II. HISTORY

Public health may be defined as the collective action by a community or society to protect and promote the health and welfare of its members. In a world where sickness and accidents were attributed to spirits, the welfare of the tribe and its individual members depended upon paying proper homage to the spiritual realm. Since public-health measures are based upon the level of existing medical knowledge or prevailing assumptions, the observance of taboos and rituals by early tribal societies represents a form of public health. The origins of modern public health lie in efforts to prevent pestilential diseases, but in the past centuries public health has broadened its aims and now applies the findings of social and scientific fields to promoting physical and mental well-being.

Public health in its modern sense arose as a phenomenon of urbanization. As towns and cities emerged, communal living created special problems relating to food, water, sanitation, and disease. In an urban environment, the responsibility for providing safe food and water and disposing of garbage and human wastes could no longer be left to individual initiative, and what were essentially public-health regulations appeared. Both health and aesthetics supplied the motive for these early sanitary regulations, since foul odors were associated with the miasmic theory of disease, a belief that some obnoxious gaseous substance was the cause of epidemic disease.

The classical civilizations evolved relatively sophisticated public health measures. In the second millennium b.c.e. the Minoans developed elaborate plumbing systems that included flush toilets. The great Roman aqueducts that were built between 312 b.c.e. and about 100 c.e., sections of which still survive, are familiar to all; but what is not so well known is that the Roman water systems, at least the one for Rome, differentiated between water for common use and that for drinking. The decline of the Western Roman Empire meant a return to a rural society, and it was not until the rise of towns and cities in the medieval period that public-health measures were reinstituted. The need to live within the town walls for safety intensified crowding and its concomitant sanitary and health problems. In the medieval period fear of two horrible diseases, leprosy and bubonic plague (the Black Death), was responsible for the practice of isolating the sick and instituting quarantines to keep the sickness at bay. Victims of leprosy were literally read out of society, and the first quarantine laws appeared in 1348 in response to the spread of the Black Death.

The late Renaissance and early modern period witnessed two developments that helped pave the way for the institutionalization of public health. The first of these was the concept of mercantilism, which, among other factors, counted population as a source of a nation's wealth. The second was the development of what was termed political arithmetic. Morbidity and mortality statistics are basic to understanding the health of a population and to determining health policy. Two Englishmen, William Petty (1623–1687) and John Graunt (1620–1674), were among the first to recognize this need. They urged the collection of statistics pertaining to health and social matters in order to promote a more healthy and productive population. The astronomer Edmund Halley in 1693 published a life expectancy table that made possible the first life insurance company. Later, life and industrial insurance companies in the United States were to play a role in promoting public health.

John Locke (1632–1704) in 1690 published his classic treatise, Essay on Human Understanding, in which he asserted that human beings were the product of their environment. By applying intelligence to social problems and creating a better society, it would be possible to improve humankind. The French philosophers Denis Diderot, Jean Le Rond d'Alembert, Voltaire, and Jean-Jacques Rousseau carried the idea even further by assuming the perfectibility of humanity. Joining this assumption to the mercantilist principle that a growing and healthy population strengthened the power of the state, the "benevolent despots" of the eighteenth century sought to impose public-health measures by fiat. This form of public health, in which administrators issued decrees relating to health and sanitation, was called "medical police" or medical policy; and its leading exponent was Johann Peter Frank, whose six-volume Complete System of Medical Policy (1779–1817) dealt with virtually all aspects of public health, from sanitation to the health of workers.

In Britain, the Civil War and the Glorious Revolution of 1688 had made the British people suspicious of the central government; consequently, much administration was kept at the local level. As in the United States, the major impulse for public-health reform came in the nineteenth century and was led by middle-class reformers motivated by a mixture of Christian benevolence, humanitarianism, and rationalism. The dislocations resulting from economic changes in the eighteenth and early nineteenth centuries created a large impoverished class and led to efforts by humanitarians to reduce the enormous mortality among infants, to alleviate the suffering of prisoners and the insane, and to fight against widespread alcoholism among the working class.

By the early nineteenth century, the industrial revolution was drawing thousands of workers from rural areas into crowded city slums, compounding the growing urban sanitary problems. In Britain, the harsh conditions of the poorly paid men, women, and children working long hours in the newly spawned factories and mills came to the attention of several humane individuals, and, under the leadership of Lord Ashley, a series of factory acts was enacted. The first of these, passed in 1833, restricted the working hours of children below the age of eighteen to twelve per day and sixty-nine per week. In the legislative battle for this law, parliamentary hearings drew attention to the atrocious living conditions of the workers and their high rates of sickness and death. The hearings also showed that the excessive use of alcohol and opium was a means of escape for workers condemned to lifelong toil in a brutalizing environment.

Meanwhile, the physicians C. Turner Thackrah, James Philips Kay, Thomas Southwood Smith, and Neil Arnott were drawing attention to the need for health reform. They were fortunate in enlisting Edwin Chadwick (1801–1890) in their cause. Chadwick was a single-minded reformer who dedicated himself to promoting the welfare of the working class. His investigations and reports on behalf of government commissions, culminating in his report for the Health of Towns Commission, were largely responsible for the passage of the Public Health Act of 1848. This measure marks the first step in the institutionalization of public health in the West.

In France the work of Louis René Villerme (1782–1863) roughly paralleled that of Chadwick. Like the latter, his morbidity and mortality statistics demonstrated the close correlation between health and living standards, and led the French government to establish a national public-health advisory committee in 1848. The committee, which included professionals such as physicians, chemists, pharmacists, and veterinarians, was purely an advisory body. Although it dealt with a wide range of public-health issues, from epidemics to industrial health, it was devoid of all powers, and the successive French governments did little to strengthen it during the rest of the century.

The industrial revolution and its concomitant problems arrived late in the United States, but by 1800 cities were beginning to establish temporary boards of health. The chief impetus for these early health agencies came from a series of yellow fever epidemics that struck port cities from South Carolina to New England in the years from 1793 to 1806. These boards were appointed whenever yellow fever threatened or was present. With medical opinion divided as to whether the disease was an imported contagion or the result of a miasma arising from foul, putrefying substances or some other source, the health officials played safe by promptly quarantining incoming vessels and instituting large-scale sanitary programs. Privies were cleaned, dead animals removed from the streets, stagnant pools drained, and slaughterers, tanners, and other members of the "noxious" trades required to cleanse their premises. After 1806 the danger from yellow fever in the region north of Norfolk, Virginia, receded, and health boards virtually disappeared. The appearance in 1832 of the first of three great epidemic waves of Asiatic cholera that swept through the United States revived these temporary boards, but generally they functioned only in times of emergencies.

By the 1830s and 1840s, American cities were beginning to experience the worst aspects of the industrial revolution. Rural Americans and immigrants flooded into urban areas that were ill prepared to handle the influx. Housing and sanitary conditions deteriorated, and morbidity and mortality rose. The movement to remedy these conditions was initiated largely by physicians, most notably by Benjamin W. McCready, whose 1837 essay drew attention to the deplorable health conditions in the workplace and the slums housing the workers, and by John H. Griscom, whose 1845 report, The Sanitary Condition of the Laboring Population of New York, laid the basis for establishing the first effective municipal health department in the United States. In other cities, too, physicians led the reform movement: Wilson Jewell in Philadelphia, Edwin Miller Snow in Providence, Edward Jarvis in Boston, and Edward H. Barton and J. C. Simmonds in New Orleans.

The outstanding layman in the early health movement was Lemuel Shattuck of Boston, who pioneered in the collection of vital statistics and promoted sanitary reform. The success of the early reformers in drawing public attention to the need for action led in the 1850s and 1860s to the appearance of civic sanitary organizations and agencies such as the New York Association for Improving the Condition of the Poor. As in England, the public health movement was both a humanitarian and a moral crusade. A few reformers emphasized improving the morals of the poor, but most recognized that immorality and intemperance were closely associated with the crowded and brutally degraded living conditions of the poor.

In 1857, an abortive attempt was made to unite the health reformers at the national level when Wilson Jewell of Philadelphia summoned a national quarantine convention. The original purpose was to respond to the danger from yellow fever, a disease still ravaging southern ports and threatening the Mississippi Valley. In the first meeting the delegates generally agreed on the necessity to standardize state quarantine laws, but many of them felt that the real need was complete sanitary reform. In the following three annual meetings, sentiment among the delegates swung in favor of a program affecting all areas of community health. At the 1860 meeting a resolution was passed suggesting that the delegates form a national health association. The out-break of the Civil War ended these hopes, and a national organization awaited the postwar years.

Although the Civil War temporarily set back a nationwide organization of public health leaders, it stimulated the health movement. Wartime experiences in army camps and hospitals demonstrated the value of cleanliness and proper food and housing. In addition, the U.S. Sanitary Commission, a civilian body given official status at the outset of the war, introduced thousands of Union soldiers to the principles of personal and public hygiene. Leading members of this commission also played a key role in establishing the New York Metropolitan Board of Health in 1866, an agency that set the pattern for municipal health departments throughout the United States. Four years later, the Massachusetts State Board of Health, the first effective state health agency, came into existence. The founding of the American Public Health Association in 1872 indicated that the institutionalization of public health in the United States was under way.

Until the 1870s, the only action by the federal government relating to health had been the creation of the U.S. Marine Hospital Service in 1798. Although designed to provide medical care for sick sailors, for much of the nineteenth century it served primarily as a form of political patronage. Two yellow fever epidemics, one in 1873 and a major one in 1878 that spread far up the Mississippi River Valley, resulted in the federal government's briefly moving into the area of public health. Responding to widespread alarm, in 1879 Congress established the National Board of Health. The board was given little authority and limited funds, and was expected to act primarily in an advisory capacity. It immediately encountered strong opposition from the U.S. Marine Hospital Service, which was seeking to expand into the health area, and from state and municipal health officials reluctant to surrender any of their authority. The board performed quite well, promoting scientific health studies, assisting local health boards, and encouraging standardization of local quarantine laws. Nonetheless, political pressure led to its demise in 1883. During the nineteenth century Congress voted substantial funds to promote the health of domestic animals and fowls but virtually nothing for human health.

The Progressive movement at the turn of the century promoted political reform, economic efficiency, and social justice and, in the process, gave an impetus to U.S. public health. By the early twentieth century, public health in all developed countries was both professionalized and institutionalized. The bacteriological revolution had provided a new basis for action by health authorities, shifting the emphasis away from sanitation and environmental considerations and toward utilizing the newly developed antitoxins and vaccines to cure and prevent the great epidemic disorders of earlier years. Advances in technology and improvements in civic administration enabled health departments to spin off to separate agencies many former responsibilities, such as street cleaning and garbage removal, inspecting housing, and supervising water supplies and sewage removal. Their place was taken by new concerns: maternal and child care, the health of schoolchildren, the development of laboratory techniques for diagnostic purposes, and the health of people in rural areas. The major gains during the first forty years of the twentieth century were the elimination or drastic reduction of smallpox, measles, diphtheria, scarlet fever, tuberculosis, and other killer diseases.

Until the bacteriological revolution and the advances in basic sciences in the last decades of the nineteenth century, the medical profession, particularly in the United States, was viewed with considerable skepticism. In an effort to improve their status, physicians took an active role in the early public-health movement, and in England and on the Continent they gained control of it. The institutionalization of public health in the United States, however, assumed a different form, in part because the American Public Health Association from its founding in 1872 included sanitary engineers, bacteriologists, and other nonphysician members. In the early twentieth century, as public health moved into the area of school, maternal, and child health, health officials recognized the inadequacy of the medical care available to the lower-income groups and began establishing clinics. The medical profession by this time had gained control of hospitals and medical education, and dominated medical care. Recognizing that clinics represented a threat to the lucrative fee system, the American Medical Association used its political power to force public-health agencies out of direct healthcare. Health departments in general were restricted to supplying free vaccines to physicians, referring patients screened by public-health doctors or nurses, gathering statistics, and dealing with community health problems.

As the great killer diseases of former times were brought under control in the first forty years of the twentieth century, health authorities began turning their attention to chronic and constitutional disorders and to the long-neglected area of occupational hazards. Although the danger from miasmas had been dismissed, the post–World War II period saw a rising concern over the environment. The thousands of new chemicals polluting the air and water presented subtle but potentially serious dangers to health, and radiation introduced still another possible threat. In addition, stimulated in part by the psychiatric problems uncovered during the war years, public health was broadened to include community mental health.

The development of sulfa drugs and antibiotics in the World War II period seemed to have ended contagious diseases as major public-health problems. Even venereal disorders appeared to be in full retreat by the 1950s. Within another decade the situation began to change. The success of the new "miracle drugs"—such as penicillin—in curing venereal disorders led physicians to prescribe antibiotics for almost every form of infection, whether the cause was bacterial or viral. The result was the rapid creation of resistant strains of pathogenic organisms. The emergence of resistant forms of syphilis and gonorrhea coincided with the sexual revolution of the 1960s and contributed notably to a sharp rise in the incidence of venereal diseases. Since the 1970s new or newly diagnosed disorders such as genital herpes, Legionnaire's disease, Lyme disease, and acquired immunodeficiency syndrome (AIDS) have appeared, further confirming that infectious diseases remain a serious public-health threat.

Of the above disorders, AIDS best epitomizes the interrelationship between the social and biological factors in defining and dealing with disease. In the U.S., public fears aroused by the rising incidence of AIDS have led to the ostracizing of its victims, demands that physicians and health workers be tested, and pressure upon Congress to divert funds from other medical research to investigate AIDS. The public reaction to this new and fatal disorder has antecedents going far back in history. Bubonic plague, smallpox, yellow fever, and Asiatic cholera all evoked a similar response. In the nineteenth century, Asiatic cholera victims were not infrequently dumped from river boats and left to die on the banks. AIDS bears an additional burden because it is equated with sexual immorality, a venereal disorder compounded by its association with homosexuality. Since the eighteenth century any disease associated with sexual activity has been equated with immorality. As late as 1897 Howard Kelly of Johns Hopkins objected in the American Medical Association's annual meeting to a discussion of "the hygiene of the sexual act," on the grounds that the subject "was attended with filth."

AIDS also illustrates the perennial question of the rights of the individual versus those of society. When, as was true for most of history, epidemic diseases were strange, inexplicable occurrences, isolating or casting out the sick or effectively quarantining an infected area was taken for granted. Pesthouses in the colonial period were designed more to protect the town than to provide care for the sick. When inoculation for smallpox was introduced into the United States in 1721, the early laws forbade its use on the justifiable grounds that it would spread the disease. In the nineteenth century, laws requiring vaccination were bitterly opposed by many citizens, with antivaccination societies flourishing in a number of areas.

Public-health regulations by their nature are designed to restrict certain activities on the part of individuals. The 1867 annual report of the New York City Health Board declared: "The Health Department of a great commercial district which encounters no obstacles and meets no opposition, may safely be declared unworthy of public confidence." The vast majority of health regulations affect private property or place an extra cost on individuals or businesses; hence they have invariably led to protests. In New York and New Orleans, when health officials designated certain buildings as hospitals during yellow fever epidemics, mobs rioted and burned them to the ground. During an 1894 smallpox epidemic in Milwaukee, the Health Department sought to isolate cases and vaccinate all individuals in the infected areas. The result was rioting and the dismissal of the health officer. Health officers are government officials subject to political pressures; they must always seek a balance between what needs to be done and what can be done.

Limiting the right of individuals to practice medicine, requiring vaccinations, setting standards for food processing, and requiring physical examinations for food handlers, or establishing sanitary regulations with respect to housing or other property is an assertion that the community's health transcends individual or property rights. Laws requiring physicians to report contagious diseases have always raised strong objections from the medical profession, whether they involved reporting yellow fever in the eighteenth and nineteenth centuries or venereal disease in the twentieth century. When the New York City Health Department issued an order requiring the reporting of tuberculosis cases, the city's medical societies were outraged and appealed to the state legislature to restrict the powers of the Board of Health. In contrast, when on several occasions the New York City Board of Health ordered the evacuation of many blocks during the early yellow fever outbreaks, no one objected, nor were any protests made in 1907 when the New York City Health Department decided that in the interest of public welfare Mary Mallon (Typhoid Mary) should be kept on North Brother Island in the East River, where she remained until her death in 1938. Since medical experiments on the poor had long been taken for granted, neither physicians nor laymen, black or white, objected to the 1932 Tuskegee syphilis experiment, funded by the U.S. Public Health Service and designed to study the course of untreated syphilis in blacks.

The latter decades of the twentieth century have seen an increasing sensitivity to individual rights. The most obvious example is the deinstitutionalization of the mentally sick, who now constitute a large portion of the homeless. The question arises of whether individuals, the homeless in particular, have the right to refuse treatment for mental illness or contagious disorders. The presence in the community of cases of tuberculosis and other communicable diseases represents a threat both to the individual concerned and to the citizens at large. The main issue—as alcoholism, drug addiction, and smoking illustrate—is not whether the government should regulate individual conduct but the degree to which it does so.

As the United States moves toward revising its healthcare system, decisions must be made as to the role of public-health agencies. Maternal and child care for the lowest income groups and preventive medicine have traditionally been in the domain of public health. At present the vaccination of children is left to private medicine or state and local authorities, with the result that thousands of children remain unprotected. These responsibilities should, and probably will, be of major concern in a comprehensive healthcare system. In devising a new health system, will public-health departments expand their work in these areas or surrender them? Or should public health be incorporated into a comprehensive healthcare system? Whatever the case, serious thought must be given to formulating any major changes in the nation's healthcare system.

john duffy (1995)

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Public Health: II. History

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