Chapter 2. HISTORICAL DEVELOPMENT OF THE PUBLIC HEALTH MOVEMENT  DR. D. T. CAPPUCCI, JR.

 

 

2.1 Objective:

To review the historical development of the public health movement. 

2.2 Introduction/Historical Developments

The ideas, attitudes and institutions associated with contemporary public health practices are more clearly defined when studied in a historical context. At any point in time, the public health movement reflects concerted efforts to achieve a state of physical, mental and emotional well-being in a defined population. These efforts are conditioned by four basic phenomena:

• The nature and severity of disease
• Theories on disease causation
• Practices regarding disease control and treatment
• The character (such as theologic, economic, political and social factors) of the prevailing society

2.2.1 Ancient World

Primitive concepts held that disease and infirmity resulted from environmental influences that inhabited the streams, air, trees and animals. The religious attitude was that the afflicted had committed or were the recipients of sin. Expulsion from the community was the usual control measure exacted by non-medical priests.

2.2.2 Greco-Roman Era

This period focused on personal hygiene. Governmental public health practices were effected to augment the prevailing religious attitude. Medical care hospitals, staffed with public physicians, and programs in environmental sanitation (water supply and sewage) were developed. These measures which placed a high priority on a clean mind and body were developed for the upper classes.

2.2.3 Middle Ages

A period identified as an era of paganism, barbarism and anti-intellectualism. Following are some factors that influenced the public health movement:

• When Christianity became the official religion of the Roman Empire, the poor and afflicted were given status and recognition. Society was given an obligatory responsibility for care and treatment of the sick.

• Various diseases (leprosy, consumption, typhoid fever and the black death) fatally affected approximately one-third of the population living in middle and southern Europe.

2.2.4 Mercantilism

In the Middle Ages, commerce and industry developed which were based on economic theory involving exchange of goods and services. Through the accumulation of wealth, individuals and nations became powerful. Because of such affluence, concern developed for labor as it related to productivity. The concern for health care became focused on populations and not individuals. 

2.2.5 18th-19th Centuries (Europe)

This was the period of the industrial revolution, laissez-faire and cholera epidemics. The industrial revolution brought about the need for increased manpower and massive use of laboring classes. The life expectancy rate based on social class was: gentry, 35 years; tradesmen, 22 years; and laborers, 15 years. Approximately one-half of the children of the working classes died before age 5.

The prevailing social conditions in England resulted in an illustrative national survey, known as the Edwin Chadwick Report, which focused on the health of the laboring classes. The Chadwick Report affected sweeping reforms: such as the establishment of a National Board of Health, advances in environmental sanitation and hygiene, new legislation regulating factory management; child labor and welfare, and care for the aged and mentally ill. 

2.3 Public Health in the United States

In the 17th - 18th Centuries in Colonial America, life expectancy was less than in Central Europe. Towns and cities were generally unsanitary, contagious diseases were rampant and most physicians were self-designated and itinerant. The Lemuel Shattuck Report encouraged social reform, including documentation of disease conditions and collection of vital statistics. Some pertinent recommendations of the Shattuck Report were:

• Establishment of sanitary inspection system
• The collection and analysis of vital statistics
• The promotion of health care
• Establishment of regulations to expose and eliminate quackery.
• Implementation of the Shattuck Report was incomplete due to underpromotion.

Port cities such as Boston, Baltimore, New York and their respective states sought ordinances and legislation to reduce mortality, establish medical services for seamen, and raise the professional status of physicians.

2.4 Evolution of Organized Governmental Health Services

Outline of events:

• Establishment of State and Local Health Departments
• Establishment of National and Community Health Care Facilities
• Disease reporting and collection of vital statistics
• Formation of a National Quarantine Convention and later the American Public Health Association (APHA)
• Golden Age of Bacteriology
• Development of maternal and child health programs
• Establishment of the United States Public Health Service/Federal Hospital system for leprosy, tuberculosis and drug addiction
• Establishment of the National Hygienic Laboratory (later to be named the National Institutes of Health - NIH) for basic research on diseases
• Passage of Pure Food & Drug Act and Meat Inspection Act in 1906 (Upton Sinclair furnished a literary documentation of deceptive trade practices in the meat packing industry, with the publication of his book, "The Jungle.")
• Passage of the Federal Social Security Act in 1935 to assist states in the establishment and maintenance of public health services, including training
• Establishment of the Department of Health, Education and Welfare (Public health given cabinet level status)
• Hill-Burton Legislation enacted
• Development of professional training coordinated by the American Public Health Association

2.5 Evolution of Theories on Disease Causation

The following are some major concepts of disease causation:

• Disease as a manifestation of sin
• The description of disease as an entity by physical characteristics, i.e., age/sex distribution, population description, precipitating factors, and so forth
• A manifestation of unfavorable environment (Disease was the result of an unfavorable environment conceived in cosmic, astrological or theological terms and a result of visible and olfactory stimuli known as miasma.)
• The germ theory was based on the concept that specific microbes caused specific diseases (A model was developed in which one agent was related to one disease.)
• Disease as a social phenomenon and having social causes (The control of infectious diseases was due to changes in the environment, lifestyles and provision of safer food and water.)
• Theories on multicausational factors recognize that personal experiences, significant emotional life events, personality and psycho-dynamics have a profound affect on the physical processes of health and disease

2.6 Contemporary (19th and Early 20th Centuries) Public Health

During the 19th Century and the first half of the 20th century, the perception of public health was limited to prevention of communicable diseases through environmental sanitation. For example, a dramatic increase in industrialization in the late 19th century, coupled with urbanization, had profound affects on urban water supplies. There was pollution from human wastes from homes and the workplace disposed in the waterways. Effluents containing organic and inorganic toxic and non-toxic material were dumped into the same waterways. During this time medical theories were limited to bacteriological paradigms.

Bacteriological analysis was used to determine the presence of coliform bacteria in municipal water supplies. Since coliform bacteria are present in great numbers in humans and animals but are not typical water organisms, their presence served as an indicator of fecal pollution and possible pathogenic organisms. Since industrial wastes did not contain these coliform organisms, it was concluded that water sanitary hazards at industrial sites were generally remote with the exception of anthrax from tanneries and wool scouring facilities.

2.7 Current Public Health

Classical infectious disease rates have declined while increased rates of so-called modern diseases (heart disease, cancer and immune deficiency diseases) are now being observed in epidemic proportions throughout the world. Classical public health organizations and systems are now in a state of flux because these structures were erected for classical communicable disease control. New problem-solving systems are needed in areas such as health care financing, medical care for the aged, environmental health protection, and health care planning and administration.