WHAT IS PUBLIC HEALTH?

The U.S. based Institute of Medicine has set out the domain of public health as dealing with: epidemiology, health promotion and education, public health administration, international health, maternal and child health, biostatistics, environmental health, and nutrition.1 No single volume dealing with public health could hope to deal with all of these. In fact, it is the general character of this book to expand the purview even further. In order to get some clarity and focus in this regard, this volume will seek to approach public health first by establishing the theoretical, moral basis for public health, then by examining the nature and structures of certain policies balancing the needs of individuals and society, and finally getting to the practice of public health from a panoramic lens aimed at the landscape already claimed. The end result aspires to infuse a progressive clarity of vision in order to garner support for the expanded topology of public health.


THE HISTORY OF PUBLIC HEALTH

An individual’s concern for her own health is as old as conscious humanity. The concern for the health of others when “others” means one’s own family or clan must be just as old (for ”others” here is virtually synonymous with “self ”). What is interesting is when health includes others outside the clan. For example, when Noah is told by God, “I have determined to make an end of all flesh, for the earth is filled with violence, because of them; now I am going to destroy them along with the earth.”2 Noah just gets to the business of building an ark. There is no real compassion shown by Noah for the rest of humanity who would soon die. However, when the issue of Sodom’s destruction is on the table, Lot (Abraham’s brother) declares, “I beg you, my brothers, do not act so wickedly.”3 Lot’s plea to the people of Sodom was made so that they might be saved from the promised destruction. In this way, Lot demonstrates a concern for the health of others (in a fashion more pronounced than Noah). Unfortunately, Lot’s call went unheeded so Lot and Abraham gathered up their clan and prepared to depart. In this case the invocation of Public Health fails, but the clan survives—except for Lot’s wife who was too concerned about what was happening to others. She ended up as a pile of salt.
Then there is Joseph who helped the Egyptian pharaoh stave off famine by adopting a public policy that created a store of grain in times of plenty so that an impending famine (in which many might starve) could be avoided.4 The public policy waseffective. This is a true instance of effective public health.
But not all Egyptian pharaohs were so concerned with public health. It took nine plagues before the pharaoh at the time of Moses was willing to release the oppressed Israelites.5 Power and political might were more important than his people’s health. It wasn’t until the pharaoh’s own child6 was killed that the ruler relented (at first). This is an instance of a prudential grounding of public health.
In Plato’s Republic the whole state’s health was a mirror of individual health: a balance of the classes of people as per the balance of an individual’s soul. This may be understood as an exhortation for public health. Plato’s holistic vision linked health and happiness with a virtuous life within one’s own limits.
Among ancient biomedical writers the Hippocratic writers and Galen were particularly interested in the common causes of disease. In the Hippocratic writers this concern takes the form of very general treatises such as Airs, Waters, and Places and more clinical works such as the Epidemics.7 Though there are no clear accounts of Hippocrates engaging in public health practice (as such), Galen was a key physician of the Roman emperor and was called upon for treatment and prevention of disease among those in the army as well as in ancient Rome.8 The concern among the Romans was prudential: a well-run army to thwart invaders and a healthy capital capable to governing the empire.
For most of human history public health has been reactive. In the ancient world and the Middle Ages there were few preventative measures taken. It was generally a case of reacting to plagues or natural disasters. Few structural fixed programs were maintained except the alienation of lepers from the general population that in some societies occurred for a thousand years. During the Enlightenment, it has been argued that Johann Peter Frank, Benjamin Rush and John Gregory advocated physicians to take a public view of medicine.
The major change in public health occurred in the nineteenth century. Two significant events during this time were: (a) the discovery of the microbial causation of infection, and (b) the recognition that these causal agents could be controlled via measures of sewage treatment, clean water and food, and the use of quarantine forinfected individuals.
The understanding of some of the causal mechanisms of disease created a new efficacy for public health that has extended to the present. By knowing underlying causes, the strategies for public health become more efficient. There is a greater confidence that measures taken for prevention of disease or to control the outbreak of infectious disease will be efficacious. It is also the case that some preventative measures, such as vaccination and sanitation, may actually work to protect the populationagainst several sorts of microbial threats.
Today, we are in this last phase of public health. It is more linked to the biochemistry of disease. But there are some who think that we should not lose some of the emphases upon balance and life-style that characterized earlier periods. The future of public health may very well be in uniting these emphases in an effort to protect ourselves positively (by the possession of goods that seem necessary to lead an effective life) and negatively (by the prevention of sickness and accident). In the process the rights of the individual often come into conflict with the good of the group. This tension frames much of public health discourse. Within this volume public health ethics are explored from a number of vantage points (individual vs. community) and our scope ranges far beyond disease to ‘health’ more broadly understood.


Resources: Boylan, Michael. 2004. Public Health Policy And Ethics. USA: Kluwer Academic Publishers