A History of Public Health

New Internationalist magazine, Jan/Feb 2001

Plague days

Plague first appeared in Roman Europe in the sixth century under the Emperor Justinian as sanitation systems of the ancient world decayed. Later, as the caravans made their way along the Silk Routes of Asia in the fourteenth century they took with them yerisnsa pestis, a plague-causing bacteria carried by fleas and the rats on which they lived. Yet another theory puts the fleas on ships and sailors entering Black Sea ports from the East. In either case these first tentacles of globalization were the source of the 'Black Death' that swept the then known world from Indochina to Northern Europe. Millions died, particularly in the crowded, unsanitary conditions of the newly chartered towns. In response, the first rudimentary measures of public health were created: ship inspections, quarantine, leprosariums, mass burials. In the following centuries, as global commerce and conquest spread, infectious diseases hitchhiked along, with devastating consequences for the indigenous populations of the Americas and the South Pacific. A radical change in people's circumstances - contact with outsiders, changing climate, expulsion from land, altered diet, hard wage labour or urbanization - added stress factors and increased vulnerability to disease.

Pioneers of public health

The first significant wave of public-health advocates emerged in response to the slum and desperate working conditions of nineteenth-century Europe and North America. In centres like New York, London and Berlin the struggle for proper sewerage, decent housing, clean water, factory inspectors, district health officers and a regime of food inspections was born. Such figures as Herman Biggs in New York and Edwin Chadwick (who introduced the small-bore sewer pipe) and John Simon in the Britain led the way. The movement was quite diverse ranging from birth control and family-planning advocates like Margaret Sanger to scientists such as the Frenchman Louis Pasteur concerned with food safety. Other voices included sanitariums, germ theory zealots, prohibitionists, child-labour activists and a plethora of other campaigners. The movement was divided. One wing, under the influence of Social Darwinism, blamed ignorant individuals for their own poor health - such as the paternalistic middle-class campaign to overcome 'maternal inefficiency' (thought to be a major cause of infant mortality) or to teach the poor how to budget properly and to stop drinking. Other liberal and radical campaigners concentrated on poverty and strove to improve living and working conditions, bringing them into immediate conflict with the conservative owner class. This same question divides public health advocates to this day: is health basically an individual responsibility or part of a broader fight for social justice?

The medical model

For all its diversity the first wave of public-health advocates was remarkably successful. Some 86 per cent of the gains in life expectancy in the industrial world have been due to decreases in infectious diseases, most of which occurred before the discovery of antibiotics and the present development of modern medical technique and technologies. In the US less than four per cent of the total improvement in life expectancy can be credited to today's sophisticated medicine. Clean water, decent housing, vaccination programmes for children, proper waste disposal, knowledge of personal health needs and practices, plentiful and uncontaminated food and breathable air were the keys. Gradually the slums of early industrialization gave way to more liveable communities and a public-health infrastructure was established. While the medical system should be judged on the basis of its record for cures and care and the equality of access, the fundamental health of a population lies outside its scope. Public health must deal more broadly with the quality of a society- its physical and social environment and the opportunities for a decent life it provides to all citizens.

The South

Back in the mid-nineteenth century public-health pioneer Edward Chadwick compared the situation of a Latin American populace 'sunk into the lowest vice and misery amidst the means of the highest abundance 'with the wretched population in the vast parts of Glasgow, Edinburgh, London and Bath'. While the situation in the slums of the industrial world has improved dramatically, almost five billion of the world's six billion people still live in the global equivalent of New York City's 18905 tenements. While mass vaccination has largely freed the peoples of the South from some diseases (polio, leprosy, smallpox) the basic public-health infrastructure that would provide clean water, ample food and healthy living conditions is not in place for most of the world's peoples. Commitments to primary healthcare have been undermined by debt, exploitation, war and economic stagnation. Even the vaccinations to prevent diseases like malaria and others are proving ineffective as microbial resistance to a number of vaccines is on the rise. Major pharmaceutical companies have simply given up researching drugs for diseases like malaria and tuberculosis - drugs to cure these diseases of the poor are simply not profitable enough. Anyway, as the Swiss medical thinker Henry Sigerist pointed out: 'It is a grim joke to immunize people against disease with one hand and to exploit them into starvation with the other.'

Rats and sucking insects

The science on which public health was traditionally based is running into trouble. Diseases once thought defeated or least controlled, like TB and malaria, are back with a vengeance and have developed resistance to the drugs once thought to have vanquished them. Hospitals are today besieged by new forms of infection, such as the Staph bacteria, that are resistant to most known antibiotics. In the 1990s between 100,000 and 150,000 patients died from the infections they contracted inside US hospitals. A more holistic science is evolving that looks at how humankind alters environments and ecologies favouring some viruses, bacteria and their hosts. Sometimes it's as simple as overuse of antibiotics or doctors who don't wash their hands. Others are more complex. For example the hemorrhagic fevers appearing today in tropical Africa and South America (Ebola, Lassa, Yellow River, Marburg disease) are connected to the clearing of land, the elimination of snakes, owls and jaguars who normally eat rodents and the development of grain economies on which rodents thrive. Similarly the development of large Southern cities provide the perfect breeding ground for Aedes aegypti the mosquito which carries dengue and yellow fever but is normally a poor competitor in tropical rainforest conditions where more hardy breeds dominate. In the abandoned lots, puddles, water barrels and old tires of tropical slums Aedes can thrive. Even in the air-conditioned comfort of the modern hotel and office block we have created the rare conditions (chlorinated high temperature) in which the Legionnaire's Disease bacterium does well. Public-health science needs to pay more attention to the vectors - such as the mosquito, the rodent - of particular diseases and the 'spaces' in our development models and medical practices in which they may find a niche.

A new agenda

Today's public-health movement varies dramatically from the wave of activism in the nineteenth and early twentieth centuries. Then, the main emphasis was stopping contagion by altering the conditions under which infectious disease spread. This is still a crucial issue in the South where the basic necessities of clean water and adequate food top the agenda. In the industrial world, however, the main focus is dealing with chronic diseases (cancer, heart ailments) and their causes. The modern environmental movement, born in the crucible of 19605 discontent, is an important actor in the field of public health. All of its main touchstones - opposition to nuclear power, resistance to chemical pollution in general and agro-chemicals in particular, advocacy of liveable cities, concern over a deteriorating climate and getting the balance right between humans and nature - are also key public health issues.

These are emerging as crucial issues in the South too, where environmentalism links solidly to issues of social justice. As we move into the 21st century there is an important coming together of movements around a new environment- and equity-based public-health agenda. Its scope is as broad as the diversity of issues it must tackle. Public health is no longer the exclusive concern of a few beleaguered government professionals but involves energy and analysis coming from many quarters. There are workers concerned with health and safety; NGOs committed to global equity; medical practitioners who realize the limits of sophisticated medicine; and advocates of alternative medicines and therapies. A common thread of understanding is starting to bind such groupings together: you cannot expect to be healthy if you live in an unhealthy society.

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