The History of Public Health

The history of public health is directly related to the evolution of thinking about health. Ancient societies in one way or another realized the connection between sanitation and health and the role of personal hygiene, nutrition, and fitness. The sanctity of human life (Pikuah Nefesh) established an overriding human responsibility to save life derived from Mosaic Law from 1500 bc. The scientific and ethical basis of medicine was also based on the teachings of Hippocrates in the fourth century bc. Sanitation, hygiene, good nutrition, and physical fitness for health all had roots in many ancient societies including obligations of the society to provide care for the poor. These ethical foundations support efforts to preserve life even at the expense of other religious or civil ordinances.
Social and religious systems linked disease to sin and punishment by higher powers, viewed investigation or intervention by society, except for relief of pain and suffering, as interference with God’s will. Childbirth was associated with pain, disease, and frequent death as a general concept of “in sorrow shall you bring forth children.” Health care was seen as a religious charitable responsibility to ease suffering of the sinner.
The clear need and responsibility of society to protect itself by preventing entry or transmission of infectious diseases was driven home by the pandemics of leprosy, plague, syphilis, smallpox, measles, and other communicable diseases in the Middle Ages. The diseases themselves evolved, and pragmatic measures were gradually found which were meant to control their spread, such as isolation of lepers, quarantine of ships, and closure of public bathhouses. Epidemiologic investigations of cholera, typhoid, occupational diseases, and nutritional deficiency
disorders in the eighteenth and nineteenth centuries began to show causal relationships and effective ways of intervention before scientific proof of causation was established. Even in the twentieth century, public health practice has continued to proceed on a pragmatic basis long before the full scientific basis of the causation of diseases has been worked out. Public health organizations to ensure basic community sanitation and other modalities of prevention evolved through the development of local health authorities, fostered, financed, and supervised by civic, state, or provincial and national health authorities as governments became more and more involved in health issues.
Freeing human thought from dogmas which restricted scientific exploration of health and disease led to the search for the natural causation of disease. This was of paramount importance in seeking interventions and preventive activities. This concept, first articulated in ancient Greek medicine, provided the basis for clinical and scientific observations leading to the successes of public health in the past two centuries. The epidemiologic method led to public health interventions before the biological basis of the condition was determined. Sanitation to prevent disease was accepted in many ancient societies, and codified in some as part of civil and religious obligations. Lind’s investigation of scurvy, Jenner’s discovery of vaccination to prevent smallpox, and Snow’s investigation of cholera in London demonstrated in modern scientific epidemiologic terms the cause of disease and were accepted despite lack of contemporary biochemical and bacteriologic proof. They helped to formulate the methodology of public health.
Public health developed through pioneering epidemiologic studies, devising many forms of preventive medicine and community health promotion. Reforms pioneered in many areas, from abolition of slavery and serfdom to provision of state legislated health insurance, have all improved the health of the general population. In the last years of the twentieth century, the relationship between health and social and economic development has gained recognition internationally. The twentieth century has seen a dramatic expansion of the scientific basis for medicine and public health. Immunology, microbiology, pharmacology, toxicology, and epidemiology have provided powerful tools and results in improving the health status of the population. New medical knowledge and technology have come to be available to the general public in many countries in the industrialized world through the advent of health insurance. In this century, virtually all industrialized countries established systems of assuring access to care for all the population as essential for the health of the individual and the population.
Major historical concepts have had profound effects on the development of public health. Sickness as punishment for sin prevented attempts to control disease over many centuries. This mentality continues by “blaming the victim.” AIDS patients are seen as deserving their fate because of their behavior, workers are believed to get injured because of their own negligence, and the obese person and the smoker are believed to deserve their illnesses because of the way they conduct their lives. Conversely, public health is associated with charity in which there is a religious responsibility for kindness and relief of suffering. Ethical controversies are still important in such diverse areas as managed care, reproductive health, cost–benefit analysis, euthanasia, and care of prisoners.
Acceptance of the right to health for all by the founders of the United Nations and the World Health Organization added a universal element to the mission of public health. This concept was embodied in the constitution of the WHO and given more concrete form in the Health for All concept of Alma-Ata which emphasizes the right of health care for everyone and the responsibility of governments to ensure that right. This concept also articulated the primary importance of prevention and primary care, which became a vital issue in the competition for resources between public health and hospital-oriented health care.
The lessons of history are important in public health. The basic issues of public health need to be relearned because new challenges for health appear while old ones reappear. The philosophical and ethical basis of modern public health is a belief in the inherent worth of the individual and his/her human right to a safe and healthful environment. The health and well-being of the individual and the community are interdependent. Investment in health, as in education, is a contributor to economic growth, as healthy and educated individuals contribute to a creative and economically productive society.
The New Public Health is derived from the experience of history. Organized activity to prevent disease and promote health had to be relearned from the ancient and post-industrial revolution worlds. As the twentieth century draws to a close, we need to learn from a wider framework how to use all health modalities, including clinical and prevention-oriented services, to effectively and economically preserve, protect, and promote the health of the individual and of society. The New Public Health, as public health did in the past, faces ethical issues which relate to health expenditures, priorities, and social philosophy. Throughout the course of this book, we discuss these issues and try to indicate a balanced approach toward the New Public Health.