PUBLIC HEALTH

In 1793 the French Revolution invented health citizenship when the National Convention's Committee on Salubrity added health to the democratic state's obligations to its citizens. The Committee believed this could be achieved by establishing a network of rural health officers who, while trained in clinical medicine, would also become responsible for reporting on the health of communities and monitoring epidemics among both humans and farm animals. The citizen's charter of health, however, was double-sided. The idéologue Constantin-François Chasseboeuf, comte de Volney (1757–1820), raised the issue of citizens' responsibility to maintain their own health for the benefit of the state. In the new social order the individual was a political and economic unit of a collective whole. It was a citizen's duty to keep healthy through temperance, both in the consumption of pleasure and the exercise of passions, and through cleanliness.

This dialectical relationship of health citizenship, entitlements, and responsibilities was subsequently expressed in the political and social development of public health systems and practices up to the twenty-first century. The relative roles of the state and its citizenry in achieving population health, however, oscillated and changed focus throughout the period. In the nineteenth century, new sciences of socio-medical inquiry were developed in Europe, which expanded the possibilities for investigating the health of populations.

france

France led the development of public hygiene as an academic discipline in the first half of the nineteenth century. The "birth of the clinic" in Paris following the end of the Napoleonic Wars was matched by the birth of a public hygiene movement. But unlike clinical medicine, preventive medicine remained largely an intellectual pursuit focusing on the analysis of social conditions and the way in which they influenced the spread of disease. The translation of public hygiene theory into public policy was restricted in France by a commitment to a liberal political-economic philosophy that was shared by politicians, public servants, the medical profession, and the "partie d'hygiene." Social analysis of health conditions did not translate into the construction of a state-apparatus of disease prevention as it did in England. Instead the central state relied on old structures of health surveillance set up under the ancien régime and left reform to local initiative. Local physicians were appointed as "health officers" to coordinate state action during epidemics, but full-time salaried employment of doctors by the state was limited to medical relief for the poor. Medical relief reached only a fraction of the population in need. Most provincial districts instituted few health reforms, but a local prefect could make a difference.

The Paris Health Council was the most active public health body in France in the early nineteenth century. The Paris prefect of police was responsible for the control of pollution, the inspection of markets and slaughterhouses, street and sewer cleaning, public lighting, monitoring and authorizing industrial establishments, the supervision of animal slaughter, maintaining the salubrity of public places, and the control of quackery. Health ordinances were issued by the prefect but, as the Health Council Reports demonstrate, few of these powers were ever enforced. From 1802 the Paris Health Council compiled medical statistics and mortality tables and produced reports on epidemics, rivers, cemeteries, slaughterhouses, refuse dumps, dissection rooms, and public baths. When it was expanded in the 1830s, some of the major figures of the hygiene movement, such as Louis-René Villermé and Parant du Chatelet, were appointed to it and undertook innovative research into social and sanitary conditions within the city. But the Council remained an advisory body only, and many of its recommendations were never taken up by the Paris political administration because they were costly and they challenged an ideological allegiance to economic liberalism. Numerous programs proposed by the Health Council were never adopted, such as the creation of new municipal drainage and systematic refuse-removal systems. Nevertheless the Council was able to have some effect on industrial development in Paris through its power to authorize commercial establishments, and after 1848 it gained the power to regulate the salubrity of private dwellings.

britain

While France developed the academic discipline of public hygiene, the midcentury British state translated its premises into public policy, creating a national system of public health administration by the early 1870s. Despite the pervasive rhetoric of liberal individualism, the promotion of the economic ideology of laissez-faire and the reliance on voluntary effort to provide social services to those in need, the British Victorian state nevertheless continued to expand and become increasingly interventionist. Expansion was justified by utilitarian beliefs that the profitable operations of a market economy could be maximized if it was protected by a political, legal system that created the best conditions for its freedom. Nowhere were the contradictory tensions of Victorian political and economic philosophies more obviously reflected than in the growth of public health intervention. Public health policy in Britain exemplified the growth of a bureaucratic system within the liberal democratic state. The British state sought solutions to the epidemic costs of economic expansion through the creation of an interventionist bureaucratic system of health administration. Initially the role of the state was to "enable" local authorities to intervene to protect their environments. But the grammar of public health legislation increasingly adopted the syntax of compulsion. The architects of state intervention justified it by assuming that a large proportion of poverty and destitution—and

its costs on solvent individuals, industry, and society in general—could be reduced by preventing premature mortality of breadwinners caused by epidemic disease.

In Britain the initiative for public health intervention was driven by the actions of central government but relied on local government for its practical application. In this respect public health provision continued to be open to a degree of local government discretion and accessible to public participation in local democratic processes. However, the opponents of public health intervention in Britain perceived it as a massive threat to local government autonomy and an unacceptable intervention by the central state in their affairs. Public health intervention was perceived by early Victorians as the most infamous growth of authoritarian, paternalist power of central government on the one hand and the growth of the despotic influence of a particular profession—the medical profession—on the other.

Industrialization in Britain exponentially multiplied environmental threats to health primarily through the massive growth of towns. For example, London had 800,000 people in 1801 and there were only 13 towns with populations of over 25,000. By 1841 London's population rose by one million and 42 towns contained over 25,000 people. By 1861 six British cities contained more than a quarter million inhabitants. In the early 1800s approximately 20 percent of the population of England and Wales lived in towns of over 5,000; by 1851 over half the population did so; and by 1901 almost 80 percent. By contrast in rural areas some counties contained less population in 1901 than they did in 1851.

demographic explosion

These patterns were repeated in Europe as industrialization gathered momentum. No urban development could accommodate such a demographic explosion, which resulted in mass overcrowding, inadequate housing, dramatic accumulation of human, animal, and industrial waste products together with rising levels of industrial and domestic atmospheric pollution, and deadly pollution of insufficient potable water supply. In Britain and on the Continent the grotesquely squalid conditions imposed on the slum-dwelling proletariat were revealed by a host of observers, from social reformers to investigative journalists, and soon produced dramatic rises in infant mortality, rising levels of epidemic diseases, such as "fever"—both typhoid and typhus—and rising levels of dependency created through sickness. The physical expansion of cities could not keep pace with population migration and growth. Existing building stock became grossly overcrowded with huge densities of people. The amenities designed for vastly smaller numbers were totally inadequate. The need for new housing led to building methods that sacrificed quality for speed. Sanitary facilities designed for less dense levels of population were the most serious failure. Traditional methods of waste disposal such as cesspits and middens served more sparsely distributed populations adequately but became dangerously overburdened under these new conditions. Cesspools turned into manure swamps and seeped into the local water supplies and wells. Dry middens and their consequent dung heaps turned into mountains infested with flies and vermin. Existing levels of intermittent water supply could not possibly serve the expansion of demand. The traditional life of market towns became fatally hazardous under these new pressures. The defining feature of the heavily overstressed industrialized towns throughout nineteenth-century Europe was their stench, encouraging the popularity of an atmospheric theory, miasmatism, which identified a general etiology of disease through nonspecific contamination of the atmosphere by gaseous material given off by putrefying, decomposing, organic matter.

By the early 1840s sanitary reformers in Britain such as the Poor Law Commissioner, Edwin Chadwick, were convinced that the construction of massive new drainage and sewage removal systems was the primary means of preventing epidemic diseases such as typhoid, typhus, and cholera. Chadwick, in particular, believed that existing square-bricked sewers with large tunnel pipes that did not flush or empty should be replaced by small egg shaped sewers lined with glazed brick and connected by small earthenware pipes that would be constantly flushed by high-pressurized water. Liquid sewage could be recycled as manure fertilizer to outlying farming districts. Street widening, the removal of cesspools and all other noxious nuisances together with an end to intermittent drinking water were fundamental. With sanitary reforms such as these as its goal, the first British Public Health Act was passed in Britain in 1848. While comprehensive, it remained permissive. The Act created a central authority, the General Board of Health, with Anthony Ashley Cooper, the seventh Earl of Shaftesbury as its president and Chadwick as its secretary. The Act encouraged the appointment of local boards of health and local medical officers of health which became a national compulsory system under the later Public Health Act of 1872.

reform on the continent

The British model was intermittently reproduced throughout Europe in the latter half of the nineteenth and first half of the twentieth century, but different routes were taken in each national context. Although early-nineteenth-century French politics were dominated by economic and philosophical liberalism, France was the breeding ground for socialist theory in the 1830s and the Saint-Simonians incorporated public health reform into their critique of economic individualism and their belief in a new industrial order based on brotherhood.

Revolutionaries in 1848 identified a new social and political role for medicine when the editor of the Gazette médicale de Paris, Jules Guérin, promoted a "brotherhood of physicians" dedicated to "social medicine." Guérin believed it was time for medicine to participate in government itself through the establishment of a Ministry of Public Health. The radicalism of 1848 matched that of the 1789 revolution but withered as the revolution failed. The emperor Napoleon III (r. 1852–1871) suppressed the Left after 1851. While he liberalized trade and took a new interest in alleviating the conditions of poverty, the central state continued to remain largely inactive in terms of health reform.

German states

Similar health radicalism that wanted medicine to play a role in national government emerged within the German states during the 1848 revolutions. Within Prussia a philosophy comparable to Guérin's was outlined by the physician who became the founder of cellular pathology and a liberal politician, Rudolph Virchow. Following an investigation in 1848 of typhus in Upper Silesia, Virchow identified insanitary conditions as the cause of the epidemic. He developed what he called a "sociological" epidemiology, which led him to conclude that the strength of the disease among the Upper Silesians was due to their subjugated political state. The impoverished conditions and levels of squalor in which they lived would never have been tolerated by citizens living in a "free-democracy with general self-government." Therefore, Virchow concluded that "Free and unlimited democracy" was the only way to prevent typhus. A well-fed and politically emancipated population would produce a society in which both capital and labor had the same rights to health. Within this context Virchow outlined a political role for the physician as an ambassador for the poor, with the responsibility of identifying and recording sickness and devising measures to prevent it.

The revolutions of 1848 failed, but the political role of medicine in the state regulation of health expanded within the German states albeit incrementally and largely on a localized basis. Virchow encouraged Berlin to build sanitary infrastructures to supply pure water and remove sewage and refuse by the end of the 1860s. In Munich reform was led by the first German professor of public hygiene, Max Josef von Pettenkofer. Pettenkofer was a major figure both in the development of the academic study of public hygiene and sanitary reform in the nineteenth century. Pettenkofer was made professor of hygiene in 1865 and persuaded the Bavarian government to create an Institute of Hygiene in Munich in 1878 under his direction. His allegiance to a contingent-contagionist theory of disease transmission based on chemical fermentation led Pettenkofer to oppose the direct interventionist policies of the contagionists and support a broad-based agenda for disease prevention. In the 1870s he pushed the Munich authorities into acquiring a fresh mountain-water supply and to installing a modern sewage-removal system. He believed that whatever the medium of disease transmission, it required favorable local conditions to be effective, including climate and soil quality. Thus he thought that sewage must be removed down river in order to preserve the purity of the local soil from contamination. He argued that quarantine was a useless measure against epidemic invasion and advocated instead, improved housing and education of the population in healthy diet, exercise, and temperance. Pettenkofer's influence over policy continued until it was overtaken by Robert Koch, the champion of the new discipline of bacteriology, who, based in Berlin, was embraced by the Prussian state's power within the Second Reich of unified Germany. Bacteriology facilitated a new administrative centralization of public health but with a less economic interventionist approach focusing instead on the isolation of infectious individuals and disinfection of effects. Prussia established full-time medical officers of health in 1899 but the replacement of part-time state doctors throughout Germany took place over a long period. Various municipalities such as Berlin, Charlottenburg, Schöneberg, and Neukölln soon created full-time medical departments. As in other European states, bacteriology was succeeded by the Darwinian inspired science of eugenics, which aimed to explain disease and biological degeneration by understanding the mechanisms of heredity. Eugenics inspired the creation of two new movements in Germany, social hygiene and racial hygiene. The rise to prominence of social hygiene along with new concerns over social assistance and health insurance demonstrated the level of political importance that population health had reached in Germany by the end of the nineteenth century.

France

In the late nineteenth century public hygiene began to take on a new profile in France when the Third Republic, established in 1870, made an ideological commitment to the health of the people. Although the republic continued to prioritize the political rights of private property, socialists and moderate republican progressives all believed that public health programs would help sustain social stability. Bacteriology provided renewed ideological legitimation for public hygiene stimulated by the impact of Louis Pasteur's discoveries and his political influence within French society. Responsibility for the disparate features of health policy was brought together in a new Bureau of Public Health and Hygiene created within the Ministry of the Interior. This brought medical assistance and public health control under one administration headed by a Pasteurian-minded politician Léon-Victor-Auguste Bourgeois. In addition, the Consultative Committee on Public Health (CCHP), which maintained jurisdiction over quarantine, headed by the dean of the Paris Medical Faculty, Paul Brouardel, was moved from the Commerce Ministry to the Ministry of the Interior. The CCHP promoted new legislation making vaccination, notification of infectious disease, and death registration compulsory and making disinfection services and pure water supply universally available. No national system of public health administration was created comparable to that developed in England by the 1875 Public Health Act, but three-quarters of the regional départements had active health councils even though they still remained advisory bodies to the prefect. In 1884 France battled cholera with systematic environmental improvement and the closure of places of public congregation. By the time of the 1892 epidemic individual patients were isolated and their surroundings decontaminated.

Within a new context of political collectivism, represented not only by socialism but also by solidarism, new liberalism, and enthusiasm for social insurance, support for state health care provision expanded in Europe from the end of the nineteenth century up to the outset of World War I. In Germany in the 1880s statutory social security against the misfortunes created by sickness, disability, old age, and unemployment was established under the Health Insurance Law of 1883, and state support for old age and disability was established by a further statute in 1889. Together this legislation allowed the Reich chancellor, Otto von Bismarck, to create a model of social insurance that was subsequently reproduced throughout the industrializing European community, as both liberals and socialists feared the rising industrial and social strength of the unified German state with its state-supported systems of comprehensive health and welfare provision. In the 1890s and 1910s new laws were introduced that revived the 1789 principles of rights and obligations of health citizenship, transferring medical assistance from poor relief into a system of national insurance in Britain, France, the Netherlands, and Scandinavia.

See alsoCholera; Cities and Towns; Disease; Prostitution; Tuberculosis.

bibliography

Porter, Dorothy. Health, Civilisation, and the State: A History of Public Health from Ancient to Modern Times. London and New York, 1999.

Virchow, Rudolf. Gesammelte Abhandlungen aus dem Gebiete der öffentlichen Medicin und der Seuchenlehre: Collected Essays on Public Health and Epidemiology. Edited and with a foreword by L. J. Rather. Canton, Mass., 1985.

Dorothy Porter