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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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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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Public Health

Public Health

Definition

Public health is the science and clinical practice of population and community-based efforts to prevent disease and disability, and promote physical and mental health. It considers the health of groups, communities, or populations as opposed to the health of individuals. Public health addresses a variety of medical and social issues including:

  • environmental health
  • nutrition and food safety
  • immunization and infectious diseases
  • injury and violence prevention
  • maternal, infant, and child health
  • substance abuse
  • chronic disease prevention and treatment
  • access, availability, and affordability of health care
  • education, screening, and outreach services

Description

The science of public health is called epidemiology. It is the study of the occurrence of disease in naturally existing populations, such as nations, cities, or communities. The term "epidemiology" comes from the Greek word epidemic, which means "upon the people." The earliest epidemiologists (public health scientists) worked to prevent the spread of epidemics.

Today, epidemiologists gather and analyze information about populations to manage and prevent disease. Epidemiologists are trained in highly specialized research methods: surveillance, investigation, analysis, and evaluation. Surveillance refers to systematic data collection and analysis; it enables the epidemiologists to detect changes that may require investigation. Epidemiological investigation involves observation, detailed descriptions of the problem, documentation of data, and analysis. Evaluation is the process that helps to answer a question, such as "How often should men between the ages of 40 and 60 be screened for hypertension (high blood pressure)?"

By analyzing population data, epidemiologists also are able to describe diseases and determine the factors that cause them. Epidemiology is a quantitative science; it measures rates and proportions. Two commonly used rates are prevalence and incidence rates. Prevalence describes the characteristics of a given population at a specific moment in time; it is like a snapshot.

Incidence describes the rate of development of a disease in a given population over a specified time interval. Incidence offers a longer view of population dynamics, like a video, as opposed to the snapshot offered by the prevalence rate. Epidemiologists also analyze other rates, such as morbidity (disease-related illness) and mortality (death).

Public health practitioners rely on the findings of epidemiologists to develop health services, allocate resources, and determine standards of care. The results of epidemiological studies also influence health policy. For example, epidemiological research helps to determine how many health care professionals are needed based on population; the effectiveness of various treatments; and schedules for immunization or screening.

Viewpoints

Historically, public health disease prevention activities focused primarily on sanitation (also referred to as environmental health) and hygiene. Public health measures aimed to ensure the safety of food and water supplies, and to prevent transmission of communicable (capable of being transmitted) diseases. In some developing countries, these same basic public health problems, such as adequate food supplies and potable (fit to drink) water, continue to threaten health and longevity.

During and after World War II, advances in medicine such as the development of antibiotics, cardiac surgery, and physical rehabilitation changed the emphasis of public health in the United States. Federal, state, and local governments enacted legislation to protect public health. Federal laws aimed at safeguarding public health. Major regulations passed during the twentieth century include:

  • the 1938 Food, Drug and Cosmetic Act, which bans distribution of unsafe products and prohibits false advertising
  • the 1972 Clean Water Act, which forbids release of pollutants into rivers, streams, and waterways
  • the 1974 Safe Drinking Water Acts, which established standards for safe drinking water
  • the 1976 Resource Conservation and Recovery Act, which stipulates the safe storage, transport, treatment and disposal of hazardous waste materials
  • the 1990 Clean Air Act, which reduced industrial discharge or emission of pollutants into the air and set standards for vehicular emissions

Today, public health practitioners continue to work to prevent disease. However, their efforts are often directed to addressing social issues, such as access to health care, and promoting lifestyle change, such as smoking cessation, responsible sexual behavior, and violence prevention.

Frequently, public health professionals must work cooperatively with persons in other disciplines to achieve health promotion objectives. For example, public health practitioners may work with educators and schools to help combat illiteracy, since persons unable to read may be less able to obtain needed health care services. Similarly, they may work with urban planners and housing specialists to identify health hazards such as lead-based paints or asbestos.

The Healthy People 2010 initiative is a national plan to assist states, communities, and professional associations to develop programs to improve health. Coordinated by the Office of Disease Prevention and Health Promotion (ODPHP) of the Department of Health and Human Services, the program's goals are to: increase quality and years of healthy life; and eliminate health disparities. Healthy People 2010 targets ten areas for improving the health standards in the United States. They are:

  • physical activity
  • overweight and obesity
  • tobacco use
  • substance abuse
  • responsible sexual behavior
  • mental health
  • injury and violence
  • environmental quality
  • immunization
  • access to health care

Professional implications

Medical, nursing and allied health professionals and practitioners work in the field of public health. Public health professionals are employed by hospitals, health plans, managed care organizations, clinics, medical relief organizations (e.g., American Red Cross, American Heart Association, American Cancer Society) and schools as well as federal, state, and local government health departments. Careers in public health include:

  • public health nursing
  • environmental health technologists and specialists
  • restaurant and food safety inspectors
  • community health educators
  • epidemiologists, biostatisticians, and researchers
  • administrators
  • patient and consumer health advocates

Public health nursing began in the United States during the late 1800s. Public health nurses helped to prevent and manage outbreaks of smallpox, cholera, typhoid, tuberculosis, and other communicable diseases. The profession continues to attract nurses interested in community health education and preventive services. Public health nurses (also called community health nurses) work in clinics, schools, voluntary agencies, and provide skilled nursing assessments, visiting nurse services, and home care.

Federal government agencies that belong to the U.S. Department of Health and Human Services provide many vital public health services. The agencies devoted to health care include the Health Care Financing Administration (HCFA), Office of Development Services, Food and Drug Administration (FDA), National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC).

HCFA administers Medicare and Medicaid, programs that finance health care services for older adults, persons with disabilities and those unable to afford medical care. The FDA is the agency responsible for ensuring food, drug, and cosmetic safety. It also enforces labeling practices, so that consumers receive accurate, truthful information about the content, benefits, and risks of products.

Each of the 13 institutes of the NIH is involved in organ or disease-specific research activities. The seven centers of the CDC research and track infectious and other diseases in order to identify sources of disease and prevent their spread.

KEY TERMS

Communicable— Capable of being transmitted.

Epidemiology— The study of disease occurrence in human populations.

Incidence— The rate of development of a disease in a given population over time.

Potable— Safe to drink.

Prevalence— The rate describing the characteristics of a given population at a specific moment in time.

Resources

BOOKS

Wallace, Robert B., ed. Public Health & Preventive Medicine Stamford, CT: Simon & Schuster, 1998.

PERIODICALS

Clark, Noreen M., and Elizabeth Weist. "Mastering the New Public Health." American Journal of Public Health 90, no. 8 (August 2000): 1208-1211.

Meyer, Ilan H., and Sharon Schwartz. "Social Issues as Public Health: Promise and Peril." American Journal of Public Health 90, no. 8 (August 2000): 1189-1191.

ORGANIZATIONS

American Public Health Association. 800 I. Street, NW Washington, DC 20001-3710. (202) 777-2532. 〈http://www.apha.org〉.

Centers for Disease Control and Prevention. 1600 Clifton Rd. Atlanta, GA 30333. (800) 311-3435. 〈http://www.phppo.cdc.gov〉.

OTHER

Partners in Information Access. 〈http://www.nnlm.nlm.nih.gov/partners/index.htm〉.

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Public Health

Public Health

September 1945

In the last Presidential campaign, both the Republican and the Democratic Parties acknowledged the fact that something must be done to make available to the whole population of our nation, adequate medical care from pre-natal days to old age.4

The Democratic Administration, of course, has accepted the responsibility for putting its promises in the form of a Bill which will start the ball rolling toward better public health. This Bill is known as the Wagner-Murray-Dingle Bill.5 But now we are beginning to see the same old game develop as we saw it at the end of the last war. We learned the same lessons then, namely, that our people are not the healthiest people in the world and need not only better medical care, but better food and more knowledge on the subject of health. But we quarreled as to how we would achieve our objectives and did nothing. We are headed that way again.

The way to begin is to begin. This Bill may not be perfect, but it is a step in the awakening of interest in the question of health for everyone, not for those alone who can afford to pay for it.

Let us tell our representatives in Congress that this is one of the things we want to do and keep on doing, so that twenty-five years from now our young people will be far healthier than they were found to be during this last draft.

Without health no nation can successfully defend itself against the aggression of other nations, either in the military or the economic fields. If we want to retain our leadership in the world we must see that our people are healthy and vigorous. The spirit of adventure and the power to show initiative will die out if we do not preserve the health of the nation. I can see objections to almost any plan that is attempted, but like so many things, I believe it is better to begin and make the changes as we learn from experience. We need to make the attempt to improve the general health of the people of our country.

TMsd AERP, FDRL

1. Lash, Eleanor, 465-67; Cook, vol. 2, 62-63, 416-18.

2. MD, 7 September 1945.

3. See Document 45.

4. In his January 11, 1944, annual address to Congress, the "Economic Bill of Rights" speech, FDR called for "a Second Bill of Rights under which a new basis of security and prosperity can be established for all—regardless of station, race or creed," which included "the right to adequate medical care and the opportunity to achieve and enjoy good health" (Zevin, 396).

5. The Wagner-Murray-Dingell bill proposed using funds collected from employees and employers to create a social insurance trust fund (with government contributions beginning within the next fifteen years) to finance a dramatic expansion of social security coverage. Not only would it add an additional 15,000,000 domestics, farm workers, small businesspeople, and employees of nonprofit institutions to the social security rolls, it would also cover workers and their families. The social insurance system would include prepaid health, unemployment, and disability insurance, as well as provide more generous retirement and survivors benefits. States would receive federal grants to enlarge hospitals and expand existing health coverage for pregnant women, infants, and children (C. P. Trussell, "Congress Gets Security Bill Adapting Beveridge Plan," NYT, 4 June 1943, 1; "Expanding Social Security," NYT, 26 May 1945, 14).

ER misspelled "Dingle."

On the Pearl Harbor Commission and Congress

The surprise attack on Pearl Harbor produced immediate congressional cries for investigation. In January 1942, FDR appointed Associate Justice Owen Roberts to chair a special inquiry into the attack. Roberts's commission placed the blame at the feet of navy and army commanders at Pearl Harbor, Admiral Husband E. Kimmell and Major General Walter C. Short, faulting them for inadequate preparation and communication and "too lightly heed[ing]" the warnings from Washington. FDR refused to make the committee report public, arguing that doing so in wartime would put military personnel at risk. Congress thus passed resolutions extending the statute of limitations for the commanders' courts-martial until the war's end.

By 1944, election politics ignited more speculation, especially after Colliers published an article by Senator (and vice-presidential nominee) Harry Truman in its August issue indicting Kimmell and Short for their lack of cooperation. Kimmell, whom the navy had just placed on inactive duty, denied Truman's allegations and declared the Roberts report did "not contain the basic truths about the … catastrophe." The following December, Secretaries Stimson and Forrestal announced that separate boards of inquiry conducted by the army and navy found that while some unidentified army officers "lacked skill and judgement" the evidence investigated by both panels "does not warrant and will not support" court-martial proceedings.

Congress waited until Japan surrendered August 15 to press for hearings. August 17, Senator David Walsh (D-MA), chair of the Senate Naval Affairs Committee, asked Forrestal to deliver the "complete file of the navy's investigation" to the committee and make recommendations for how its content should be released to the public. August 23, Truman summoned Roberts to the White House. August 29, the Pearl Harbor Army and Navy Boards of Inquiry released their reports to the press. The army blamed Short for his "failure … to adequately alert his command for war"; Secretary of State Cordell Hull for delivering a series of demands to the Japanese November 26, 1941, which the Japanese construed as an ultimatum "to withdraw from the Asiatic mainland"; and General George Marshall for his "failure to advise his deputy chiefs of staff" about "the critical situation in the Pacific," as well as his "failure to keep General Short fully informed on the international situation and the probable outbreak of war." The navy report, while citing inadequate communication procedures, held no officer accountable.1

ER wrote the following column August 30, the day after the president released the reports from the military boards of inquiry.

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Public Health

Public Health

Providing public health care has long been a special challenge for Latin America. Because much of the region lies in the tropics, Latin America is home to many microorganisms that can bring illness and death to human hosts. Economic underdevelopment has impeded governments' efforts to provide clean water, proper sewage disposal, vaccinations, and care for the sick. And because many people in Latin America are poor and malnourished, they have weak or compromised immune systems, depriving them of the best defense against illness. Only in the twentieth century have significant strides been made in improving public health care in Latin America, but this progress has been very uneven.

COLONIAL ERA

Until the arrival of the Europeans in the late fifteenth century, the Western Hemisphere had enjoyed complete isolation from some global disease pools. The conquerors and their African slaves introduced into the Americas many deadly epidemic diseases from which the natives had no natural immunities to protect them. Smallpox, measles, influenza, typhus, and many other afflictions ravaged the New World; its population fell by roughly 90 percent in the first 110 years after the Conquest. Almost nothing could have been done to halt this disaster, and certainly little was tried. At the time, about the only public health measure taken was sometimes to quarantine incoming ships and isolate their crews during the worst epidemics.

European notions about the origin and spread of disease generally focused on miasmas (Greek for "pollution" or "stain"), which were believed to be foul, disease-bearing airs that arose from putrefying organic waste. Traditional medicine stressed the need to rid the body of poisons and recommended frequent bleedings, induced vomiting, sweating, and repeated enemas. One stood a better chance of recuperating if a doctor's ministrations could be avoided. During the era of the Spanish Bourbon Reforms, especially under King Charles III (1759–1788), enlightened colonial officials began to take more aggressive public sanitation measures to rid communities of the sources of miasmas. The clean-up campaigns served to make urban settings less foul but could do little to prevent or halt most epidemics.

THE NINETEENTH AND TWENTIETH CENTURIES

Beginning in the closing decades of the nineteenth century, several critical advances led to the rise of the modern era of public health in Latin America. The economy of Latin America rose swiftly in these years on the strength of increased primary product exports to the developed world. In the cities that served as the focal points for this expanding trade, control of epidemics became an urgent business concern, for quarantines halted commerce. Fortunately, these socioeconomic developments coincided with some stunning scientific breakthroughs in the field of medicine. In Europe the work of Robert Koch, Louis Pasteur, and others established the germ theory of disease. Their work, along with that of many others—including Latin Americans Oswaldo Cruz, Carlos Chagas, and Carlos J. Finlay—provided a sound theoretical basis for attacking the spread of infectious diseases.

Accordingly, by the late nineteenth and early twentieth centuries Latin American cities underwent significant sanitary reforms, including the construction of their first mass potable water systems and underground sewers (greatly reducing the risk of cholera, typhoid fever, and other water-borne diseases). They established vaccination programs against smallpox (which was quite effective) and bubonic plague (less so); developed mosquito abatement programs (greatly reducing the risk of yellow fever and malaria); began to inspect and regulate the sale of food, especially milk and meat; and opened modern laboratories to test foods and drugs for purity. They also built many new hospital facilities, incorporating modern medical methods developed in Western Europe and the United States, in particular better diagnostic and surgical techniques (including anesthesia and asepsis) and more specialized training of physicians. Doctors typically received their advanced training in France, although some good schools were established in the leading Latin American cities. National health departments were also formed across Latin America, beginning in Argentina and Uruguay.

These advances in medical treatment and urban sanitation contributed to an overall lowering of death rates in Latin America, which followed from a reduced incidence of infectious diseases such as yellow fever, cholera, typhoid fever, bubonic plague, smallpox, typhus, and tetanus. But other factors may actually have played a larger role. Scholars disagree as to what best explains the transition from lower overall death rates to rapid population growth. Some believe that microorganisms were gradually changing, becoming less deadly. Certainly there would be an evolutionary tendency for microorganisms to move in that direction: if they killed their hosts, they, too, died. Another possible factor for Latin America may have been the end to the African slave trade by the 1860s, which halted the steady importation of people from other disease environments. Perhaps most important of all was a general improvement in diet and housing conditions, although measuring such progress is difficult.

Certain political circumstances made government action in the field of public health more likely. Health care reforms came fastest in those nations where the urban middle class and the trade union movement first grew strong. As they pushed for incorporation into the political system, they also advanced a social agenda that included health concerns. Where skilled export workers occupied a strategic bottleneck position in the economy, they could sometimes join with privileged middle-class employees and press effectively for reforms. The elites responded by co-opting these groups with the creation of health programs to serve them, even as the health needs of those with less political leverage were ignored. Social programs to provide medical insurance for the middle class and favored sectors of the urban working class were enacted in Argentina, Brazil, Chile, Cuba, and Uruguay as early as the 1910s and 1920s.

In some circumstances, imperialism led directly to sanitation and public health reform. The United States occupation of Cuba, Haiti, the Dominican Republic, and Panama and, likewise, British control of Jamaica, meant stationing officials and troops in unhealthy tropical zones. Responding to this threat to their own citizens, the United States and Great Britain carried out massive public works projects in their colonial holdings, including effective mosquito abatement measures and the construction of hospitals, potable water systems, and underground sewers, thereby greatly reducing public health risks for all.

TWENTIETH-CENTURY PROGRESS

During the twentieth century international organizations played an important role in the advancement of Latin American public health care. Based in the United States, the Rockefeller Foundation's International Health Division (created in 1913) took an active role, launching campaigns against malaria, yellow fever, and hookworm. The programs against yellow fever and malaria proved quite effective, even if the hookworm campaign did not. Overall, however, the foundation's usual practice of retaining direct control over policies and funding often rankled public officials in host nations.

The Pan American Health Organization (PAHO) also played a key role in Latin American public health progress in the twentieth century. The first Pan American Sanitary Conference met in 1902, under the aegis of the Pan American Union (now the Organization of American States). This small organization was actually run and staffed through the Surgeon General's Office of the U.S. Public Health Service. By 1924 the organization had drawn up the Pan American Sanitary Code, adopted everywhere in the Americas by 1936. In 1947 the Pan American Sanitary Bureau (PAHO since 1958) finally obtained its own building in Washington, D.C., and added more personnel. In 1949 this bureau became a Latin American regional organization under the newly created World Health Organization. PAHO came to play an important role in the eradication of infectious diseases such as smallpox, malaria, and yellow fever.

Over the course of the twentieth century life expectancy doubled in Latin America, with most of the gain coming from the lowering of infant mortality rates (the number of deaths ages 0-1 per 1,000 live births). (The infant mortality rate for Latin America fell from 125 in the five years from 1950 to 1955 to 36 in the five years from 1995 to 2000.) But whereas prior to 1930 most Latin American public health care advances could be linked to the improved economic circumstances, after 1930 the gains stemmed principally from the importation of new sanitation and medical technologies from the United States and the rest of the developed world.

One key development was the mass spraying of the insecticide DDT. In the late 1950s PAHO undertook massive effort to wipe out the mosquitoes that serve as vectors for yellow fever, malaria, and dengue (or "breakbone") fever. The program was an enormous success, and illness and death from most mosquito-vectored diseases were all but eliminated. However, the overuse of DDT, especially in commercial agriculture, in time reduced its effectiveness against mosquitoes. Concerns in the 1960s over the possible harmful implications of introducing massive amounts of DDT into the environment brought an end to the program.

Other public health efforts included the chlorination of potable water; better sewage disposal and treatment; expanded vaccination; and the widespread introduction of new antibiotics (which proved especially effective in reducing the number of deaths due to pneumonia and tuberculosis). These steps, in the words of Nicolás Sánchez-Albornoz, were "grafts from other civilizations" (The Population of Latin America, p. 5). Through them, the risk from nearly all major infectious illnesses in Latin America was eliminated or greatly reduced, at least for a time.

POVERTY, EQUITY, AND HEALTH

In the largest sense, the economic context most determines success in providing for public health. Two macro-measures are most significant: per capita gross domestic product (GDP) and distribution of income. As a rule, the more advanced the economy, the better the overall public health situation. Because economic growth usually brings a reduction of poverty, it usually results in improvement in the public health situation.

Although historically this general relationship among economic performance, reduction of poverty, and improvement in public health has held true in Latin America, since the 1990s it has no longer been the case. When the region's economy grew in the 1960s and 1970s, the number of families living in poverty fell; the deep economic decline of the 1980s brought a sharp increase in poverty levels. (During the 1980s, workers' real wages across Latin America fell by about one-quarter.) However, when economic growth eventually returned in the 1990s, albeit at a much slower pace than in the 1960s and 1970s, the percentage of those living in poverty did not decrease. Indeed, in the late 1990s the percentage of Latin Americans living in extreme poverty (earning less than a dollar a day) began to grow again. In the twenty-first century, in Nicaragua and Haiti over half of the population lives on less than a dollar a day. More than half of the population of Bolivia, Colombia, Ecuador, Guatemala, and Paraguay live in poverty (less than two dollars a day). In Haiti, Nicaragua, and Honduras more than seven out of ten people live in poverty. In Latin America as a whole, six of every ten children live in poverty.

The problem is that Latin America has the most unequal distribution of income of any region in the world, a situation that has significantly worsened since the 1990s. From 1990 to 1995, a time of economic recovery and growth, the income share received by to the bottom 10 percent of the population fell 15 percent. If Latin America's income were only as unevenly distributed as that of Eastern Europe or South Asia, its economic growth since the 1990s would have all but eliminated poverty (reducing poverty to around 3 percent of the population). In Latin America income is so unequally distributed that economic growth cannot reduce poverty. This has enormous implications for Latin America's public health.

The poor are more likely to become ill, less likely to receive medical attention when they become ill, and more likely to suffer premature death. Infant mortality is especially associated with poverty. In Peru, for example, the infant mortality rates for the poorest one-fifth of the population is five times higher than that of the wealthiest one-fifth. In Bolivia the infant mortality rate of the poorest one-fifth of the population is 107 while that of the wealthiest one fifth is 26. Moreover, in Latin America racial and ethnic minorities are more likely to live in poverty, and these groups suffer worse public health conditions as a result. In Brazil, for example, the infant mortality rate for whites is 37, but for people of color it is 62. In Mexico, childhood mortality (ages 5 or younger) is two and a half times higher for indigenous than nonindigenous people.

Improvement in public health is much more strongly linked to income equity than to economic growth: the more even the distribution of income, the better the overall public health situation. To illustrate, the per capita GNPs of Haiti and Cuba are roughly equal (ranking at the bottom of all Latin American nations), but in Haiti income is very unevenly distributed whereas in Cuba it is very evenly distributed. As a result, by almost any measure Haiti has the worst public health situation in Latin America and Cuba has the best. Life expectancy in Haiti is 60 years; in Cuba it is 82. Most contemporary public health experts therefore regard social inequality as the leading source of deficiencies in public health care in contemporary Latin America.

HEALTH INSURANCE

Beginning in the 1930s, many Latin American nations developed national health insurance programs, although these systems tended to cover only salaried employees. Consequently, even by the late 1960s only one of six Latin Americans was covered by a social health insurance program. In the early 1980s Chile, as part of its conversion to free market (or neoliberal) economic policies under the Augusto Pinochet dictatorship (1973–1990) privatized its public health care system. Soon many other Latin American nations followed, establishing private, for-profit health insurance systems. This policy direction continues to be actively supported by the United States, acting through the Inter-American Development Bank and the World Bank. The reforms are patterned after the U.S. health care system, even though it is the most expensive per capita in the world and ranks behind most developed nations in nearly all leading public health indicators.

A key concern with the privatization of public health care in Latin America is that for-profit health insurance companies seek naturally to enroll those individuals who are both in excellent health and can afford to pay high premiums. Moreover, providing health care through private insurance systems works best in urban areas among workers employed in the formal sector, but works far less well for peasants and urban informal sector workers. For Latin America the difficulty is that these latter two categories make up the bulk of the economically active population. During the 1990s and to 2005 at least seven of every ten new jobs created was in poorly paid informal sector. In Latin America today more than three-quarters of the population has no health insurance of any kind.

Women have been especially disadvantaged by the changes to the health care system. The new private health insurance systems are tied to employment in the formal sector, with payment coming in the form of paycheck withholding. Women who do not work for pay (half of the working age population of females in Latin America) or work in the informal sector and are paid less than men (Latin American women earn on average three-quarters of what men earn) are extremely unlikely to be able to afford the cost of private health insurance. Compounding this are the special health care needs of women. Beyond the health burdens of childbirth (a woman's risk of dying from maternal causes was 1 in 160 in Latin America, but 1 in 3,500 in the United States and Canada), women tend to live longer and suffer higher rates of morbidity and disability than do men. Reflecting this reality, health insurance premiums are higher for women than for men. In Chile, for example, health insurance premiums cost on average two and a half times more for women than men.

TRENDS IN SCHOLARSHIP

Public health care officials have long recognized the link between poverty and problems in public health, but historically most treated poverty as a given, focusing their efforts instead on measures that seek to ameliorate the social conditions that stem from poverty. But by the 1930s an influential minority of Latin American public health researchers and physicians began to push beyond just noting the health implications of poverty, taking a more activist political stance. These "social medicine" critics sought to diagnose the etiology of poverty itself, offering socioeconomic and political prescriptions: government-provided food, clothing, and shelter, and above all, income redistribution. The writings of Salvador Allende Gossens, especially La realidad médico-social chilena (The Chilean medico-social reality, published in 1939, when he was Chile's minister of health), stimulated increasing interest in the "social medicine" approach. Elected to the presidency in 1970, Allende sought to put in place some of the leading precepts of social medicine. Since the late twentieth century, a host of new studies and specialized journals have come to focus on research into the relationship between social inequities and health care problems in Latin America.

PRESENT CHALLENGES

There has been some heartening progress in public health care in Latin America, most notably in the area of vaccination coverage. Routine childhood vaccinations against diphtheria, whooping cough, and tetanus have dramatically reduced the incidence of these afflictions across Latin America. Vaccination programs have also succeeded in eradicating both polio and measles in Latin America, even as these diseases continue to disable and kill people, especially children, elsewhere in the developing world.

Yet in several key areas Latin America has failed to progress in the provisioning of public health. Whereas life expectancy in Latin America was five years longer than in East Asia in the mid-1960s, by the mid-1990s Latin America had fallen behind by 1.2 years. Contemporary neoliberal economic policy has stressed the need to reduce the role of government, favoring instead free market solutions to social concerns. However, reductions in public spending on both potable water and sewers has had serious public health implications. Beginning in 1991 contaminated water supplies led to a widespread Latin American outbreak of cholera, a disease that had been unseen in the region for nearly a hundred years. Nevertheless, today roughly two-thirds of Latin American cities make no attempt to treat their raw sewage before dumping it into nearby rivers or the sea. In several nations only half of the population has in-home potable water, and its purity is by no means guaranteed. Across Latin America, only about a quarter of piped water is routinely checked for contaminants. These deficiencies represent a substantial failure in the provisioning of public health needs in Latin America, for with each percentage point increase in potable water coverage for the population, the infant mortality rate drops 1 person per 1,000 births.

Another serious concern is rising antibiotic resistance, a result of massive overuse and/or inappropriate use of antibiotics. Fully two-thirds of all pharmaceutical drugs used in Latin America are purchased without a doctor's prescription. Today a wide array of antibiotics have been rendered partly or completely ineffective, and lethal strains of multi-drug-resistant tuberculosis have appeared in Peru and Haiti. Their spread to the rest of the world is but a plane ride away.

Although maternal mortality is rare in the developed world, in Latin America it remains the main cause of death for women aged 20 to 34. A leading cause of maternal mortality in Latin America is complications from abortions. Abortion is generally illegal in Latin America, except in Cuba. (In Cuba the number of abortions has dropped sharply because of widespread availability and use of contraception.) Nevertheless, about half of all pregnancies in Latin America end in abortion. Another leading cause of female mortality is cervical cancer, especially in poorer nations where women are unlikely to undergo periodic Pap smears.

Another concern is HIV/AIDS, which now infects at least 2.4 million people in Latin America. The Caribbean region has been especially hard hit, and prevalence there is higher than any other region in the world except sub-Sahara Africa. In the Caribbean HIV/AIDS is the leading cause of death for people aged 15 to 49. All told, at least half a million people have died from AIDS in Latin America. Education remains a problem: a third of Latin American adolescents do not understand how to protect themselves from the disease.

Several mosquito-borne diseases, once thought to be eradicated, have now either come back or are on the verge of doing so. Lapses in mosquito control have led to the reemergence of dengue fever (a debilitating and painful affliction) and dengue hemorrhagic fever (a less frequently occurring but lethal counterpart) across much of the Caribbean. There is no vaccine, no cure, and no effective treatment for dengue. Urban yellow fever, driven from all Latin American cities in the early twentieth century, now appears poised to return. The reinfestation of the mosquito vector, aedes aegypti, and the advance of human settlements into the Amazon where jungle yellow fever is endemic among some species of monkeys, raises the risk of reintroduction of yellow fever into urban areas.

Despite continuing and serious public health concerns, today most spending on health in Latin America goes for modern, expensive, curative measures and for private physicians serving the more privileged in society, while less-expensive, mass preventive measures are not usually well funded. Critics argue that the existing system misallocates scarce public health spending, for preventive programs could help attack the health concerns of poorer, especially rural regions, and diseases that especially affect children. To critics, Latin America's pattern of spending on health represents a massive shift of resources from the poor to the rich and from the young to the old.

See alsoAcquired Immune Deficiency Syndrome (AIDS); Cities and Urbanization; Diseases; Medicine: Colonial Spanish America; Medicine: The Modern Era; Population: Brazil; Population: Spanish America.

BIBLIOGRAPHY

Abel, Christopher. Health, Hygiene and Sanitation in Latin America c. 1870 to c. 1950. London: Institute of Latin American Studies, 1996. Provides a historical sketch of public health care history in Latin America.

Barrientos, Armando, and Peter Lloyd-Sherlock, "Health Insurance Reforms in Latin America: Cream Skimming, Equity and Cost-Containment," in Social Policy Reform and Market Governance in Latin America, edited by Louise Haagh and Camilla T. Helgϕ. New York: Palgrave Macmillan, 2002.

Casas, Juan Antonio, J. Norberto W. Dachs, and Alexandra Bambas. "Health Disparities in Latin America and the Caribbean: The Role of Social and Economic Determinants." In Equity and Health: Views from the Pan American Sanitary Bureau. Washington, DC: Pan American Health Organization, 2001. Provides a summary of equity issues.

Pineo, Ronn. "Misery and Death in the Pearl of the Pacific: Health Care in Guayaquil, Ecuador, 1870–1925," in Hispanic American Historical Review 70, no. 4 (1990): 609-637. Discusses public health care at the turn of the twentieth century.

Kiple, Kenneth F., ed. Cambridge World History of Human Disease. Cambridge, U.K., and New York: Cambridge University Press, 1993. The best place to begin a study of the history of Latin American public health.

Londoño, Juan Luis, and Miguel Székely. "Persistent Poverty and Excess Inequality: Latin America, 1970–1995," Journal of Applied Economic, 3, no. 1 (2000): 93-134, Supplies numbers on economic growth and inequality.

Pan American Health Organization. Health in the Americas, vols. 1 and 2. Washington, DC: Pan American Health Organization, 2002.

Sánchez-Albornoz, Nicolás. The Population of Latin America: A History, translated by W. A. R. Richardson. Berkeley: University of California Press, 1974. Demography and public health.

United Nations. The Millennium Development Goals: A Latin American and Caribbean Perspective. Santiago, Chile: United Nations, 2005. Provides a full overview of existing conditions.

                                       Ronn Pineo

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Public Health

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Public Health

Public health

Definition

Public health is the science and clinical practice of population and community-based efforts to prevent disease and disability, and promote physical and mental health. It considers the health of groups, communities, or populations as opposed to the health of individuals. Public health addresses a variety of medical and social issues including:

  • environmental health
  • nutrition and food safety
  • immunization and infectious diseases
  • injury and violence prevention
  • maternal, infant, and child health
  • substance abuse
  • chronic disease prevention and treatment
  • access, availability, and affordability of health care
  • education, screening, and outreach services

Description

The science of public health is called epidemiology. It is the study of the occurrence of disease in such naturally existing populations as nations, cities, or communities. The term "epidemiology" comes from the Greek word epidemic, which means "upon the people." The earliest epidemiologists (public health scientists) worked to prevent the spread of epidemics.

Today, epidemiologists gather and analyze information about populations to manage and prevent disease. Epidemiologists are trained in highly specialized research methods: surveillance, investigation, analysis, and evaluation. Surveillance refers to systematic data collection and analysis; it enables the epidemiologists to detect changes that may require investigation. Epidemiological investigation involves observation, detailed descriptions of the problem, documentation of data, and analysis. Evaluation is the process that helps to answer such a question as "How often should men between the ages of 40 and 60 be screened for hypertension (high blood pressure)?"

By analyzing population data, epidemiologists also are able to describe diseases and determine the factors that cause them. Epidemiology is a quantitative science; it measures rates and proportions. Two commonly used rates are prevalence and incidence rates. Prevalence describes the characteristics of a given population at a specific moment in time; it is like a snapshot.

Incidence describes the rate of development of a disease in a given population over a specified time interval. Incidence offers a longer view of population dynamics, like a video, as opposed to the snapshot offered by the prevalence rate. Epidemiologists also analyze such other rates as morbidity (disease-related illness) and mortality (death).

Public health practitioners rely on the findings of epidemiologists to develop health services, allocate resources, and determine standards of care. The results of epidemiological studies also influence health policy. For example, epidemiological research helps to determine how many health care professionals are needed based on population; the effectiveness of various treatments; and schedules for immunization or screening.

Viewpoints

Historically, public health disease prevention activities focused primarily on sanitation (also referred to as environmental health) and hygiene. Public health measures aimed to ensure the safety of food and water supplies, and to prevent transmission of communicable (capable of being transmitted) diseases. In some developing countries, these same basic public health problems, such as adequate food supplies and potable (fit to drink) water, continue to threaten health and longevity.

During and after World War II, such advances in medicine as the development of antibiotics , cardiac surgery, and physical rehabilitation changed the emphasis of public health in the United States. Federal, state, and local governments enacted legislation to protect public health. Federal laws aimed at safeguarding public health. Major regulations passed during the twentieth century include:

  • the 1938 Food, Drug and Cosmetic Act, which bans distribution of unsafe products and prohibits false advertising
  • the 1972 Clean Water Act, which forbids release of pollutants into rivers, streams, and waterways
  • the 1974 Safe Drinking Water Acts, which established standards for safe drinking water
  • the 1976 Resource Conservation and Recovery Act, which stipulates the safe storage, transport, treatment and disposal of hazardous waste materials
  • the 1990 Clean Air Act, which reduced industrial discharge or emission of pollutants into the air and set standards for vehicular emissions

Today, public health practitioners continue to work to prevent disease. However, their efforts are often directed to addressing such social issues as access to health care, and promoting such lifestyle changes as smoking cessation, responsible sexual behavior, and violence prevention.

Frequently, public health professionals must work cooperatively with persons in other disciplines to achieve health promotion objectives. For example, public health practitioners may work with educators and schools to


KEY TERMS


Communicable —Capable of being transmitted.

Epidemiology —The study of disease occurrence in human populations.

Incidence —The rate of development of a disease in a given population over time.

Potable —Safe to drink.

Prevalence —The rate describing the characteristics of a given population at a specific moment in time.


help combat illiteracy, since persons unable to read may be less able to obtain needed health care services. Similarly, they may work with urban planners and housing specialists to identify such health hazards as lead-based paints or asbestos.

The Healthy People 2010 initiative is a national plan to assist states, communities and professional associations to develop programs to improve health. Coordinated by the Office of Disease Prevention and Health Promotion (ODPHP) of the Department of Health and Human Services, the program's goals are to: increase quality and years of healthy life; and eliminate health disparities. Healthy People 2010 targets ten areas for improving health standards in the United States. They are:

  • physical activity
  • overweight and obesity
  • tobacco use
  • substance abuse
  • responsible sexual behavior
  • mental health
  • injury and violence
  • environmental quality
  • immunization
  • access to health care

Professional implications

Medical, nursing and allied health professionals and practitioners work in the field of public health. Public health professionals are employed by hospitals, health plans, managed care organizations, clinics, medical relief organizations (e.g., American Red Cross, American Heart Association, American Cancer Society) and schools as well as federal, state, and local government health departments. Careers in public health include:

  • public health nursing
  • environmental health technologists and specialists
  • restaurant and food safety inspectors
  • community health educators
  • epidemiologists, biostatisticians, and researchers
  • administrators
  • patient and consumer health advocates

Public health nursing began in the United States during the late 1800s. Public health nurses helped to prevent and manage outbreaks of smallpox, cholera, typhoid, tuberculosis , and other communicable diseases. The profession continues to attract nurses interested in community health education and preventive services. Public health nurses (also called community health nurses) work in clinics, schools, voluntary agencies, and provide skilled nursing assessments, visiting nurse services, and home care .

Federal government agencies that belong to the U.S. Department of Health and Human Services provide many vital public health services. The agencies devoted to health care include the Health Care Financing Administration (HCFA), Office of Development Services, Food and Drug Administration (FDA), National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC).

HCFA administers Medicare and Medicaid , programs that finance health care services for older adults, persons with disabilities and those unable to afford medical care. The FDA is the agency responsible for ensuring food, drug, and cosmetic safety. It also enforces labeling practices, so that consumers receive accurate, truthful information about the content, benefits, and risks of products).

Each of the 13 institutes of the NIH is involved in organ or disease-specific research activities. The seven centers of the CDC research and track infectious and other diseases in order to identify sources of disease and prevent their spread.

Resources

BOOKS

Wallace, Robert B., ed. Public Health & Preventive Medicine Stamford, CT: Simon & Schuster, 1998.

PERIODICALS

Clark, Noreen M., and Elizabeth Weist. "Mastering the New Public Health." American Journal of Public Health 90, no. 8 (August 2000): 1208-1211.

Meyer, Ilan H., and Sharon Schwartz. "Social Issues as Public Health: Promise and Peril." American Journal of Public Health 90, no. 8 (August 2000): 1189-1191.

ORGANIZATIONS

American Public Health Association. 800 I. Street, NW Washington, DC 20001-3710. (202) 777-2532. <http://www.apha.org>.

Centers for Disease Control and Prevention. 1600 Clifton Rd. Atlanta, GA 30333. (800) 311-3435. <http://www.phppo.cdc.gov>.

OTHER

Partners in Information Access. <http://www.nnlm.nlm.nih.gov/partners/index.htm>.

Barbara Wexler

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Public Health

PUBLIC HEALTH

france
britain
demographic explosion
reform on the continent
bibliography

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

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Public Health

PUBLIC HEALTH.

THE "BACTERIOLOGICAL REVOLUTION"
THE RISE OF SOCIAL MEDICINE
POSTWAR EUROPE
NEW CHALLENGES
RECENT SCHOLARLY INTERPRETATIONS AND DEBATES
BIBLIOGRAPHY

Public health refers to the science and practice of protecting and improving the health of a community through a variety of means, including preventive medicine, health education, control of communicable diseases, application of sanitary measures, and monitoring of the environment.

Although the sanitary movement of the mid-nineteenth century helped to lower death rates from enteric diseases, particularly cholera, epidemic disease remained commonplace throughout an increasingly industrialized Europe. Scholars therefore trace the modern era of public health in Europe to the late-nineteenth-century "bacteriological revolution" and to broader contemporary health programs initiated by state governments as they took shape during the last quarter of the nineteenth century. At the root of these programs was the realization among state leaders that proper maintenance of public health could help ensure social stability, prosperity, and order. Indeed, better public health could help to make healthier and therefore more productive citizens. The tension that existed in this rationale—namely the exercise of government authority to achieve community health, on the one hand, and the restriction of individual rights, on the other hand—is a recurring theme in the history of modern European public health programs, and it informs issues of public health in early-twenty-first-century Europe.

THE "BACTERIOLOGICAL REVOLUTION"

Led by the research of two scientific rivals—Louis Pasteur (1822–1895) in France and Robert Koch (1843–1910) in Germany—the emerging sciences of microbiology and immunology paved the way to substantial changes in thinking about the cause and transmission of disease.

Until the 1880s, the miasma theory of disease prevailed in scientific circles. This theory held that diseases such as cholera were caused by a noxious form of miasma, a term meaning "bad air," derived from the Greek word for "pollution." Through the therapeutic research of Pasteur and the bacteriological research of Koch, the germ theory of disease took shape, advancing the claim that microorganisms may be the cause of disease. Further breakthroughs by Koch, by his assistants Friedrich Loeffler (1852–1915) and Georg Gaffky (1850–1918), and by others who used Koch's methods of cultivating and isolating bacteria yielded identification of the bacteria responsible for diphtheria, typhoid, tetanus, and cholera. Such efforts, combined with further scientific and technical advancements, led to the introduction of the first generation of vaccines for use in humans, including those for rabies (1885), plague (1897), diphtheria (1923), pertussis (1926), tuberculosis (1927), tetanus (1927), and yellow fever (1935). Bacteriology also opened the door to better disease control among infected populations. State public health policies had long implemented quarantines and isolation to control the spread of disease. But with the advent of greater knowledge of disease-causing bacteria, authorities could exact a more targeted response to a disease outbreak, whether among travelers in rural areas or populations in dense urban centers.

The "bacteriological revolution" yielded a reaction that became integral to the further development of public health in Europe through the first two decades of the twentieth century. Even as deaths from infectious disease declined, deplorable health conditions remained for the working classes and urban poor. Contemporary commentators found the germ theory by itself to be insufficient in the promotion of better public health. Increasingly, socialists and radical physicians questioned the value of leaving community health to scientific thinking alone. Greater social measures, they claimed, such as improved diet, safe and hygienic living and working conditions, and health education, would prove equally if not more beneficial to improving community health. Across Europe, state governments and local municipalities reacted by initiating a variety of public health measures that sought not only to improve public welfare but also to protect and enhance government authority. Reform-minded voluntary health agencies joined the effort by reacting to the perceived failure of public leaders to address deplorable conditions among the working classes. As responsibility for the health of the public shifted from the individual to the government, such responsibility became a matter of politics and, therefore, an entitlement of citizenship.

THE RISE OF SOCIAL MEDICINE

The period from 1914 to 1918 and the decades following the "war to end all wars" mark complex chapters in the history of public health in Europe. Although social medicine was already under way before the war as a means to ameliorate various causes of poor health—or, in some cases, the perceived causes of poor health—it grew significantly from wartime experience and yielded uneven results across nations. Among the many conditions addressed in a variety of ways were infant mortality and maternal welfare, venereal disease and prostitution, and poor working conditions.

During the first two decades of the twentieth century, ubiquitous rates of infant mortality became major threats to public health. Child and maternal health programs therefore emphasized nutrition to counterbalance malnourishment, health education and inspection to correct parental ignorance and school environments, and hygiene to eliminate contaminated food. The pronatalist campaign emerged in France, while across Britain voluntary and local government sanitary societies taught hygiene to children. In Germany, Czechoslovakia, Russia, and Italy schoolteachers taught children games, drills, and gymnastic exercises as means to stay healthy. Significantly, German concerns about the broader implications of child and maternal health, and no less reproductive hygiene, took on new meaning during the 1930s as Adolf Hitler radicalized what had earlier been a relatively moderate national eugenics movement. In Nazi hands, positive eugenics became a means to achieve a "pure" German race. "Racial hygiene" programs of the Third Reich included awards to "Aryan" women who had large numbers of children. These programs also involved impregnation of "racially pure" single women by members of the Schutzstaffel (SS), which formed the basis of the Nazi police state and was the major instrument of racial terror in the concentration camps and occupied Europe.

The interwar period also saw negative eugenics become a means to address concerns about child and maternal health and no less the health of the nation. Following its establishment in 1922, Sweden's National Institute for Race Biology sponsored research in social engineering that ultimately led to the forced sterilization of an estimated sixty thousand "unfit" men and women between 1936 and 1976. While Nazi eugenics programs offered rewards to certain people, they also involved forced sterilization of hundreds of thousands of men and women who were viewed as mentally and physically "unfit," compulsory "euthanasia" programs that killed tens of thousands of institutionalized individuals with disabilities, and the systematic killing during the Holocaust of millions of "undesirable" Europeans including Jews, Gypsies, and homosexuals. Such programs existed alongside extensive experimentation on live human beings to test Nazi genetic theories, ranging from simple measurement of physical characteristics to horrific experiments carried out in concentration camps.

Contemporaries also understood that venereal disease and prostitution threatened public health, especially during World War I. From 1914 through the demobilizations that extended into the early 1920s, military authorities of the major combatant nations used education and official entertainment as means to keep their soldiers away from liquor and local prostitutes, and therefore fit for service. In Britain, voluntary-aid organizations such as the YMCA and Salvation Army assisted in this effort by establishing distinctive "rest huts" on the home front and overseas where soldiers could enjoy hot drinks, hearty meals, and the company of "motherly" women volunteers. Based in part on prewar efforts to ameliorate living conditions of the urban poor, these "homes away from home" were intended to help preserve men not only for battle but also for postwar life as husbands and fathers. After the war, such efforts to promote abstinence gave way to a pragmatic acceptance that distributing condoms was a more effective means of controlling venereal disease.

Following World War I, poor working conditions and the poor health of laborers were also identified as threats to public health. This concern was perhaps most evident in the establishment of the International Labour Organization (ILO) in 1919 through the negotiations of the Treaty of Versailles. Adopted by the Paris Peace Conference in April 1919, the constitution of the ILO stated plainly that "conditions of labour exist involving such injustice hardship and privation to large numbers of people as to produce unrest so great that the peace and harmony of the world are imperiled." Politics and economy certainly drove the mission of the ILO, but so too did health and welfare. "The solemn obligation of the International Labour Organization," as its constitution concluded, was to "further among the nations of the world programmes which will achieve … adequate protection for the life and health of workers in all occupations; provision for child welfare and maternity protection; … [and] the provision of adequate nutrition, housing and facilities for recreation and culture."

POSTWAR EUROPE

Across Europe after World War II, spending on all aspects of public health increased in real terms as government leaders held that economic growth could emerge through welfare state programs that made citizens healthier and better educated. West Germany's welfare model took shape from roots in the late-nineteenth-century Bismarck Era, while France's social security system emerged from conservative politics and Britain's National Health Service did so from the Labour government and its minister of health from 1945 to 1951, Aneurin Bevan. The hopes of the future did not come to pass, however. Even as the rates of infectious diseases and infant and child mortality in Europe reached unprecedented lows, economic growth slowed, making public health and medical programs more difficult to finance. Poverty, unemployment, and a host of new conditions placed increasing demands on welfare states. By the late 1960s, the purview of public health in Europe, and no less in industrialized nations around the world, had expanded to encompass chronic diseases (such as heart disease and cancer) and their causes (such as smoking), aging populations, disparities in health (because of race, ethnicity, gender, and occupation), obesity, and domestic violence. European state intervention in public health grew through the mid-1970s when economic crises of that decade required unprecedented cuts in public spending. Critics of the welfare state at this time claimed that its attempt to "provide for all" revealed a substantial failure to discriminate in favor of those in greatest need. This failure, critics argued further, had created a culture of dependency.

NEW CHALLENGES

In 2000 the European Commission issued the first coherent and coordinated strategy for a Europe-wide public health strategy. Adopted formally by the European Union in 2002, the program indicated three priority objectives: to improve information and knowledge for the development of public health; to enhance the capability of responding rapidly and in a coordinated fashion to threats to health; and to promote health and prevent disease by addressing health determinants across all policies and activities.

The commission's strategy, alongside those of individual European nations, helps illuminate the variety of public health priorities facing Europe in the twenty-first century. The foremost among these is how best to recalibrate the welfare state commensurate with promises of freedom and security, with economic and political constraints driven by European unification and interdependence, with the market forces unleashed by globalization, and, to be sure, with new, emerging, and changing threats to public health such as influenza, severe acute respiratory syndrome (SARS), West Nile virus, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).

RECENT SCHOLARLY INTERPRETATIONS AND DEBATES

First published in 1958 and updated and expanded in 1993, George Rosen's A History of Public Health documents health regulation in Western societies from ancient Greece to the modern United States. It is a standard text that should be read by anyone who wishes to know more about the history of public health and understand recent scholarly interpretations and debates. Rosen's story is a chronological account of social progress arising chiefly from the technological advance of science and medicine in combating endemic and epidemic diseases. The growth of public health, Rosen argued, paralleled the rise of centralized government and was the result of scientific and medical knowledge triumphing over ignorance.

In the 1970s and 1980s, however, scholars substantially challenged the heroic interpretation of public health progress held by Rosen and his contemporaries. In his book The Modern Rise of Population (1976), Thomas McKeown agreed that modern medicine and public health had relieved suffering, but he argued that the decline of epidemic diseases, and especially those that affected children and young adults, stemmed not from the outcome of triumphant state medicine and public health programs but rather from better immunity resulting from better nutrition. In his book The Great War and the British People, first published in 1986 and revised in 2003, J. M. Winter advanced the paradox that while World War I and the mobilization of British society brought with it unprecedented slaughter, it was an occasion of substantial improvement in the life of the civilian population of Britain. Munitions canteens made food easily available to the nearly one million workers in munitions factories, rates of infant mortality declined, and rationing resulted in the healthy developments of scarcer alcohol; weaker beer; less consumption of sugar, butter, and meat; and more of consumption of bread and potatoes. Winter's book is a landmark study that deserves attention by anyone interested in wartime health, regardless of time period.

The 1980s and 1990s saw further challenges to and modifications of Rosen's interpretation. These new arguments were based largely on views of public health programs as instruments of social control through which elite society protected its power rather than emancipated the underprivileged classes from conditions that caused disease, famine, and poverty. Michel Foucault, for example, identified repressive discipline emerging from the centralized state and its clinics and hospitals. Other scholars of this period, including David Armstrong and Bryan S. Turner, recognized more broadly the inevitable tension that arises in the power of the expanding regulatory state, between individual civil liberties, on the one hand, and the collective needs of the community, on the other hand. Recent scholarship in the field, including work by Daniel Kevles, Paul Weindling, and others, has explored this tension in a variety of contexts, including eugenics, a case in which they show how rational and comprehensive public health planning can yield murderous public policy rather than freedom from disease and suffering.

Other scholars have revealed further complexities in the history of public health that depart substantially from Rosen's view. For example, no longer do historians see public health programs as being emblematic of or the result of centralized industrial government. In Germany, France, and elsewhere, local governments have at times exerted substantial local autonomy in matters of public health. Local studies, therefore, have been integral to recent scholarship, but so too have been projects that examine global public health, such as the new, emerging, and changing threats described above, and international agencies, such as the World Health Organization, that have attempted to work both within and across nations to achieve for all peoples the highest possible levels of physical, mental, and social well-being.

See alsoBevan, Aneurin; Eugenics; Welfare State.

BIBLIOGRAPHY

Armstrong, David. Political Anatomy of the Body: Medical Knowledge in Britain in the Twentieth Century. Cambridge, U.K., 1983.

Brown, Theodore M., Marcos Cueto, and Elizabeth Fee. "The World Health Organization and the Transition from 'International' to 'Global' Public Health." American Journal of Public Health 96, no. 1 (2006): 62–72.

Brunton, Deborah, ed. Medicine Transformed: Health, Disease, and Society in Europe, 1800–1930. Manchester, U.K., 2004.

Foucault, Michel. The Birth of the Clinic: An Archaeology of Medical Perception. Translated by A. M. Sheridan Smith. New York, 1973. Reprint, New York, 1994.

McKeown, Thomas. The Modern Rise of Population. London, 1976.

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

Porter, Dorothy, ed. The History of Public Health and the Modern State. Amsterdam, 1994.

Rosen, George. A History of Public Health. Expanded ed. Baltimore, 1993.

Sigerist, Henry. Landmarks in the History of Hygiene. London, 1956.

Turner, Bryan S., with Colin Samson. Medical Power and Social Knowledge. 2nd ed. London, 1995.

Weindling, Paul. Health, Race, and German Politics between National Unification and Nazism, 1870–1945. Cambridge, U.K., 1989.

Winter, J. M. The Great War and the British People. 2nd ed. Houndmills, Basingstoke, U.K., 2003.

Jeffrey S. Reznick

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Public Health

Public Health

John Snow's Map...266
Immigrant Girl Receives Medical Exam at Ellis Island...268
AAAS Resolution: Death of Dr. James Carroll from Yellow Fever Experimentation...270
Report on Condition of Women and Child Wage-Earners in the United States...272
Typhoid Mary Has Reappeared...274
Sanitation...276
Preliminary Survey and Current Data...279
March of Dimes...282
Constitution of the World Health Organization, Chapters I and II...284
On the State of Rural Hygiene...287
Thalidomide and Congenital Abnormalities...291
Famine and Public Health...293
Has Your Child Had a Lead Test Yet?...295
President Nixon Declares "War" on Drugs...297
Marlboro Man; Bob, I've Got Emphysema...300
Ali Maow Maalin Survives the Last Endemic Smallpox Case...303
Camp Devens Letter...306
Immunization Campaigns...310
Community Mental Health Centers Construction Act of 1989...313
A Hand and a Home for Pregnant Addicts...317
The Clean Air Act, Title 1: Air Pollution Prevention and Control...320
Motor Vehicle Safety and Public Health...322
Pasteurization and Aseptic Processing...325
Bioterrorism at the Salad Bar...328
Priority Traffic Safety Laws...330
Carrier of SARS Made Seven Flights Before Treatment...333
For a Few Pennies More...338
Drug Recalls...341
Alps Still Contaminated by Radiation from Chernobyl...343
World Water Crisis...346
Fluoridation of Drinking Water to Prevent Dental Caries...347
Water, Sanitation Key to Disaster Response, Long-Term Development...351
The Initial Assessment: A Quick Checklist...353
Memories of Polio...358
Outbreak Notice...361

Public health encompasses legislation, medical surveillance, health care delivery, and other means that aim to safeguard the public from disease, and to maintain and improve the general health of the population. Ongoing public health efforts address the health and safety of the workplace, public, and home environments. Public health initiatives and policies often must balance the collective good with individual rights. Hygiene standards, noise abatement laws, traffic safety laws, water fluoridation, and equipment safety standards are just some of the areas where public safety measures may be regarded as an infringement on personal liberty.

In order to be effective, public health initiatives must come into direct contact with the population they are intended to benefit. The annual wintertime vaccination campaign against influenza, for example, is targeted to the elderly and those who are least able to resist infection. Broader approaches include publicity campaigns that encourage the adoption of more healthy diets and lifestyles, and legislation that prohibits cigarette smoking in public buildings.

Another example of public health legislation involves water quality standards and testing criteria that exist in many developed countries, which have helped to reduce the contamination of water by pathogenic (disease-causing) microorganisms and nonbiological material. In the United States, adoption of water quality guidelines has almost eliminated outbreaks of typhoid, a bacterial disease spread through contaminated water. Elsewhere in the world, however, as summarized in the "World Water Crisis" report from the United Nations, access to clean water is still a problem in the spread of disease.

Although the threat from infectious diseases has eased tremendously in developed countries, the same is not true for many underdeveloped countries, where access to health care may be limited. At the global level, agencies such as the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) provide help through such efforts as vaccination and nutritional campaigns that seek to combat diseases such as polio and improve overall health.

When disease outbreaks occur investigative teams from groups like the WHO and the U.S. Centers for Disease Control and Prevention (CDC) fan out across the globe to determine the cause and possible spread of the outbreak. These efforts to track and control disease are especially important to developing and underdeveloped nations. Both direct testing and mathematical models are used to predict the spread of diseases such as SARS and the emerging avian flu viruses. If a public threat is evident, mandated restrictions (such as quarantine) may be imposed on animals and humans. The power to monitor and impose such restrictions across politically diverse boundaries is set to become one of the most critical of social and political issues in the modern era where diseases can leap continents in a few jet-age hours.

Food safety is another public health issue that can sometimes have global ramifications. Restrictions are sometimes placed on agricultural products, including bioengineered food and beef from countries where Bovine Spongiform Encephalopathy (Mad Cow Disease) has been detected. Additionally, in the era of bioterrorism, food and water supplies must be safeguarded from deliberate contamination.

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Public Health

PUBLIC HEALTH

Dorothy Porter

The health of populations helps to reveal transformations in social and economic conditions and highlights the changing relationships between the state and civil society. At one time the history of public health was written by public health professionals who wrote administrative histories of preventive health services and of the control of epidemic diseases. This historiographical tradition often traced a chronology of events from ancient to contemporary times, identifying the development of public health as a progressive achievement representing a triumph of rational knowledge over superstitious ignorance. In the late twentieth century, however, the history of public health was investigated by social historians, who explored the cultural significance of epidemics, the impact of disease upon demographic structure and economic change, and the role that protecting population health has played in state formation. Social histories of public health have also revealed the political and ideological conflicts created by collective actions aimed at improving the health of populations. This essay will examine the impact of such actions upon the changing social, political, and cultural relations of European societies from late medieval times, when Europe experienced one of its most devastating pandemics, the Black Death.

THE PLAGUE AND EPIDEMIC CONTROL

As the historian Paul Slack has pointed out, epidemics share many characteristics with other natural catastrophes like earthquakes and tidal waves. But the responses provoked by each vary widely. While all natural catastrophes disrupt social order, they attack the basis of social cohesion in different ways. Epidemic diseases not only cause widespread mortality that affects economic production and the defense capacities of societies, they also impose social stigma and alienation upon individual victims. The enduring metaphor of the social death of medieval leprosy sufferers, who were ordered to be segregated from the rest of society by the Third Lateran Council in 1179, continued to haunt the world of the infectious and chronically sick. Collective actions taken to limit the impact of epidemics therefore risk heightening social tension as much as they manage it.

The disease that eliminated up to a third of Europe's population in the fourteenth century, commonly referred to as the Black Death, is much disputed by contemporary historians. The traditional view that the Black Death was an epidemic of bubonic plague does not fit easily with the pattern and rapidity of the spread of the disease between 1348 and 1353 or some of the contemporary accounts of victims' symptoms. Some historians have therefore attributed the epidemic to other rapid killers such as anthrax. Whatever the organic origin of the disease, the Black Death affected European societies dramatically. Not only did it thin out social and political elites, it also devastated the agricultural laboring population, creating opportunities for social and economic mobility that severely weakened an already fracturing feudal system based upon rigid hierarchies and tied labor. Epidemic visitations of plague continued over the next three hundred years. New civil administrative structures to deal with plague were created in Renaissance and early modern Italian city-states that became models for public health administration throughout Europe.

The Black Death stimulated the first application of what became the favored method of epidemic control by early modern states, quarantine. Venice first closed its port to all suspected vessels for thirty days in March 1348. The period was extended to forty days, and quarantine was eventually adopted by all European port authorities to prevent the importation of numerous infectious diseases. Political authorities also adapted the system to isolate inland communities by enforcing military cordon sanitaires to prevent diseased travelers and goods from entering cities or fleeing from them. In premodern times, the most rational response to an infectious disease like plague was to flee an infected location, and this was resorted to by many who had the resources to do so. Political authorities anxious to maintain existing ruling structures tried to limit the hemorrhage of both the powerful and the productive classes. Reduction of ruling elites could create opportunities for social rebellion, especially as epidemics stimulated panic. Thus, from the time of the Black Death, Italian city-states set up special health boards to institute measures to control the spread of the disease by controlling the movements of both sick and healthy populations.

As outbreaks of plague continued after 1348, civil policing to suppress panic and disquiet grew incrementally throughout Europe during the Renaissance and the early modern period. Local civil authorities sometimes taxed those wishing to flee and posted guards to protect the property of the absent. Elaborate regulations were developed in order to control the behavior of the urban poor, whose swelling numbers were viewed as an increasing risk to social stability. The poor and the socially deviant were perceived as the prime victims and bearers of plague. Political authorities in Italian city-states recognized that economic deprivation, social deviance, and plague were a potentially volatile cocktail. Health regulations targeted the movements of the morally outcast, such as prostitutes, "ruffians," and beggars, as well as the plague-sick poor. Measures were also taken to separate the sick from the healthy through the establishment of isolation hospitals, often outside city walls. While health authorities justified their actions as necessary steps to prevent the spread of plague, their primary goal was maintaining social stability by controlling the mobility of the anarchic, unpredictable underclass. For similar reasons, the English central state in the sixteenth and seventeenth centuries reproduced many Italian plague controls. Here house arrest and isolation of victims' families were adopted in order to keep people in their place at moments of crisis in the same way as the Elizabethan Poor Law enforced local settlement when communities faced periods of economic failure and shortage. The English plague regulations, however, stimulated violent opposition and thereby contributed to increasing disorder.

Plague controls brought civil authorities into conflict with the interests of other ruling elites. Quarantine greatly interfered with trade and was vigorously resisted by merchants and their laborers, who were both adversely affected. Such tensions increased throughout the early modern period. By the seventeenth century the power and prestige of many Italian city health boards grew to the point where they were able to challenge the authority of the church. Festivals, religious assemblies, processions, and other public gatherings were often banned in epidemic times despite the strong opposition of the clergy. Health authorities justified their actions on the basis of experience. For the church, plague was the result of divine wrath that could be assuaged only by penance and observance. For health officials the divine origin was less significant than the miasmas that spread the disease along with the anarchy that it threatened to provoke.

SYPHILIS AND STIGMATIZATION

If plague prevention instituted new levels of political intervention into civil life, epidemic syphilis in the fifteenth and sixteenth centuries highlighted the consequences of stigmatization for disease sufferers. In the Renaissance and early modern world fears of social disorder were matched by the dread of the moral corruption that could result from disease. In the late fifteenth century the disease that came to be identified as morbus gallicus (French disease) was believed to be a new contagion. Numerous contemporary observers wrote accounts of a new epidemic pox appearing in Italy in 1495 following Charles VIII's campaign against the Spaniards for control of Naples. His army, which consisted largely of mercenaries from Belgium, Germany, southern France, Italy, and Spain, was believed to have spread the disease as it disbanded and soldiers returned to their homelands. Within a decade of the first outbreak noted at Fornovo, epidemic syphilis had spread throughout Europe. The stigma of syphilis is reflected in the way that national cultures frequently identified it as the disease of their enemy, but it was most commonly referred to as morbus gallicus.

The morbus gallicus was recognized to be spread venereally. Christian ideology accounted for it as divine retribution for licentiousness, but contemporaries such as Joseph Grunpeck also attributed it to astrological sources. From the sixteenth century the American origin of the disease was the source of much controversy and remains so even today. Isolation of sufferers was attempted by some authorities, the syphilitic being subjected to stigmatization similar to lepers in medieval times. Stricter controls were instituted against beggars and vagrants in France, where old leper houses were converted into accommodations for "incorrigible paupers." The hôtel-Dieu (city hospital) overflowed with émigré pox victims in the 1520s, who were provided with money to return home. In France inspection and stricter regulation of prostitutes was established from 1500. In Edinburgh in 1497 the city council required patients sick of the "gradgor" to be removed to the island of Inch until they were completely cured. Anyone resisting the regulations faced the penalty of complete exile and the branding iron.

Changing attitudes toward sexual practices were already evident in Renaissance societies. The late medieval tradition of the steam bath, which had been part of a cult of pleasure rather than an instrument of cleanliness or hygiene, began to decline in the sixteenth century. Many famous hotels offering the steam bath as a main attraction disappeared throughout Europe. The custom of visiting the steam bath to conduct a discrete liaison or simply to enjoy free and easy frolicking among naked men and women also began to decline. The pleasure dome of the steam bath became a target of the guardians of public morals, but their decline coincided with the rise of epidemic syphilis. The epidemic significantly affected changing attitudes toward libertine pleasure, adding caution to the justification for new codes of moral discipline. The aims of public authorities to control syphilitic contagion were assisted by broader changes in cultural beliefs and social behavior regarding the pursuit of pleasure. What may not have been successfully achieved through coercive public policy was perhaps accomplished through new moral ideologies.


THE SOCIAL SCIENCE OF HEALTH IN THE EARLY MODERN PERIOD

As plague retreated from Europe from the late seventeenth century, geographical exploration, urban development, and imperial expansion created new disease patterns in the eighteenth and nineteenth centuries. Epidemic diseases of isolated communities became endemic in urban environments. By the eighteenth century shock invasions were replaced by rising levels of endemic infections and chronic sickness that occasionally became epidemic, such as malaria, smallpox, and gout. The absence of catastrophic disasters meant that emergency disease control was no longer a priority. Instead, the age of the Enlightenment became a period in which a new interest in the social scientific analysis of the health of populations developed. The eighteenth century also witnessed innovations in sanitation and immunization, and late Enlightenment thought made new connections between social improvement and environmental reform. By the nineteenth century the Enlightenment study of political arithmetic and human longevity evolved into the statistical enumeration of human misery and the social physics of human improvement. The Enlightenment pursuit of happiness through a felicific calculus translated into a social science of amelioration (investigations undertaken by voluntary researchers and social reformers into the social conditions of economic depravation and destitution that were aimed at informing social policies of improvement) in the nineteenth century that was inherently bound to the improvement of population health. ("Political arithmetic" is the term used by the seventeenth-century English man of letters William Petty to describe his quantitative analysis of what he called the political anatomy of Ireland; Petty believed that the quantitative analysis of the strength of the state—including the analysis of the health of the population, levels of production and "market research" into the sale of individual commodities—should become a general form of enquiry called political arithmetic. "Social physics" is the term given by the early nineteenth-century Belgian astronomer Lambert Adolphe Jacques Quételet to the quantitative analysis of social conditions, including the health of the population, using the statistical concept of the normal frequency distribution. "Felicific calculus" is the term given by the late eighteenth- and early nineteenth-century English political philosopher Jeremy Bentham to the analysis of the greatest happiness of the greatest number as the founding principle on which to base utilitarian philosophy of government.)

The relationship between the health and wealth of nations was extensively explored in political, economic, and social theory in the eighteenth century. The development of what the French ideologue Condorcet called "social mathematics" was highly significant in the development of the relationship between the emergent modern state and the health of its subjects. Various methods of counting the subjects of the state and measuring its size and strength in terms of their number and their health were introduced in the early modern period. These practices were supported by the political philosophy of mercantilism, which viewed the monarch's subjects as his paternalistic property and equated the entire well-being of society as coterminous with the well-being of the state as embodied by the sovereign. The political bookkeeping that enabled the state to measure its strength in terms of the size of its healthy population guided its administrative goals and objectives.

These were the early foundations of "vital statistics" and epidemiology that, by the nineteenth century, became a prerequisite for systematic disease prevention. Lambert Adolphe Jacques Quételet (1796–1874), a Belgian astronomer who devised the theory of the normal frequency distribution curve, took up the quantitative analysis of social physics in the early nineteenth century. A generation younger than Condorcet, Quételet believed that social physics could provide the basis of the scientific management of society.

In France in the early nineteenth century, the application of social physics did not lead to social reform. Instead, it created a new academic inquiry into the conditions that determine health and disease, an inquiry that founded the nineteenth-century European science of hygiene. An ex-army surgeon, Louis René Villermé, who was a friend of Quételet, translated social physics into elaborate studies of the differential mortality of the rich and poor and the health conditions of the proletariat and their average expectation of life. However, these studies did not stimulate political action. Villermé warned against the involvement of the state in health reform and suggested instead that the remoralization of the poor would eliminate epidemic disease and premature mortality.

In Britain the "geography of health" was examined as part of the discovery of the social conditions of the poor. Statistics was embraced as a tool for measuring social inequality by early Victorian reform movements. Statistical studies of health and the social determinants of disease were set up in response to the shocking effects of the cholera epidemics of the 1830s and 1840s, and subsequently Victorian epidemiology sought to eliminate the spread of disease by destroying the environment that bred it.

HEALTH AND THE MODERN STATE

The early modern state linked the investigation of population health to political strength through a mercantialist philosophy. This philosophy also inspired Enlightenment public health promotion through methods of "medical police" developed in Prussia and Sweden and explored theoretically, above all, by the Austrian court physician Johan Peter Frank. Public health featured prominently in the rhetoric of revolutionary democracy at the end of the eighteenth century, both in the newly established American republic and in the declarations of the revolutionary governments in France. The French revolutionaries declared health, like work, to be a right of man, making it an obligation of the social contract between the modern democratic state and its citizens. By the middle of the nineteenth century, the British state had translated this principle into a civil right, in which all possessed equal rights under the law to protection from epidemic disease. In 1848 French and German revolutionaries identified the key to improved population health to be the establishment of "state medicine." In France Jules Guérin, in the Gazette médicale de Paris, and in Prussia Rudolf Virchow, in his reports on typhus in Upper Silesia, both suggested that democratic freedom, universal education, and social amelioration would prevent epidemic diseases. In France and Prussia supporters of social medicine urged the medical profession to take on a political role and become attorneys to the poor and statesmen in disguise.

The political role of preventive medicine within the modern state became an urgent material as well as an ideological issue as exponential rises in epidemic and endemic infections among urbanized populations accompanied the process of industrialization in European societies. The diseases of industrial, urbanized civilization were those transmitted relentlessly among overcrowded populations living in appalling insanitary slums with totally inadequate refuse and sewage removal, drainage, and little or no access to uncontaminated water. Typhus, typhoid, amoebic diarrhea, tuberculosis, diphtheria, and, despite the introduction of smallpox vaccination throughout Europe, smallpox continued to haunt industrialized as well as agricultural populations. But perhaps the disease that conjures up the classic image of industrial society under siege from contagion is cholera. Asiatic cholera followed troop movements out of India through eastern, central, and western Europe between 1830 and 1832 and became the first of several pandemic invasions. Overall, cholera killed far fewer than endemic fevers, but the social psychological effect of the suddenness of its invasion and the speed and manner in which it killed was dramatic. Cholera highlighted the tenuous social stability of the class structures of European societies. Conspiracy theories were rife among the European proletariat and peasantry. Rioters in Russia attacked nobles and officials because they believed that the water was being poisoned as part of a Malthusian effort to reduce surplus population. The homes of noblemen and the offices of health authorities were ransacked throughout Prussia, and officials were murdered in Paris. In Britain Bristol's poor rioted in protest against the removal of the sick to isolation wards, believing that this was a means of providing the medical profession with bodies to anatomize.

Cholera coincided with crisis in nineteenth-century Europe, but often conditions were made ripe for its spread by social upheaval. Cholera was spread by social dislocation—the mobility of population created by the expansion of trade in the nineteenth century, which brought rural populations into the cities—and subsequently exacerbated it. This pattern of social dislocation and epidemic spread is equally demonstrated for another acute infection characteristic of the times, typhus. Typhus has a long history of being associated with war and famine, frequently flourishing in military encampments and jails, but it became almost endemic among some urban populations during the nineteenth century.

Sanitary reform developed at different rates in European states throughout the nineteenth century. By the end of the century most major European cities had sewage and drainage infrastructures and improved water supplies. Most northern European states established various types of local and, in some cases, central government health authorities who monitored health conditions and administered a wide range of public health regulations. Some city administrations, such as the Paris Health Council, became models for national governments. Other cities avoided the costs of public health imperatives as long as possible. When cholera attacked Hamburg in 1892, long after it had retreated elsewhere in Europe, the city-state paid a political price for neglecting to filter its water systems by being taken over by Prussian administration. Incremental environmental sanitary reform throughout Europe in the nineteenth century slowly reduced the effects of lethal infections. While historians and historical demographers continue to dispute the determinants of population growth, increased protection from the environmental hazards of industrial urbanization continue to figure prominently in assessments of mortality decline by the turn of the twentieth century. Historical epidemiologists still consider the reduction of infant amoebic diarrhea through cleaner, filtered water supplies to have played a significant role in that decline.

Providing for the health of communities, however, could lead the modern state to sacrifice the civil liberties of individuals. Movements developed in mid-nineteenth century Britain, France, and Germany opposing compulsory smallpox vaccination as tyranny rather than salvation. Acts passed by the British state establishing the compulsory inspection of prostitutes in garrison towns in the 1860s were opposed on similar political grounds. In the 1870s and 1880s the campaign to repeal the Contagious Diseases Acts in Britain interpreted the enforcement of health as a gross violation of civil liberties by a centralized power exercising a form of medical despotism and a double moral standard. By the end of the century, however, the Notification of Infectious Disease Acts in Britain interned those sick of a listed infection in an isolation hospital until they either recovered or not, but they provoked no libertarian opposition or alarm.

The civil disorder stimulated by state action during the cholera epidemics throughout Europe in the early nineteenth century was not repeated at the end of the century as modern democratic states made more and more interventions into the socioeconomic and biological lives of citizens. In industrialized and modernizing European states, a new political ethos of collectivism encouraged the development of compulsory social insurance schemes to protect workers from injury, sickness, unemployment, and old age. Population health policies began to incorporate medical services to vulnerable groups, including mothers, infants, school children, and the mentally retarded. In the twentieth century, obtaining population health was no longer limited to the prevention of disease but began to include public provision to cover the costs of medical services along with new strategies for encouraging individuals to adopt healthy lifestyles.

HEALTH CARE SYSTEMS IN THE TWENTIETH CENTURY

The twentieth century witnessed the incremental growth of comprehensive, state-funded public health and medical services throughout Europe. In the interwar years a preliminary model welfare state with integrated health and medical services developed in Weimar Germany. Between 1919 and 1933 the Weimar Republic viewed the economy as an organism that could be managed by the state, which would redistribute wealth through welfare benefits. Weimar welfare facilitated the socialization of health and prioritized the goals of the social hygiene movement, focusing on the prevention of chronic disease, the health of mothers and children, and the treatment of psychiatric disorders.

The development of health services under Weimar was motivated by organisist, collectivist social ideology that included beliefs in regenerationist biology. Eugenic ideals about the need to plan population development were compatible with ideals of collective responsibility for welfare in numerous other European contexts during the same period. Demographic and eugenic concerns led to new directions in health and social policy in Scandinavia, Britain, and France. On the one hand, prioritizing the health of mothers, infants, and children and encouraging large families was legitimated as protecting the health of future generations and ensuring demographic balance. Pronatalism was promoted in Sweden and France following World War I. In Scandinavia, Belgium, France, and Germany various forms of family allowance were developed to ease the economic burdens of parenthood. On the other hand, preventing the reproduction of the eugenically "unfit" through restrictive marriage laws, the segregation of the mentally retarded and mentally ill, and the voluntary or compulsory sterilization of various social groups was aimed at reducing the potential for biological and racial decline.

Positive and negative eugenics in Europe before World War II was one expression of the increasingly influential ideology of social planning. The corporate management of capitalist economies based upon the ideas of John Maynard Keynes gained legitimacy in European states as the failures of unregulated markets threatened the survival of industrial capitalism. A comprehensive, integrated system of health and medical services for workers and their dependents was one of the linchpins of the vision of the welfare state outlined by the British liberal intellectual William Beveridge, whose 1942 report influenced the development of health and social security policies throughout Europe following the war.

According to the social policy theorist Gosta Esping-Andersen, three "worlds" of welfare emerged after World War II that relied on more or less bureaucratically administered state funding, voluntary and compulsory insurance, and market mechanisms. A significant division developed between the generous insurance-based social security systems that operated in parts of continental Europe and the lower level of insurance plus tax-funded, means-tested state benefits that operated in Britain. Further divisions occurred between universal statutory insurance-based systems constructed in Europe and the private insurance plus means-tested welfare provision that operated in the United States.

Within these broad frameworks different rates of welfare expansion continued for the first three decades following 1945, until international economic crises in the 1970s ended what has been eulogized as a "golden era" of political consensus, economic growth, rising living standards, and social justice. While the viability of the welfare state was increasingly challenged in the 1980s, comprehensive health coverage has been the most politically resilient of its features. In the 1980s New Right assaults on what it viewed as the culture of dependency produced by "nanny states" sought only to reform rather than remove state-funded health care systems. The continued popularity of state-funded health care perhaps emanated from the fact that, as the left wing British economist Julian Le Grand pointed out in 1982, the middle classes benefited from them most.

HEALTH CARE AND INDIVIDUAL BEHAVIOR

While the public provision of health care continued to be politically popular in the 1990s, fears concerning the demographic structures of twenty-first-century postindustrial societies support a culture of personal health responsibility that had been promoted by the state and commercialized by the marketplace throughout the twentieth century. As state medicine throughout Europe became involved in the provision of personal services, new emphasis was placed upon individual prevention through the development of healthy lifestyles. In the interwar years new perspectives on preventive medicine were developed in the Soviet Union, Germany, Belgium, and Britain that attempted to make clinical medicine a social practice through the interdisciplinary amalgamation of medicine and social science. Following World War II social medicine focused upon prevention through public education about health hazards to the individual. A precedent was set in the health education campaign aimed at reducing lung cancer through the prevention of cigarette smoking.

The antismoking campaign in Europe exemplified the new message of the clinical model of social medicine: the key to the social management of chronic illnesses—such as lung cancer—was individual prevention, fostered by raising health consciousness and promoting self-health care. While antismoking has achieved a degree of success in Europe, it has had much greater influence in North American societies. However, the model of prevention through individual education gathered momentum in the wake of the antismoking campaign. Subsequent postwar campaigns offered lifestyle methods for preventing heart disease, various forms of cancer, liver disease, digestive disorders, venereal disease, and obesity.

In 1981 T. Hirayama published the results of a study that demonstrated that nonsmoking wives of heavy smokers had a higher risk of contracting lung cancer than did the wives of nonsmokers. The campaign to prevent "passive smoking" subsequently took on the character of a nineteenth-century campaign to prevent infectious disease. Like all such public health campaigns, the collective benefit of state action penalized and stigmatized a specific social group, whose members were represented as social pariahs and failures and moral inferiors.

The mixed messages involved in the prevention of tobacco consumption have been fully represented in the campaigns against a new lethal infectious virus appearing in the early 1980s, human immunodeficiency virus (HIV), which leads to a fatal syndrome commonly referred to as AIDS. The emergence of a new killer infection in the early 1980s reawakened all the public health concerns associated with an earlier era. AIDS was initially compared to dramatic historical invasions of the past such as plague and cholera. The initial impact of AIDS upon popular, political, and expert perceptions raised familiar issues regarding the right of the state to police and regulate the spread of infection through surveillance, notification, screening, and quarantine. Those who favored authoritarian intervention called for the institution of compulsory testing, identity cards for people who were HIV-positive, and their isolation. Most of these goals were not taken up by national policymakers, but the question of identity cards came close to realization in some local contexts, such as Bavaria.

By the late 1980s its transmission through needle-sharing among impoverished intravenous drug users meant that AIDS was spread more and more by poverty and social despair rather than unprotected sexual intercourse. The length of time between contracting the HIV virus, the onset of the AIDS syndrome, and the death of the sufferer lengthened as more effective therapeutic treatment slowed the physiological progress of the disease. Thus by the 1990s AIDS began to be perceived as a chronic disease among minority high-risk groups rather than an epidemic infection. AIDS victims have suffered legal and social discrimination in the popular mind and by official agencies. The implication of bodily and spiritual corruption has persisted as a powerful contemporary trope.

A new social contract of health has been promoted in public health campaigns from antismoking to AIDS prevention. It is a contract based upon a model of prevention that utilized medical and social scientific analysis to maximize health chances by encouraging individuals to change their lifestyles. However, the state and its public health agencies have not had a monopoly on the promotion of health through lifestyle management. Health promotion through lifestyle education has also been successfully commercialized.

Since the eighteenth century "self-health" has been successfully commercialized through the publication of advice manuals and the promotion of dietary aids and exercise regimens by various entrepreneurs. In the nineteenth and early twentieth centuries health reformers promoted physical culture cults such as calisthenics, eurythmics, vegetarianism, and mastication techniques. Such traditions continued in the advertising campaigns for mass-produced foods such as cereals as health aids and in a commercialized exercise culture. In the early twentieth century the value of exercise for healthy living was commercialized by American entrepreneurs such as Eugene Sandow, Bernarr Macfadden, and Charles Atlas, who established their own brands of competitive bodybuilding and physical culture systems. In the United States and in Europe, the interwar years witnessed the symbolic association of the healthy body with racial health and national supremacy.

Following World War II bodybuilding expanded as a commercialized competitive sport and, along with the increased popularity of spectator sports as a leisure pastime, spawned a new fitness industry. The fitness and beauty industries in the late twentieth century became hugely successful international markets involving the sale of sportswear, health foods and dietary aids, commercial health and gymnasium clubs, health and beauty holiday resorts, fitness training, and plastic surgery. Slimming alone has become a large market industry. The message of the commercialized health industry mirrors that promoted by the state: health is an individual responsibility that has to be worked for through individual effort and paid for from individual pockets. By the early 1990s the healthy body became a symbol of social and economic success and the diseased became associated with social failure and dysfunction. As liberal democratic societies within and beyond Europe retreated from the public funding of health and social welfare, both the state and the marketplace sought to blame ill health on individual irresponsibility and ignorance.

Although the contract of health between the social democratic state and its citizens is thus being reconfigured, at the beginning of the twenty-first century there are, nevertheless, signs that the structural causes of ill health are not being entirely overlooked. As the gap between the affluent and the impoverished widens in postindustrial societies throughout Europe, the relationship between poverty and ill health has again become a focus of state concern. Mortality differentials and rising levels of the traditional diseases of poverty, such as tuberculosis, have re-created an awareness of the impact of inequality on levels of health. Poor people die earlier because their health is compromised by low incomes, unemployment, poor housing, and social exclusion. Population health is compromised in areas with poor social facilities and where people are intimidated by high levels of crime and disorder. The poor and industrial workers are also often exposed to greater risks from environmental pollution and occupational hazards.

The impact of inequality upon health is beginning to be taken into account by social democratic policymakers in Europe. In Britain, for example, New Labour health ministers acknowledge that in tackling the root causes of avoidable illness, "in recent times the emphasis has been on trying to get people to live healthy lives" (Dobson and Jowell, Our Healthier Nation, p. 2). The New Labour government suggests, however, that they want to try an approach with "far more attention and Government action concentrated on the things which damage people's health which are beyond the control of the individual" (Our Healthier Nation, p. 2). The consequences of the absence or shrinkage of welfare states in industrial societies throughout the world also impacts upon European thought regarding the restructuring of networks of social security that help to ensure population health. Population health within and beyond Europe, however, continues to be an ongoing negotiation between civil society and the state. The outcome of that negotiation depends, as it has always done, upon the political will of both.

See alsoHealth and Disease (volume 2);Urbanization (volume 2);The Welfare State (volume 2);Doctors and Medicine (volume 4); and other articles in this section.

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