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International Encyclopedia of the Social Sciences Macmillan Encyclopedia of Death and DyingInternational Encyclopedia of the Social SciencesEurope, 1450 to 1789: Encyclopedia of the Early Modern World Further reading

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Public Health

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.

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Public Health

Public Health

Public health services can prevent premature death from epidemics such as the plague, cholera, and many other infectious and environmentally determined diseases; and enhance the quality of life. Public health is among the most important institutions of organized societies, almost entirely responsible for the immense improvements in life expectancy everywhere in the world in the past 150 years. Its aims are to promote, protect, and preserve good health, and to sustain people when disabilities render them incapable of fending for themselves. Public health is practiced by a team of specialists trained in medicine, nursing, sanitary engineering, environmental, social, and behavioral sciences, health education, administration, and a variety of other fields. In many nations, including the United States, public health is organized hierarchically at national, regional, and local levels.

Public health services are distinguished from other aspects of the health care system because they are financed by taxation, with no fees paid by the users of these services. This phenomenon can lead to funding crises and staff layoffs when there is political pressure to cut taxes. People and their political representatives often take their health for granted when no epidemics threaten them, so they are not motivated to maintain public health services, staff, and infrastructure at a high level of efficiency and effectiveness, even though ensuring public health is an essential component of the health care system. No nation remains healthy if public health services break down, as they did in Russia after the collapse of the Soviet Union. In this case, infant mortality rates rose, life expectancy fell, and epidemics of diphtheria, typhoid, and other lethal infections occurred. Public health services are as vital to national security as efficient armed forces and the police and fire services. The people of the United States recognized this fact when cases of anthrax occurred in 2001, caused by the introduction of anthrax spores into letters sent through the U.S. Postal Service.

Deadly Epidemics

Since the origins of agriculture and permanent settlements 10,000 years ago, human progress has been punctuated by deadly epidemics. Often arising seemingly out of nowhere, they cut a swath through the population, arousing fear among victims and survivors alike. They were perceived as due to the wrath of a vengeful god, retribution for sinful conduct, or manifestations of evil spirits. Before their causes were understood, survivors full of grief and rage sometimes blamed witches, or those perennial scapegoats, the Jews, extracting vengeance by burning them at the stake or conducting pogroms. Epidemics of plague, smallpox, typhus, cholera, malaria, influenza, and measles have contributed to the fall of civilizations and the defeats of campaigning armies, and they have long fascinated historians as well as epidemiologists. Biblical stories of epidemics indicate the people of those times encountered smallpox and bubonic plague. The historian Thucydides described the plague that decimated the Athenian forces at the end of the first year of the Peloponnesian War (426 b.c.e.), but despite his meticulous description (based partly on having had it himself) the cause remains uncertain. It may have been influenza complicated by bacterial infection. The vitality of the late Roman Empire (200400 c.e.) was sapped by two diseases better described as endemic than epidemicmalaria, spread by mosquitoes in the Pontine marshes nearby, and lead poisoning, caused by drinking from cups made of tin-lead alloys.

The greatest of all epidemics was the Black Death, which entered Europe at Genoa on ships trading from Asia Minor in 1347, and spread over the next two to three years until it had laid waste to the entire continent. The Black Death killed at least one-third of the population. Sometimes whole villages were wiped out and, in cities such as Paris, organized life and everyday commerce came to a halt. Plague had struck before, for instance at the time of Justinian (543 c.e.), and continued to cause occasional epidemics such as the one in London in 1665 described in Samuel Pepys's diary. However, society had not seen anything on the scale of the pandemic of 13471349. The plague bacillus primarily infects rodents and is transmitted by the rats' fleas. Human epidemics occur when ecological conditions bring rats, their fleas, and people together at close quarters in dirty, verminous conditions.

Typhus, caused by a microorganism called Rickettsia, a small bacterium, is spread by the body louse. Epidemics of typhus occur when large numbers of people are confined in close quarters in dirty, verminous clothing (e.g., war refugees and campaigning armies). An impending epidemic that would have had a serious strategic impact was stopped in Naples in 1944 by liberal use of the insecticide DDT. In his classic work Rats, Lice and History (1935), the microbiologist Hans Zinsser vividly describes how the outcome of wars has often been decided by which side was more successful in withstanding the deaths from typhus among its fighting forces. The European conquest of the Americas and colonization of the rest of the world was materially assisted by the impact of measles, smallpox, and tuberculosis on the people who had been there before them. Europeans had some inherent resistance to those diseases after many centuries of exposure had weeded out those most susceptible. The Allied campaigns in the Pacific during World War II were facilitated by the fact that American, Australian, Indian, and British forces had effective anti-malarial agents and their Japanese adversaries did not. This fact may have played a larger part in the victory than the atom bombs dropped on Hiroshima and Nagasaki.

In the eighteenth and nineteenth centuries an arrogant assumption by medical men that they could lay their healing hands upon women in childbirtheven when those hands were laden with dangerous bacterialed to a tragic epidemic of fatal childbed fever. The epidemic ended only when the studies of Ignaz Semmelweiss in Vienna and Budapest and Oliver Wendell Holmes in Boston in the 1840s were translated into hand washing in antiseptic lotion. The use of antisepsis in labor wards and operating rooms, as practiced and advocated by the surgeon Joseph Lister, followed hand washing more than twenty years later.

In the late twentieth and early twenty-first centuries, the HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome) pandemic had a catastrophic impact on sub-Saharan Africa, comparable to the Black Death in medieval Europe except for the different course of the disease. The plague killed in a few days and HIV/ AIDS takes a few years, but the ultimate death rate is higher, approaching 100 percent, whereas at its worst the Black Death killed between 70 percent and 80 percent of its victims. By the end of the twentieth century, HIV/AIDS afflicted more than 40 million people and killed 30 million people.

With the insights of modern evolutionary biology and medical sciences, researchers know that epidemics and many other widely prevalent diseases originated from and are perpetuated by a combination of ecological conditions. Malaria, yellow fever, other vector-borne diseases, and many parasitic infections probably first occurred in humans as a result of evolutionary developments in the causative agents and their vectors. Smallpox, influenza, measles, plague, and several other epidemic diseases probably first afflicted humans by "jumping species" from their origins as diseases of animals that were domesticated by Palaeolithic humans.

In the second half of the twentieth century, most people in the rich industrial nations were able to live long and healthy lives, but as many as 30 to 40 percent of middle-aged men were dying before their potential life span of lung cancer or coronary heart disease, two modern epidemic diseases often attributable to tobacco addiction. Undeterred by the massive evidence that their product is the most powerful addictive substance known, and lethal if used as the manufacturers intended, the tobacco manufacturers embarked upon aggressive and successful campaigns to market cigarettes to girls and women who had previously not often smoked. The result is that lung cancer death rates among women began to rise sharply in the final two decades of the twentieth century, and can be confidently predicted to keep rising so long as women continue to fall victim to tobacco addiction. Similar aggressive and unprincipled tobacco marketing campaigns are being conducted throughout the developing nations in the early twenty-first century. The World Health Organization estimates that the annual number of deaths from tobacco-related diseases could reach 8 to 10 million worldwide by 2025 as a result. This would make tobacco addiction a lethal epidemic disease comparable to if not greater in magnitude than HIV/AIDS.

Historical Origins of Public Health

Contemporary public health services began in the middle of the nineteenth century in response to the squalid conditions that existed in the rapidly growing cities and towns of the industrial revolution. These cities and towns were dangerous places. In the early nineteenth century, a newborn had about one chance in four or five of dying before his or her first birthday, and only about half survived long enough to grow up and have children of their own. They died of diarrheal diseases, including cholera, or of respiratory infections, such as bronchitis, measles, croup, pneumonia, and tuberculosis. Life expectancy in the new industrial towns was only about thirty-five years. This appalling situation challenged the emerging medical sciences and the social reformers to act. Aided by an expanding knowledge and understanding of the times, their efforts led to reduction of infant mortality rates and rising life expectancy. By 1900 infant mortality rates in the industrial nations had fallen to about 100 per 1,000 live births, and life expectancy had risen to about 45 to 50 years. By 1950 infant mortality rates were down to about 40 per 1,000 live births and life expectancy was at or above seventy to eighty years in most of the industrial nations. By 1999 infant mortality rates were below 10 per 1,000, and life expectancy approached 80 years, even in the United States, which has traditionally lagged behind many other wealthy industrial nations.

Social, medical, and public health reform originated largely in England, but took place almost simultaneously throughout much of Western Europe and the United States. A combination of several essential factors made possible these reforms, collectively known as the sanitary revolution. The same essential factors must exist before almost any public health problem can be resolved. These include an awareness that the problem exists; an understanding of what is causing it; the capability to control the cause or causes; belief that the problem is important enough to tackle; and political will.

An awareness that the problem exists. In the middle to late nineteenth century, awareness was facilitated by rising literacy, the availability of newspapers, and the development of vital statistics that provided documentary evidence of the magnitude of the problem of deaths from diarrheal diseases and respiratory infections in infancy, childhood, and early adult life. Since the midtwentieth century, television has played an increasingly important role in drawing attention to new public health problems, such as those associated with toxic pollution of the environment.

An understanding of what is causing it. John Snow, the English physician who investigated the cholera epidemics in London in the 1840s and 1850s, provided evidence that the disease was spread by polluted drinking water. The cholera vibrio, the causative organism, was not discovered until about thirty years later, but recognition that polluted water was spreading cholera enabled some preventive actionprovision of clean water suppliesto begin.

Capability to control the cause or causes. Oliver Wendell Holmes and Ignaz Semmelweis demonstrated that washing hands in a disinfectant could prevent most cases of childbed fever. Both men were vilified by their colleagues who regarded it as an insulting slur on their character to imply that their dirty hands caused the disease. Joseph Lister was successful because his carbolic spray implied that the cause was not necessarily the unhygienic habits of the doctors but rather bacteria in the air in operating rooms and lying-in wards in hospitals. By then, many varieties of dangerous bacteria had been discovered and linked to the diseases that they caused.

Belief that the problem is important enough to tackle. Historically, a mounting emotion of public outrage about what is perceived to be an intolerable burden upon the people is the catalyst for change. The phrase "filth diseases" evokes the distaste for unhygienic conditions that contributed to the burden of premature deaths in nineteenth-century industrial Britain. Geoffrey Vickers, a British social policy specialist, referred to this rising public outrage as "redefining the unacceptable"a phrase that captures the essential factor in setting a new goal for public health.

Political will. A public health problem will persist unless there is determination to correct the conditions that cause it. This usually means disturbing the status quo and encroaching upon the livelihood of individuals and often powerful interest groupsslum landlords, nineteenth-century water supply companies, twentieth-century tobacco manufacturers, and twenty-first-century industry, energy, and transport sectors resisting action to control global climate change. Moreover, it costs money to make the necessary changes, which usually results in additional taxes and extended political debate.

Methods of Public Health

Health can be preserved, protected, and promoted in several ways, including ensuring the environment is safe, enhancing immunity, and living a healthy lifestyle.

Ensuring the environment is safe. A safe environment includes drinking water that is free from dangerous pathogenic organisms and toxic substances. This requires purification of public water supplies, a sanitation service with efficient sewage disposal, and safeguards against contamination of water and food supplies by pathogens and toxic chemicals. In modern urban industrial societies clean air is another part of the natural environment that must be protected: clean indoor air, free from tobacco smoke, as well as urban air free from smog. Efforts to clean both outdoor and indoor air are often initially resisted by various interest groups.

Enhancing immunity. Immunity is enhanced by vaccination or immunization against infectious diseases in infancy and childhood. Vaccination against smallpox began after Edward Jenner, a physician in Gloucestershire, England, experimented on his patients with cowpox lymph in the late eighteenth century. His results, published in An Inquiry into the Variolae Vaccinae (1798) were perhaps the single most important public health advance of the second millennium. Smallpox had long been one of the great epidemic scourges. It killed 40 percent or more of all who were infected by the virus, and disfigured, sometimes blinded, many more. Within one hundred years it had been brought under control in most parts of the world and in 1980, after a determined global eradication campaign, the World Health Organization proclaimed the worldwide eradication of smallpox. Vaccines and sera containing immunizing agents have been developed against many other dangerous and often lethal infectious agents. See Table 1 for a list of the most important, all of which (except polio) caused innumerable premature deaths. Vaccines to prevent smallpox and rabies, two deadly virus diseases, were developed long before the agent was discovered, which had to await the invention of the electron microscope. Discovery of the bacterial agents responsible for many other dangerous infections occurred rapidly in the late nineteenth century, following the development of high-quality microscopes and the techniques of bacterial culture.

Living a healthy lifestyle. Living a healthy lifestyle means abiding by the maxim of the ancient Greeks, "Nothing to excess." It includes avoiding harmful addictive substances, especially tobacco, and adhering to a balanced diet and regular exercise program. Living a healthy lifestyle can be encouraged by health education campaigns. Adhering to a balanced dietcomprised of the right mix of protein, fats, and carbohydrates, with vitamins and essential trace elementsis necessary to achieve good health and prevent premature death. Famine conditions have killed populations of people in the past, partly from starvation itself but also because malnutrition makes people, especially children, vulnerable to deadly infections such as measles, and reduces resistance to tuberculosis.

Other methods of public health include carefully nurturing the next generation; ensuring that children are well-borne and do not have inherent genetic defects or malformations that result from exposure to toxic substances; and prudent use of diagnostic and therapeutic medical services (i.e., avoiding multiple and often needless exposures to diagnostic X rays, coronary artery surgery for elderly people at the upper extremity of the life span, and cosmetic breast implants), which can be harmful if improperly applied.

See also: AIDS; Black Death; Causes of Death; Death System; Life Expectancy; Technology and Death

Bibliography

Last, John M. Public Health and Human Ecology, 2nd edition. New York: McGraw-Hill, 1997.

McMichael, A. J. Human Frontiers, Environment, and Disease: Past Patterns, Uncertain Futures. Cambridge: Cambridge University Press, 2001.

McNeill, William Hardy. Plagues and Peoples. Garden City, NY: Anchor Press, 1976.

Snow, J. Snow on Cholera, edited and annotated by W. H. Frost. 1936. Reprint, New York: Hafner Publishing, 1965.

Zinsser, Hans. Rats, Lice and History. Boston: Little, Brown, 1935.

JOHN M. LAST

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LAST, JOHN M.. "Public Health." Macmillan Encyclopedia of Death and Dying. 2002. Encyclopedia.com. 28 Aug. 2016 <http://www.encyclopedia.com>.

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LAST, JOHN M.. "Public Health." Macmillan Encyclopedia of Death and Dying. 2002. Retrieved August 28, 2016 from Encyclopedia.com: http://www.encyclopedia.com/doc/1G2-3407200233.html

Public Health

Public Health

BIBLIOGRAPHY

Public health is a branch of the social and health sciences, as well as a field of social and health endeavor, that aims at collective action for the prevention of disease and the promotion of health. The U.S. Institute of Medicine offers this definition: public health is what we, as a society, do collectively to assure the conditions in which people can be healthy (K. Gebbie, L. Rosenstock, and L. M. Hernandez 2003). Depending on the political philosophy of governance and the role of the state, this aim and its operational applications have taken different shapes in different contexts. In some contexts, public health refers to public-sector health; in other contexts, the term refers to the publics health.

Public health is as old as history itself. Most holy texts (including the Bible, Torah, and Quran) contain instructions regulating sanitary behavior. Other belief systems, such as the Indian Ayurveda (from the Sanskrit ayu life and veda knowledge of), have formulated prescriptions for leading healthy lives. The Hippocratic writings have been highly influential in Western conceptualizations of health and illness. Although the ancient Greek physician Hippocrates (c. 460-377 BCE) and his school are found to be the fathers (and mothers) of modern medicine, their instructions for healthy housing are the direct forebears of current perspectives on environmental health.

The rise of modern public health occurred in the mid-nineteenth century. With the advance of statistics and empirically-based science, health advocates (later known as the hygienists ) in France, Germany, England, and the United States endeavored to link disease patterns to environmental conditions. These hygienists had roots in engineering, law, and charity, and to a lesser extent in emerging scientificallopathicmedicine. British royal anesthesiologist John Snow (18131858) made a breakthrough in 1854. Using an ancestor of what is known as a geographic information system, Snow was able to attribute cholera outbreaks in Victorian London to the quality of water coming from the citys Broad Street pump.

Although public health science had certainly made its mark with the work of early epidemiologists, public health action was relatively slow to follow, mostly because the proposed interventions met with considerable political resistance. The idea that large infrastructural works (sewage systems, garbage collection, piped water) had to be put in place for the public good was persistently countered with arguments that the delivery of appropriate individual health care services, and emphasis on the responsibilities of individuals for their lifestyles, would yield better results. Ultimately, though, the political argument that the workforce was withering as a result of lack of public action won over the critics.

Formal public health training in this tradition started at the Massachusetts Institute of Technology in 1889 and at the London School of Hygiene and Tropical Medicine in 1899. A pressing debate emerged in the United States around the question of whether public health was a branch of medicine and should thus be taught in medical schools. The Flexner Report (1910), sponsored by the Carnegie Foundation, found that schools of public health should be separate entities. In Europe, however, there was a commonly shared belief that public health was an integral part of the medical realm. Outside the United States, the Rockefeller Foundation eventually sponsored schools of public health that were closely allied with medicine (in Zagreb, Beijing, and London). Public health in Europe became known as social medicine or (in the United Kingdom) as public health medicine.

The breakthrough stature that the field had acquired in the second half of the nineteenth century withered, regrettably, as a consequence of advances in vaccine development and immunology. The dominant idea became that most, if not all, disease could be treated or prevented through immunological interventions. Public health could contribute to this notion by developing population-based vaccination campaigns. The social and political aspects of public health science and action lost prominence, even in those realms where the political dimensions of health issues were blatantly obvious. Governments had been engaging, since a failed first meeting in Paris in 1851, in a series of sanitary conferences aimed at regulating the transmission of disease between nation-states through measures such as quarantine. Such efforts would clearly have had an impact on trade, which was why most of these conferences had limited success.

In the era of globalization, little has changed in the public health landscape. Trade and mobility are profound drivers of the potentially rapid spread of infectious diseases such as avian influenza or SARS (severe acute respiratory syndrome)the 2003 SARS outbreak in China led to a World Health Organization (WHO) travel warning for Torontoand tensions between individual foci on the promotion of health and community-based orientations have not been resolved.

One would, for instance, expect that modern public health knowledge and practices would have been able to prevent the Black Death (or pestilence) that ravaged Europe in the mid-fourteenth century. At the time, witchcraft, ethnicity (arguments reminiscent of those voiced in the twentieth century on the HIV/AIDS epidemic by some religious groups), and seasonal bad airs were blamed for the pandemic. Current scientific knowledge of the disease pathogen and its vectors would, supposedly, account for more effective interventions, reducing overall mortality. This supposition is only partly true. Bubonic plague is still endemic in many nations. Similarly, the global community has not been able to fully contain or control contemporary cholera pandemics, nor will it be able to fully prevent annual influenza outbreaks, including those caused by particularly virulent pathogens such as the H1N5 avian influenza virus. It must be recognized that pathogens are an inseparable element of the global ecosystem, and global public health surveillance and control systemspartly due to political indolence, sometimes referred to as a betrayal of trusthave only a limited capacity to proactively engage in their complete prevention.

Many international organizations include health in their considerations: for example, the International Labor Organization (ILO) deals with workplace health, UNICEF with maternal and child health, the UN-Habitat with urban health, and UNESCO with education for health in schools. The United Nations technical agency responsible for health matters since its inception in 1948 (its establishment urged by Brazil and China at the UN founding conference in San Francisco in 1945) is the WHO.

The WHO is the only UN technical agency that, apart from a global headquarters and national liaison offices, has six Regional Offices (in Europe, the eastern Mediterranean, Africa, Southeast Asia, the Western Pacific, and the Americas). These offices formulate regional policies following directions from the global World Health Assembly. The programs of the WHO in its first decades focused on infectious disease. The greatest accomplishment of this era is the first and only eradication of a major human disease, smallpox (19671977). This accomplishment also signaled, however, the end of the infectious disease paradigm. From the launch of the primary health care approach following an international meeting in Alma Ata (Almaty), Kazakhstan, in 1978, the community and social aspects of health promotion and the management and delivery of care became more important than biomedical intervention considerations. In this shift, the WHO has experienced great successes and failures. Under the visionary leadership of Halfdan Mahler (19731988), the WHO positioned itself as a powerful broker for health between professionals, governments, and communities. The WHOs next director-general, Hiroshi Nakajima (19881998), was accused of letting the organization fall victim to corruption, a pawn of (pharmaceutical) industries, with an ineffective bureaucracy not responsive to such global threats as HIV/AIDS nor the call for evidence-based medicine and public health. His successor, Gro Harlem Brundtland (19982003), was elected to take charge and reposition the organization. One of her most visible accomplishments was the commissioning of a series of studies into macroeconomics and health chaired by the American economist Jeffrey Sachs. Lee Jong-Wook (19452006), who became WHO director-general in 2003, further advanced the social science angle of the organization by appointing in 2005 a prestigious Commission on Social Determinants of Health. This commission is to report on early child development, health systems, employment, globalization, urban settings, and gender in public health, among other issues. This range of topics again emphasizes the intrinsically political nature of public health.

In the 1990s, the WHO established a list of essential functions to which public health agencies should strive to conform:

  • Prevention, surveillance, and control of communicable and noncommunicable diseases
  • Monitoring of health situations
  • Health promotion
  • Occupational health
  • Protection of the environment
  • Public health legislation and regulations
  • Public health management
  • Specific public health services
  • Personal health care for vulnerable and high-risk populations

The list reflects the ideal that public health must embrace insights from the social and natural sciences. These would range, for instance, from molecular medicine to empowerment and community development, toxicology, and political science. Some disciplines, such as epidemiology and health services research, are uniquely aligned to the public health realm. Others have specialized branches related to public health, notably biostatistics, health economics, sociology, anthropology, psychology, and environmental health. In many universities, schools of public health provide a critical link between faculties. However, the domain is also rich in contention, particularly where the survival or growth of established disciplines is concerned. A pivotal review by the U.S. Institute of Medicine, for instance, demonstrated the enormous untapped potential for insights from the social and behavioral sciences in the promotion of health. These insights, for reasons linked to disciplinary exclusiveness, have not yet pervaded traditional public health research and teaching.

Another level of rivalry has developed around the application of public health expertise. On a scale, two extremes are found. One, predominantly carried by laboratory-based public health sciences, poses that clinical expertise determines courses of action. This would, for instance, relate to the legitimacy to implement population-wide vaccination or risk-behavior-change campaigns (top-down). Others, notably the radical social sciences, start from the position that health is an inherently social condition and that community-driven action is most appropriate (bottom-up). Agreement is difficult to reach, and a mixed-scanning approach is often advocated by the WHO and many local public health agencies.

An organization strongly committed to the bottom-up approach is the global Peoples Health Assembly (PHA), an alliance of academics, communities, and nongovernmental organizations. The PHA endeavors to balance the expert-driven globalized stance with a community-based local (glocal) approach. A major imbalance with which both the PHA and the WHO struggle is the ninety/ten divide: 90 percent of the global public health research effort is spent on only 10 percent of the global health burden. Important players in this arena, apart from the WHO, are private sector entities. These include pharmaceutical industries and charitable organizations such as the Bill and Melinda Gates Foundation (the largest single donor to public health effortsover $5 billionin 2005).

The nexus between globalization and health is an important research challenge. Like the unresolved ninety/ten divide, most public health research resources are devoted to issues in industrialized nations. These include such matters as access to and the efficiency of health servicesfor example, medical technology assessment and health services financing schemes (often mirroring, again, the difference between public sector or the publics health). A critical issue in these analyses is the inequitable distribution of access, as well as disease burden, within and not between nations. Research into equity and inequalities in health top many European agendas; in other countries, such terms have been deemed politically taboo, which has not prevented research into areas that are alternatively labeled with less value-laden terms, such as social exclusion or diversity and health. Ethnicity, socioeconomic status, heredity, and gender issues thus remain at the core of many public health controversies.

SEE ALSO Disease; Health Economics; National Health Insurance; World Health Organization

BIBLIOGRAPHY

Breslow, Lester, ed. 2002. Encyclopedia of Public Health. 4 vols. New York: Macmillan Reference/Gale Group.

Gebbie, K., L. Rosenstock, and L. M. Hernandez, eds. 2003. Who Will Keep the Public Healthy? Educating Public Health Professionals for the 21st Century. Washington, DC: National Academies Press.

Winslow, C.-E. A. 1920. The Untilled Fields of Public Health. Science 51 (3106): 2333.

World Health Organization. Commission on Social Determinants of Health. http://www.who.int/social_determinants/en/.

Evelyne de Leeuw

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Public Health

PUBLIC HEALTH

PUBLIC HEALTH. Public health as a concept and as a program of coordinated state or communal action did not exist in early modern Europe. Not until the late seventeenth century did regimes and individuals began to perceive the health of the population as an area of legitimate, ongoing government action. Such realizations eventually led to more concentrated efforts in formulating principles of public health and launching sustained programs designed to improve health and lengthen life. Governments before the eighteenth century were, of course, not oblivious to collective health, but public health initiatives were ad hoc and piecemeal in nature. Public health fell overwhelmingly within the purview of other aspects of governing: the regulation of markets; restrictions on the practice of obnoxious trades such as tanning or slaughtering; the prevention of fires; and the provision of poor reliefto name only the most obvious and significant. Repeated waves of epidemics, especially plague, but also smallpox, syphilis, dysentery, influenza, and perplexing incidents of considerable lethality such as the mysterious English sweat of the 1480s, caused governments to swing vigorously into action to combat them or prevent their spread.

Epidemics as a presence or a threat conditioned many early modern public health responses. The plague of the mid to late 1340s (known since the nineteenth century by the anachronistic name of the Black Death) played a major role in shaping policies. Equally influential was the appearance of syphilis in the late fifteenth and early sixteenth centuries. These two diseases produced a standard set of responsesquarantines, cordons sanitaires, avoidance, flight, closing public baths, shutting up infected houses, and banning assemblages of peoplethat persisted at least until the eighteenth century and often considerably longer. The steps taken to fight or forestall pestilences depended to a large degree on how people understood their propagation. Since antiquity two concepts of how disease spread competed. Some believed in contagionthat disease circulated through contact with infected people or goods. Others adopted a miasmatic theorythat disease resulted from an insalubrious condition of the environment, a disturbance in the airs, waters, and places described in the ancient Hippocratic corpus. Whereas once historians argued that these two interpretations were mutually exclusive and antagonistic, it is now generally accepted that they could be combined and that both shaped (and still shape) responses to epidemic situations.

Western Europe lived beneath the shadow of plague until 1721 (Brockliss and Jones, 1997), and plague disappeared from eastern Europe and Russia only toward the end of the eighteenth century. Throughout early modern times, public health was intimately concerned with two measures taken to prevent the incursion or recurrence of plague: quarantines and cordons sanitaires. These methods required the coordination of government efforts often crossing territorial borders and covering huge stretches of land. While such cooperation was hardly perfect in an age lacking efficient police forces, evidence suggests that both measures could successfully retard the spread of disease. Once plague struck, however, cities constituted boards of health from their sitting magistracies (choosing, in other words, people with power and status but not necessarily those possessing medical experience or training) for the duration of the emergency. Physicians and surgeons were seldom members of such boards. Although granted wide and expansive powers for a time, boards of health tended to disappear once the threat vanished. Nonetheless, the ordinances that governed city life on a day-to-day basis continued to contain crucial elements of what would later be termed public health. Such regulations pertained not only to cities, of course. Still, evidence is more complete and available for urban sites than for the countryside and control was crisper within still-walled towns. This, too, would change in the late seventeenth and eighteenth centuries. Another institution that we today consider essential to public health is the hospital. Hospitals in early modern times served as multipurpose establishments, although some were set up and run especially for particular patients: those suffering from plague or syphilis, for instance. Hospitals, however, functioned coterminously as places to heal the sick, as homes for the aged or chronically ill, and as refuges for the destitute (and thus, formed a central element of poor relief). Hospitals provided vital economic resources for a community as employers, but also as prominent landowners and even as moneylenders.

Beginning in the late seventeenth century, public health slowly developed a more comprehensive field of action and a more tightly defined program. As states centralized authority and as rulers gathered the reins of power more firmly into their own hands, they and their ministers began to envision the wealth of nations in broader ways. According to the principles of mercantilism and its sister discipline, populationism, the riches of a state could no longer be weighed merely in bullion. Rather the true strength of a polity lay in its productive potential, and that capacity itself depended on the presence of a large, healthy, and industrious population. Thus, advocates of what in German came to be known as Medizinische Polizei ('medical police'), denoting a series of policies rather than a police force), foremost among them, Johann Peter Frank (17451821), constructed broad programs of public health that ranged from traditional concerns with the fighting of epidemics, the maintenance of hospitals, and the provision of potable water supplies to far more ambitious social policies that included the early education of children and maternal welfare.

In order to formulate rational and purposeful policies, however, it was first necessary to understand which conditions promoted health or caused illness. Thus, medical police stimulated a political arithmetic that amassed and studied information pertaining to commerce, population, and natural resources, as well as vital statistics (birth, death, and morbidity rates). Cities had often collected mortality statistics, especially during epidemic outbreaks. The London Bills of Mortality from the Great Plague of 16651666 are perhaps the most famous (but by no means the only or earliest) example of this genre. In the seventeenth and eighteenth centuries, however, the political arithmeticians, such as the Englishman John Graunt (Natural and Political Observations on the Bills of Mortality, 1662) or the German Johann Süssmilch (Die göttliche Ordnung in den Veränderungen des menschlichen Geschlechts, 1775 [The godly order in human affairs]) sought to discover patterns of mortality as a basis for the rational planning of state affairs, including but not limited to public health. These advances in political economy paralleled other trends in the eighteenth century: a new valuation on individual worth and a greater tendency to view human happiness, including physical well-being, as a positive good. These perceptions laid the groundwork for the development of public health as a humanitarian enterprise and as an accepted program of state action. Still, it would take several decades and, to some extent, the impact of cholera in the nineteenth century for states to establish health departments as permanent agencies, staffed by professionals possessing strong executive powers, or ones that functioned on a national, rather than merely on a local or municipal level.

See also Medicine ; Plague ; Poverty .

BIBLIOGRAPHY

Primary Sources

Airs, Waters, and Places and Epidemics. Parts of the Hippocratic corpus often attributed to Hippocrates of Cos (460?377? b.c.e.) but in fact written by a number of Hippocratic authors. A selection of the Hippocratic corpus is available as The Medical Works of Hippocrates: A New Translation. Translated from the Greek by John Chadwick and William N. Mann. Oxford, 1950.

Frank, Johann Peter. A System of Complete Medical Police: Selections from Johann Peter Frank. Edited by Erna Lesky. Baltimore, 1976. A selection from the eighteenth-century multivolume work System einer vollständigen medicinischen Polizey. 9 vols. Mannheim, 17791827.

Secondary Sources

Brockliss, Laurence, and Colin Jones. The Medical World of Early Modern France. Oxford, 1997.

Cipolla, Carlo. Miasmas and Disease: Public Health and the Environment in the Pre-Industrial Age. Cambridge, U.K., 1995.

Lindemann, Mary. Medicine and Society in Early Modern Europe. Cambridge, U.K., 1999.

Porter, Roy. The Greatest Benefit to Mankind: A Medical History of Humanity from Antiquity to the Present. London, 1997. Chapters 810 cover the early modern period.

Riley, James. The Eighteenth-Century Campaign to Avoid Disease. New York, 1987.

Rosen, George. A History of Public Health. New York, 1958. An old but still useful survey. Also available in an expanded edition, Baltimore, 1993.

Mary Lindemann

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Public Health

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, andlike most Americans at the timethey lived in rural areas of the country. Because the population was widely scattered most people could not afford the indirect costs of arranging a doctors visit: first a messenger would have to be sent to the doctor, who would then have to travel to the patients home. Until the mid nineteenth century these indirect costs of medical service outweighed direct costs such as the doctors 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 Listers 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).

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Public Health Practice Program Office

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 )

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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.

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

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Public Health Act

Public Health Act, 1848. An Act of Parliament for England and Wales (11 & 12 Vic. c. 63) was carried following an agitation organized by Edwin Chadwick and the Health of Towns Association. It created a General Board of Health in London and local boards of health with wide powers to enforce standards of public hygiene where the death rate exceeded 23 per 1,000 or where 10 per cent of ratepayers petitioned for a local board. Though the General Board was disbanded in 1858, over 700 local boards had been set up in England and Wales by 1871 and the Act was extended to Scotland in 1867. A consolidating measure created medical districts for the whole of Britain in 1875.

Edward Royle

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Public Health

PUBLIC HEALTH

PUBLIC HEALTH. SeeEpidemics and Public Health.

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