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.

BIBLIOGRAPHY

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Cipolla, Carlo M. Fighting the Plague in Seventeenth-Century Italy. Madison, Wis., 1981.

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Crosby, Alfred, W. Ecological Imperialism: The Biological Expansion of Europe. 900–1900. London, 1986.

Dobson, Frank, and Tessa Jowell. Our Healthier Nation: A Contract for Health. London, 1998.

Esping-Andersen, Gosta. The Three Worlds of Welfare Capitalism. Princeton, N.J., 1990.

Esping-Andersen, Gosta, ed. Welfare States in Transition: National Adaptations inGlobal Economies. London, 1996.

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Fee, Elizabeth, and Daniel M. Fox, eds. AIDS: The Making of a Chronic Disease. Berkeley, Calif., 1992.

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Hardy, Anne. "Urban Famine or Urban Crisis? Typhus in the Victorian City." Medical History 32 (1988): 401–425.

Johannisson, Karin. "The People's Health: Public Health Policies in Sweden." In The History of Public Health and the Modern State. Edited by Dorothy Porter. Amsterdam and Atlanta, 1994. Pages 165–182.

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

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Weindling, Paul. "Eugenics and the Welfare State during the Weimar Republic." In The State and Social Change in Germany, 1880–1980. Edited by W. R. Lee and Eve Rosenhaft. Munich, 1990. Pages 131–160.

Public Health

Concepts and practices

The Greco-Roman world

The Middle Ages

The modern era

Public health and sanitary reform

Development of the health sciences

The twentieth century—international trends

BIBLIOGRAPHY

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

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

Concepts and practices

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

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

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

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

The Greco-Roman world

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

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

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

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

The Middle Ages

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

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

The institution of quarantine

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

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

The modern era

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

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

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

Public health and sanitary reform

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

In England

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

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

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

In America

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

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

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

Development of the health sciences

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

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

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

The twentieth century—international trends

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

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

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

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

The welfare state

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

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

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

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

George Rosen

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

BIBLIOGRAPHY

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

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

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

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

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

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

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

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

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

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

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

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

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

Public Health

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

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 public’s health.

Public health is as old as history itself. Most holy texts (including the Bible, Torah, and Qur’an) 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 scientific—allopathic—medicine. British royal anesthesiologist John Snow (1813–1858) 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 city’s 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 Toronto—and 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 systems—partly due to political indolence, sometimes referred to as a “betrayal of trust”—have 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 (1967–1977). 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 (1973–1988), the WHO positioned itself as a powerful broker for health between professionals, governments, and communities. The WHO’s next director-general, Hiroshi Nakajima (1988–1998), 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 (1998–2003), 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 (1945–2006), 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 People’s 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 efforts—over $5 billion—in 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 services—for example, medical technology assessment and health services financing schemes (often mirroring, again, the difference between public sector or the public’s 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): 23–33.

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

Evelyne de Leeuw

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 (200–400 c.e.) was sapped by two diseases better described as endemic than epidemic—malaria, 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 1347–1349. 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 childbirth—even when those hands were laden with dangerous bacteria—led 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 mid–twentieth 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 action—provision of clean water supplies—to 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 groups—slum 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 diet—comprised of the right mix of protein, fats, and carbohydrates, with vitamins and essential trace elements—is 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