The Field of Public Health Emerges in Response to Epidemic Diseases

Overview

Public health broadly combines efforts towards ensuring physical health through medical research, city planning, regulations in the workplace, and sanitation. The field of public health emerged in the nineteenth century as a response to a surge of epidemic diseases, which were largely caused by the Industrial Revolution in the Western world and the new living conditions that industrial culture created. The concentration of the poor in urban centers provoked epidemic diseases such as cholera, typhoid, and yellow fever, and social reformers and the scientific community invested in medical and environmental safeguards to protect their populations from these widespread diseases. Over the course of the century, discoveries of the causes of disease primarily in France, Great Britain, Germany, and the United States transformed the field of public health into a socio-medical operation necessary to the health of modern communities.

Background

The philosophical roots of the public health movement are the liberal politics of the Age of Enlightenment, an eighteenth-century period notable for its optimistic belief in social progress and the perfectibility of humankind. Political revolutions in France and America inspired confidence in man's ability to transform his culture into a liberated community free from the tradition of a ruling aristocracy. This increased sense of power among the middle-classes encouraged sympathy for the underclass—the sick, the poor, children, and the elderly—which in turn motivated social reformers to work towards improving the lives of these vulnerable members of the population.

No official tradition of public health existed in the eighteenth century, largely because pre-industrial societies were relatively isolated from each other, which reduced the spread of diseases that devastated whole populations in the nineteenth century. But the rapid rise of population and the development of scientific fields in the second half of the eighteenth century set the stage for the public health movement. Reform of social services such as hospitals, prisons, and orphanages in the late 1700s anticipated the total overhaul of public institutions that most Western countries would effect in the century to come.

Optimism in science, too, encouraged members of the scientific and medical communities to apply their knowledge towards lofty goals, such as the total eradication of disease. Perhaps the greatest achievements of the late eighteenth century were the new understanding of hygiene in the spread of disease, and English physician Edward Jenner's (1749-1823) development of a vaccine for smallpox in 1796. Jenner's vaccine became a well-established method of preventative medicine by the century's end, but it principally was used by the middle and upper classes. Attention to the health of the poor would be a primary project of the public health movement in the nineteenth century.

The social and economic changes of the early nineteenth century in the Western world explain the development of public health. The shift from an agricultural economy to an industrial one set into place the conditions for the deadly rise of epidemic diseases. Industrialism initiated the immigration of numerous people from non-industrialized regions to new urban centers, and refugee populations were a major source of the passage of disease. Commercial ventures and the development of railways and shipping lines also facilitated the spread of diseases. Most importantly, industrialism concentrated great numbers of people in hastily constructed cities, and the crowded, often filthy living conditions were ideal breeding grounds for infectious disease and conditions such as malnutrition, dehydration, and infant mortality.

Impact

Most historians place the beginning of public health in France and Great Britain in the early nineteenth century. At this time, important social and scientific connections were made between poverty and disease. England's Sanitary Movement in the 1830s and 1840s best represents early efforts to unite health improvements with government policy. Led by English bureaucrat Edwin Chadwick (1800-1890), this movement focused upon making sanitary improvements to urban slums in England and Wales. England's Public Health Act of 1848 appointed medical health officers in each district of the country. Political quarrels existed, though, over the degree to which the British state should control individual health, and many thought that laws such as compulsory vaccination were infringements on personal liberty.

In France former army doctor Louis-René Villermé (1782-1863) led the public health movement in the first half of the century. In 1826 he published a statistical study of mortality in Parisian neighborhoods, concluding that disease is not a natural condition but an effect of poverty—and as such, it could be controlled. Villermé's work drew as much upon economic theory as it did upon medicine. Founded in political economy, which takes a qualitative approach to human happiness and wealth, he determined that the poor could be "civilized" away from their wretched way of life and made both richer and healthier. This process would also contribute to France's wealth, as less money would be required to fight sickness and build hospitals. Villermé's studies helped to pass laws limiting child labor (1841) and to establish a public health advisory board (1848).

The United States developed a health bureaucracy based upon the English model. In 1866 New York was the first state to develop a health department, complete with local health boards set up in each town. In 1872 the American Public Health Association was organized. The second half of the century in America witnessed a huge increase in immigration and population, and public health efforts multiplied as the country struggled to restrict communicable disease in urban slums. The American public health movement embodied medical science and evangelical piety, and the idea that "cleanliness was next to godliness" was used as a tool to educate the poor.

The middle of the century documents the beginnings of an international health organization. In 1851 the first international sanitary conference was held in Paris, and it was attended by delegates from several Western European and Mediterranean countries. In 1864 the Red Cross was established at the Geneva Convention. Although originally conceived as an international organization devoted to providing relief to wounded soldiers, the Red Cross later turned to the alleviation of human suffering in general.

One of the century's great contributors to public health was Max von Pettenkofer (1818-1901), a German physician and professor of medical chemistry. Von Pettenkofer underestimated the germ theory of disease and argued that disease was spread through environmental factors such as air-born miasma, soil conditions, clothing, and climate changes. Even though he was later proved wrong, the changes von Pettenkofer proposed to Munich's sewage and water supply virtually wiped out typhus in that city. He was so assured of his theory of disease that in order to disprove the germ theory, he famously swallowed a liquid containing what was said to be the bacteria of cholera. While he did experience some stomach discomfort, von Pettenkofer denied that these symptoms were cholera. Nevertheless, his contribution to municipal sanitation established Munich as one of the world centers of the study of sanitation, and he is credited with raising sanitation to a legitimate science.

The incidence of cholera in the nineteenth century provides a case study of the need for comprehensive public health across national and class borders. Epidemic outbreaks in 1831, 1848, 1854, 1866, 1871, and 1892 killed hundreds of thousands. The disease, which causes nausea, vomiting, and then dehydration, struck and killed fast—in as little as three hours. As English epidemiologist John Simon (1813-1858) proved, cholera is carried in drinking water and is often caused by the presence of sewage—a predicament all too common in slums where as many as 100 people shared one toilet. Military troops sometimes caught cholera, too, as their camps matched the crowded environments of the slums. Non-medical responses, such as the national day for "fasting and humiliation" declared in England's Parliament to combat cholera (1832), showed that modern medical theories of causation still operated alongside traditional religious concepts of disease as sin.

Tropical medicine became a specialty field after numerous white colonists sickened and died during their imperial ventures in Asia, India, and Latin America. The tropics became known as the "white man's grave" because Europeans were vulnerable to strains of disease and the changes of climate that did not exist in their home countries. Western medicine in these provinces, though, primarily served the colonial population and not the native peoples.

The growth of hospitals during the nineteenth century illustrates the influence of public health efforts. Major breakthroughs in the understanding of germs and hygiene radically changed the sanitary environment of hospitals. Before these discoveries, a patient might be prepared for surgery simply by having her clothes removed. English nurse Florence Nightingale (1820-1910) helped prove that a clean environment drastically curbed the spread of infection. When Hungarian pathologist Ignaz Philipp Semmelweis (1818-1848) demanded that surgeons wash their hands with chlorinated lime, the death rate in his ward dropped to just 3%.

Women's struggle for liberation from the tradition of homemaking was one social change that impacted the rise of public health. In England Nightingale's elevation of nurses from underpaid hospital maids to skilled professionals opened up one of the first respectable professions for women outside the home. Women's organizations throughout Western Europe and America sent trained female volunteers into slums to spread knowledge about disease, hygiene, and nutrition.

By the end of the century in Europe and America, most major cities had developed modern sewage and drainage systems, garbage collection, and hospitals. Due to a century of work in public health, Western populations were better educated about sanitation, pregnancy and natal care, disease transmission, and nutrition. Larger cities often boasted soup kitchens and free health clinics for the poor. Still, the severe health risks caused by continuing urban growth meant that public health measures would need to keep adapting to the challenges of modern industrial culture in the twentieth century.

TABITHA SPARKS