diseases shaped public‐health practice. As yellow fever devastated southern cities, physicians disagreed about whether it was contagious and how to combat it. Those who supported the broad exercise of government authority sought to quarantine incoming ships, whereas those favoring free trade and individual liberty urged the removal of decaying organic wastes, whose noxious “miasmas,” they believed, caused most epidemics. (In 1900 an army medical team led by Dr. Walter Reed at last discovered yellow fever's mode of transmission: the Aëdes egypti mosquito.)

By midcentury, local governments increasingly addressed public‐health issues. New York City built a municipal water system in 1842. Dr. John H. Griscom's The Sanitary Condition of the Laboring Class of New York with Suggestions for Its Improvement (1845) proved highly influential. New York created a permanent Metropolitan Board of Health in 1866, in response to a threatened cholera epidemic, and reformers in other cities soon followed suit. As municipal water and sewer systems replaced backyard wells, cesspools, and privies, outbreaks of cholera, typhoid fever, dysentery, malaria, and typhus diminished. As in the past, local business groups often led these sanitary reforms.

At the federal level, Congress in 1798 had created the U.S. Marine Hospital Service, under a Surgeon General, to care for ailing seamen. The U.S. Sanitary Commission, a volunteer agency headed by Frederick Law Olmsted, worked to improve health and sanitary conditions in Civil War military camps. Meanwhile, the Marine Hospital Service steadily expanded its activities, including a bacteriological research laboratory founded in the 1890s. Renamed the U.S. Public Health and Marine Hospital Service in 1902, it eventually became simply the U.S. Public Health Service (PHS). Early PHS campaigns combated hookworm and pellagra.

With the triumph of the germ theory of disease and the advent of bacteriology in the early twentieth century, the rationale for public‐health efforts shifted from ridding the environment of “miasmas” to attacking disease‐causing microbes. Public health became professionalized as lay reformers gave way to physicians and scientists. The laboratory became the principal battleground against disease, with impressive results. Vaccines, serums, and tests attacked rabies, diphtheria, typhoid fever, tuberculosis, and later, yellow fever, poliomyelitis, measles, and whooping cough. The Progressive Era's reform ethos opened new public‐health vistas, including school‐vaccination programs, maternal and child care, rural health efforts, medical inspection of immigrants, regulation of nuisance industries, inspection of food processors and providers, and campaigns to reduce infant mortality and tuberculosis. In many of these programs, the federal government played a central role. By World War I, there existed a vast network of governmental public‐health agencies, supported by the American Red Cross, settlement houses, and other volunteer groups. Although organized medicine, led by the American Medical Association, enthusiastically supported the public‐health movement, it strenuously sought to limit activities to prevention, not treatment.

As the acute, communicable diseases were defeated, attention shifted to the chronic and degenerative afflictions, especially cancer, diabetes, stroke, and heart disease. Public‐health workers alerted the public to risk factors they could control, such as obesity; poor nutrition; lack of exercise; and, in the case of venereal disease, unprotected sex. In the 1930s, Surgeon General Thomas Parran lifted the veil of silence surrounding syphilis. Beginning in the New Deal Era, the federal government increasingly funded municipal and state public‐health programs.

By the late twentieth century, public‐health efforts at all governmental levels had vastly expanded in size and complexity. In the 1990s the PHS, now a part of the Department of Health and Human Services, included the Surgeon General's Office, with a corps of over six thousand public‐health professionals; specialized agencies such as the Indian Health Service, the Food and Drug Administration, the data‐gathering Centers for Disease Control, and the research‐oriented National Institutes of Health; and offices addressing such issues as aging, mental illness, minority health, women's health, physical fitness, and the AIDS epidemic. The landmark Surgeon General's Report on Smoking and Health (1964) alerted citizens to the hazards of smoking and led to health warnings on cigarette packages, advertising restrictions, congressional investigations, and major legal challenges to the tobacco industry. Other federal bodies addressing public‐health issues included the Bureau of Prisons, the Environmental Protection Agency, the Consumer Product Safety Commission, the Immigration and Naturalization Service, and the Occupational Safety and Health Agency. Globally, the PHS cooperated with the World Health Organization, a United Nations agency. From small beginnings, public health had emerged as a major governmental responsibility as the twenty‐first century dawned.
See also Acquired Immunodeficiency Syndrome; Federal Government, Executive Branch: Other Departments (Department of Health and Human Services); Health and Fitness; Hospitals; Immigration; Immigration Law; Industrial Diseases and Hazards; Mather, Increase and Cotton; Professionalization; Pure Food and Drug Act; Tobacco Products; Tuskegee Experiment; Urbanization.

Bibliography

Charles E. Rosenberg , The Cholera Years: The United States in 1832, 1849, and 1866, 1962.
Judith Walzer Leavitt , The Healthiest City: Milwaukee and the Politics of Health Reform, 1982.
Allan M. Brandt , No Magic Bullet: A Social History of Venereal Disease in the United States since 1880, 1985.
Stuart Galishoff , Newark, the Nation's Unhealthiest City, 1832–1895, 1988.
John Duffy , The Sanitarians: A History of American Public Health, 1990.
Margaret Humphreys , Yellow Fever in the South, 1992.

Stuart Galishoff

Public Health

Sources

Slow Development of Public Medicine. The emergence of a modern public-health system in the United States began in the last quarter of the nineteenth century. During the first half of the century most doctors were poorly trained, and—like most Americans at the time—they lived in rural areas of the country. Because the population was widely scattered most people could not afford the indirect costs of arranging a doctor’s visit: first a messenger would have to be sent to the doctor, who would then have to travel to the patient’s home. Until the mid nineteenth century these indirect costs of medical service outweighed direct costs such as the doctor’s fee or the price of medicine.

Medicine and the Technological Revolution. With the beginning of the great movement of the American population from the countryside to the city, more doctors moved than people with other callings. The building of the railroads was critical to this process. Doctors relocated at rail centers, and once having moved, they located their offices along streetcar lines. As a result, doctors came into closer contact with their patients and their colleagues. The invention of the telephone reduced the time it took to locate the doctor. In fact some early telephone systems linked doctors’ offices directly with pharmacies.

A New Economics for Medicine. In cities doctors also tended to locate their offices near hospitals. The modern hospital was a response to the large numbers of city people who lived alone and had no family members to care for them when they were ill. When doctors’ offices were located near hospitals and could be reached by streetcar, the market for their medical services expanded, encouraging competition and lower fees, important at a time when medical insurance was largely unavailable. Insurance companies did not begin to offer general private coverage until the late 1890s. Some illness benefits were provided by some immigrant societies, other fraternal organizations, and labor unions.

The Impact of the Germ Theory. The discovery that diseases were caused by specific pathogens, or germs, and the development of different treatments for individual diseases made it possible to enact public-health measures that were disease-specific and thus more effective, cleaning up water supplies that carry cholera, for example, or pasteurizing milk to prevent the spread of diseases such as undulant fever. Many cities began educational campaigns to instruct citizens on how to avoid certain infectious diseases. During the 1890s tuberculosis testing showed that large numbers of people carried the disease in a latent form, suggesting that improved housing and working standards might be effective in holding off onset of the disease, which was then the most common cause of death in large cities.

The Surgical Revolution. Significant scientific and technical advances made surgery a more common treatment option during the 1890s than it had been in previous decades. Joseph Lister’s antiseptic method (disinfecting the operating room to kill bacteria), developed in 1865, was soon followed by the more effective technique of asepsis (using sterile procedures to prevent microorganisms from entering the surgical field of operation). This advance made possible abdominal operations, which had earlier been highly dangerous. X rays were discovered in 1895 and used as a diagnostic tool for the first time in the United States in 1896, providing an impetus for more, and earlier, surgical intervention. The increase in surgery cases was another stimulus to the growth of hospitals.

Educational Reform. Before the second half of the nineteenth century there were no standards for medical education and no provisions for licensing doctors. The right of states to license medical doctors was affirmed for the first time by the Supreme Court in Dent v. West Virginia in 1888. After this court decision state boards of medical examiners were established. Beginning around 1870, medical education was reformed. Before that time American medical schools had no laboratories and no tradition of research. At reform-minded medical schools such as Harvard, the course of instruction was lengthened from two to three years. In 1883 the Johns Hopkins Medical

School initiated the four-year course that became standard and made an undergraduate college degree a prerequisite for admission.

Sources

Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982).

PUBLIC HEALTH PRACTICE PROGRAM OFFICE

The Public Health Practice Program Office (PHPPO) of the Centers for Disease Control and Prevention (CDC) was created in 1988 to strengthen the nation's public health system by enhancing work force capacity, building information and communications systems, improving laboratory quality, and conducting systems research. The PHPPO is committed to strengthening the public health system and improving community-based public health practice throughout the United States and around the world. The office works closely with other CDC components to provide support for specific disease-control programs (e.g., infectious disease control, injury prevention, environmental health, and chronic disease prevention).

Work Force Development Programs. The PHPPO has pioneered the use of distance-based training through the Public Health Training Network (PHTN) as a means of improving the competency of the domestic public health work force. The PHTN is a distance-learning network that has reached over 400,000 people since its creation in 1992. The National Laboratory Training Network (NLTN) provides laboratory training courses throughout the United States. The Public Health Leadership Institute was created in 1991, and has provided training to over five hundred public health leaders and spawned a national network of state and regional leadership development programs. The Sustainable Management Development Program (SMDP) provides intensive management training for public health professionals from around the world and technical assistance to program graduates. In 1999, in cosponsorship with the Health Resources and Services Administration (HRSA), the Robert Wood Johnson Foundation, and the W. K. Kellogg Foundation, the Management Academy for Public Health, managed by the University of North Carolina at Chapel Hill, was created to provide management development experiences for managers in governmental public health agencies in four southeastern states. Finally, in 1999 the creation of a CDC Leadership and Management Institute was formed to address needs of CDC leaders and managers.

Information and Communication Systems. In 1991 the PHPPO pioneered the use of information technology in public health practice through its national award-winning program, the Information Network for Public Health Officials (INPHO). Subsequently, through support for CDC's bioterrorism program, the Health Alert Network initiative was created to further enhance information communications systems capacity, improve work force competency, and utilize performance standards to assess organizational capabilities.

Laboratory Quality. The PHPPO provides leadership in developing regulations under the Clinical Laboratory Improvement Act of 1988, working closely with partners at the Health Care Financing Administration (HCFA) to provide a comprehensive policy framework for assuring the quality of clinical laboratory services throughout the nation. Innovative activities in genetics testing, HIV (human immunodeficiency virus) testing, and tuberculosis testing have also contributed to the success of prevention programs in the United States and around the world.

Systems Research and Development. In 1990, working closely with NACCHO, PHPPO developed the APEX planning tool. Today, this is the most widely used comprehensive planning tool for local public health agencies in the United States. Further, PHPPO is leading the development of performance standards for local and state public health systems and for conducting systems research.

Edward L. Baker

(see also: Centers for Disease Control and Prevention; Information Technology; Laboratory Services; Mobilizing for Action through Planning and Partnerships; Training for Public Health )

public health field of medicine and hygiene dealing with the prevention of disease and the promotion of health by government agencies. In the United States, public health authorities are engaged in many activities, including inspection of persons and goods entering the country to determine that they are free of contagious disease. They are empowered to isolate persons with certain diseases and to quarantine such individuals, if necessary, for the public good. Public health officials are responsible for supervising the purity of the water, milk, and food supply as well as the persons who handle these items and the public eating places that dispense them. They are responsible for the good health of animals that supply food and for the extermination of wildlife, rodents, and insects that contribute to disease. Public health authorities are also concerned with the pollution levels in air and water, and must assure the safety of water used for drinking, for swimming, and as a source of sea food. In addition, they collect vital statistics on death rates, birth rates, communicable and chronic diseases, and other indicators of the state of public health.

The duties of carrying out the many services required to keep the population healthy and to prevent serious outbreaks of disease are divided among local, state, and federal government agencies. They provide health officers and nurses for the schools and visiting nurses for the home. They oversee the water supply, the disposal of sewage, the production and distribution of milk, and the proper handling of food in restaurants. Public health agencies impose standards of public health on local communities when needed; they give financial and technical assistance to local communities in time of crisis, such as that caused by epidemics, hurricanes, and floods.

The principal federal health agency in the U.S. today is the Public Health Services division of the Department of Health and Human Services. It consists of five agencies including the National Institutes of Health , its research arm, which conducts extensive research into neurology, blindness, AIDS, immunology, and heart disease. The Centers for Disease Control and Prevention , another agency under the Public Health Service, maintains statistical data on all diseases; it was instrumental in showing the relationship between tampons and toxic shock syndrome, as well as pinpointing the source of Legionnaire's disease to a new water-borne organism. The Food and Drug Administration is the arm charged with assuring the effectiveness and purity of food, drugs, and cosmetics. The Alcohol, Drug Abuse and Mental Health Administration was established by Congress more recently to address substance abuse and mental health problems. To carry out all these activities the public health services employ large numbers of physicians, dentists, veterinarians, laboratory technicians, nurses, sanitary engineers, health educators, psychologists, and social workers (see also Surgeon General, United States ).

Because of the frequent and rapid transportation of people and disease vectors by air there has been a growing need for the monitoring of public health on a global level. This is done by the UN's World Health Organization .

Bibliography: See studies by J. Leavitt and R. Numbers, ed. (1978), R. Bayer et al., ed. (1983), and O. Anderson (1985).

PUBLIC HEALTH

PUBLIC HEALTH. SeeEpidemics and Public Health.