History of public health

New Internationalist, Jan-Feb, 2001

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.

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 sanitarians, germ-theory zealots, prohibitionists, anti-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?

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.

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 1890s 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.'