Early history
Mass burials during the second plague pandemic (a.k.a. the Black Death; 1346-1353) intensified urban responses to disaster on the basis of earlier practices. Miniature from "The Chronicles of Gilles Li Muisis" (1272–1352). Bibliothèque royale de Belgique, MS 13076-77, f. 24v.
From the beginnings of human civilization, communities promoted health and fought disease at the population level.[73][74] Definitions of health as well as methods to pursue it differed according to the medical, religious and natural-philosophical ideas groups held, the resources they had, and the changing circumstances in which they lived. Yet few early societies displayed the hygienic stagnation or even apathy often attributed to them.[75][76][77] The latter reputation is mainly based on the absence of present-day bioindicators, especially immunological and statistical tools developed in light of the germ theory of disease transmission.
Public health was born neither in Europe nor as a response to the Industrial Revolution. Preventive health interventions are attested almost anywhere historical communities have left their mark. In Southeast Asia, for instance, Ayurvedic medicine and subsequently Buddhism fostered occupational, dietary and sexual regimens that promised balanced bodies, lives and communities, a notion strongly present in Traditional Chinese Medicine as well.[78][79] Among the Mayans, Aztecs and other early civilizations in the Americas, population centers pursued hygienic programs, including by holding medicinal herbal markets.[80] And among Aboriginal Australians, techniques for preserving and protecting water and food sources, micro-zoning to reduce pollution and fire risks, and screens to protect people against flies were common, even in temporary camps.[81][82]
Western European, Byzantine and Islamicate civilizations,
which generally adopted a Hippocratic, Galenic or humoral medical system, fostered preventive programs as well.[83][84][85][86] These were developed on the basis of evaluating the quality of local climates, including topography, wind conditions and exposure to the sun, and the properties and availability of water and food, for both humans and nonhuman animals. Diverse authors of medical, architectural, engineering and military manuals explained how to apply such theories to groups of different origins and under different circumstances.[87][88][89] This was crucial, since under Galenism bodily constitutions were thought to be heavily shaped by their material environments, so their balance required specific regimens as they traveled during different seasons and between climate zones.[90][91][92]
In complex, pre-industrialized societies, interventions designed to reduce health risks could be the initiative of different stakeholders. For instance, in Greek and Roman antiquity, army generals learned to provide for soldiers’ wellbeing, including off the battlefield, where most combatants died prior to the twentieth century
In Christian monasteries across the Eastern Mediterranean and western Europe since at least the fifth century CE, monks and nuns pursued strict but balanced regimens, including nutritious diets, developed explicitly to extend their lives.[95] And royal, princely and papal courts, which were often mobile as well, likewise adapted their behavior to suit environmental conditions in the sites they occupied. They could also choose sites they considered salubrious for their members and sometimes had them modified.[96]
In cities, residents and rulers developed measures to benefit the general population, which faced a broad array of recognized health risks. These provide some of the most sustained evidence for preventive measures in earlier civilizations. In numerous sites the upkeep of infrastructures, including roads, canals and marketplaces, as well as zoning policies, were introduced explicitly to preserve residents’ health. Officials such as the muhtasib in the Middle East and the Road master in Italy, fought the combined threats of pollution through sin, ocular intromission and miasma.[97][98][99][100][101][102][103] Craft guilds were important agents of waste disposal and promoted harm reduction through honesty and labor safety among their members. Medical practitioners, including public physicians,[104] collaborated with urban governments in predicting and preparing for calamities and identifying and isolating people perceived as lepers, a disease with strong moral connotations.[105][106] Neighborhoods were also active in safeguarding local people’s health, by monitoring at-risk sites near them and taking appropriate social and legal action against artisanal polluters and neglectful owners of animals. Religious institutions, individuals and charitable organizations in both Islam and Christianity likewise promoted moral and physical wellbeing by endowing urban amenities such as wells, fountains,
schools and bridges, also in the service of pilgrims.[107][108] In western Europe and Byzantium, religious processions commonly took place, which purported to act as both preventive and curative measures for the entire community.[109]
Urban residents and other groups also developed preventive measures in response to calamities such as war, famine, floods and widespread disease.[110][111][112][113] During and after the Black Death (1346–53), for instance, inhabitants of the Eastern Mediterranean and Western Europe reacted to massive population decline in part on the basis of existing medical theories and protocols, for instance concerning meat consumption and burial, and in part by developing new ones.[114][115][116] The latter included the establishment of quarantine facilities and health boards, some of which eventually became regular urban (and later national) offices.[117][118] Subsequent measures for protecting cities and their regions included issuing health passports for travelers, deploying guards to create sanitary cordons for protecting local inhabitants, and gathering morbidity and mortality statistics.[119][120][121] Such measures relied in turn on better transportation and communication networks, through which news on human and animal disease was efficiently spread.
Modern public health
The 18th century saw rapid growth in voluntary hospitals in England.[122] The latter part of the century brought the establishment of the basic pattern of improvements in public health over the next two centuries: a social evil was identified, private philanthropists brought attention to it, and changing public opinion led to government action.[123]
1802 caricature of Edward Jenner vaccinating patients who feared it would make them sprout cowlike appendages
The practice of vaccination became prevalent in the 1800s, following the pioneering work of Edward Jenner in treating smallpox.
James Lind's discovery of the causes of scurvy amongst sailors and its mitigation via the introduction of fruit on lengthy voyages was published in 1754 and led to the adoption of this idea by the Royal Navy.[124] Efforts were also made to promulgate health matters to the broader public; in 1752 the British physician Sir John Pringle published Observations on the Diseases of the Army in Camp and Garrison, in which he advocated for the importance of adequate ventilation in the military barracks and the provision of latrines for the soldiers.[125]
With the onset of the Industrial Revolution, living standards amongst the working population began to worsen, with cramped and unsanitary urban conditions. In the first four decades of the 19th century alone, London's population doubled and even greater growth rates were recorded in the new industrial towns, such as Leeds and Manchester. This rapid urbanisation exacerbated the spread of disease in the large conurbations that built up around the workhouses and factories. These settlements were cramped and primitive with no organized sanitation. Disease was inevitable and its incubation in these areas was encouraged by the poor lifestyle of the inhabitants. Unavailable housing led to the rapid growth of slums and the per capita death rate began to rise alarmingly, almost doubling in Birmingham and Liverpool.
Thomas Malthus warned of the dangers of overpopulation in 1798. His ideas, as well as those of Jeremy Bentham, became very influential in government circles in the early years of the 19th century.[123]
Public health legislation
Sir Edwin Chadwick was a pivotal influence on the early public health campaign.
The first attempts at sanitary reform and the establishment of public health institutions were made in the 1840s. Thomas Southwood Smith, physician at the London Fever Hospital, began to write papers on the importance of public health, and was one of the first physicians brought in to give evidence before the Poor Law Commission in the 1830s, along with Neil Arnott and James Phillips Kay.[126] Smith advised the government on the importance of quarantine and sanitary improvement for limiting the spread of infectious diseases such as cholera and yellow fever.[127][128]
The Poor Law Commission reported in 1838 that "the expenditures necessary to the adoption and maintenance of measures of prevention would ultimately amount to less than the cost of the disease now constantly engendered". It recommended the implementation of large scale government engineering projects to alleviate the conditions that allowed for the propagation of disease.[123] The Health of Towns Association was formed at Exeter Hall London on 11 December 1844, and vigorously campaigned for the development of public health in the United Kingdom.[129] Its formation followed the 1843 establishment of the Health of Towns Commission, chaired by Sir Edwin Chadwick, which produced a series of reports on poor and insanitary conditions in British cities.[129]
These national and local movements led to the Public Health Act, finally passed in 1848. It aimed to improve the sanitary condition of towns and populous places in England and Wales by placing the supply of water, sewerage, drainage, cleansing and paving under a single local body with the General Board of Health as a central authority. The Act was passed by the Liberal government of Lord John Russell, in response to the urging of Edwin Chadwick. Chadwick's seminal report on The Sanitary Condition of the Labouring Population was published in 1842[130] and was followed up with a supplementary report a year later.[131]
Vaccination for various diseases was made compulsory in the United Kingdom in 1851, and by 1871 legislation required a comprehensive system of registration run by appointed vaccination officers.[132]
Further interventions were made by a series of subsequent Public Health Acts, notably the 1875 Act. Reforms included latrinization, the building of sewers, the regular collection of garbage followed by incineration or disposal in a landfill, the provision of clean water and the draining of standing water to prevent the breeding of mosquitoes.
The Infectious Disease (Notification) Act 1889 mandated the reporting of infectious diseases to the local sanitary authority,
which could then pursue measures such as the removal of the patient to hospital and the disinfection of homes and properties.[133]
In the United States, the first public health organization based on a state health department and local boards of health was founded in New York City in 1866.[134]
Epidemiology
John Snow's dot map, showing the clusters of cholera cases in the London epidemic of 1854
The science of epidemiology was founded by John Snow's identification of a polluted public water well as the source of an 1854 cholera outbreak in London. Dr. Snow believed in the germ theory of disease as opposed to the prevailing miasma theory. He first publicized his theory in an essay, On the Mode of Communication of Cholera, in 1849, followed by a more detailed treatise in 1855 incorporating the results of his investigation of the role of the water supply in the Soho epidemic of 1854.[135]
By talking to local residents (with the help of Reverend Henry Whitehead), he identified the source of the outbreak as the public water pump on Broad Street (now Broadwick Street). Although Snow's chemical and microscope examination of a water sample from the Broad Street pump did not conclusively prove its danger, his studies of the pattern of the disease were convincing enough to persuade the local council to disable the well pump by removing its handle.[136]
Snow later used a dot map to illustrate the cluster of cholera cases around the pump. He also used statistics to illustrate the connection between the quality of the water source and cholera cases. He showed that the Southwark and Vauxhall Waterworks Company was taking water from sewage-polluted sections of the Thames and delivering the water to homes, leading to an increased incidence of cholera. Snow's study was a major event in the history of public health and geography. It is regarded as the founding event of the science of epidemiology.[137][138]
Disease control
Paul-Louis Simond injecting a plague vaccine in Karachi, 1898
With the pioneering work in bacteriology of French chemist Louis Pasteur and German scientist Robert Koch, methods for isolating the bacteria responsible for a given disease and vaccines for remedy were developed at the turn of the 20th century. British physician Ronald Ross identified the mosquito as the carrier of malaria and laid the foundations for combating the disease.[139] Joseph Lister revolutionized surgery by the introduction of antiseptic surgery to eliminate infection. French epidemiologist Paul-Louis Simond proved that plague was carried by fleas on the back of rats,[140] and Cuban scientist Carlos J. Finlay and U.S. Americans Walter Reed and James Carroll demonstrated that mosquitoes carry the virus responsible for yellow fever.[141][142] Brazilian scientist Carlos Chagas identified a tropical disease and its vector.[143]
With onset of the epidemiological transition and as the prevalence of infectious diseases decreased through the 20th century, public health began to put more focus on chronic diseases such as cancer and heart disease. Previous efforts in many developed countries had already led to dramatic reductions in the infant mortality rate using preventive methods. In Britain, the infant mortality rate fell from over 15% in 1870 to 7% by 1930.[144] The development of public health services and sanitation, and education in improving women and child health in the poorest slums of Glasgow, led by Dr. Nora Wattie from 1939 to1964, was recognised in the United Kingdom by the award of an OBE for services to public health.[145]
Country examples
France
Main article: Health in France
France 1871–1914 followed well behind Bismarckian Germany, as well as Great Britain, in developing the welfare state including public health. Tuberculosis was the most dreaded disease of the day, especially striking young people in their 20s. Germany set up vigorous measures of public hygiene and public sanatoria, but France let private physicians handle the problem, which left it with a much higher death rate.[146] The French medical profession jealously guarded its prerogatives, and public health activists were not as well organized or as influential as in Germany, Britain or the United States.[147][148] For example, there was a long battle over a public health law which began in the 1880s as a campaign to reorganize the nation's health services, to require the registration of infectious diseases, to mandate quarantines, and to improve the deficient health and housing legislation of 1850. However the reformers met opposition from bureaucrats, politicians, and physicians.
Because it was so threatening to so many interests, the proposal was debated and postponed for 20 years before becoming law in 1902. Success finally came when the government realized that contagious diseases had a national security impact in weakening military recruits, and keeping the population growth rate well below Germany's.[149]
United States
The seal of the United States Public Health Service
See also: United States Public Health Service
Modern public health began developing in the 19th century, as a response to advances in science that led to the understanding of, the source and spread of disease. As the knowledge of contagious diseases increased, means to control them and prevent infection were soon developed. Once it became understood that these strategies would require community-wide participation, disease control began being viewed as a public responsibility. Various organizations and agencies were then created to implement these disease preventing strategies.[150]
Most of the Public health activity in the United States took place at the municipal level before the mid-20th century. There was some activity at the national and state level as well.[151]
In the administration of the second president of the United States John Adams, the Congress authorized the creation of hospitals for mariners. As the U.S. expanded, the scope of the governmental health agency expanded.
In the United States, public health worker Sara Josephine Baker, M.D. established many programs to help the poor in New York City keep their infants healthy, leading teams of nurses into the crowded neighborhoods of Hell's Kitchen and teaching mothers how to dress, feed, and bathe their babies.
Another key pioneer of public health in the U.S. was Lillian Wald, who founded the Henry Street Settlement house in New York. The Visiting Nurse Service of New York was a significant organization for bringing health care to the urban poor.
Dramatic increases in average life span in the late 19th century and 20th century, is widely credited to public health achievements, such as vaccination programs and control of many infectious diseases including polio, diphtheria, yellow fever and smallpox; effective health and safety policies such as road traffic safety and occupational safety; improved family planning; tobacco control measures; and programs designed to decrease non-communicable diseases by acting on known risk factors such as a person's background, lifestyle and environment.
Another major public health improvement was the decline in the "urban penalty" brought about by improvements in sanitation. These improvements included chlorination of drinking water, filtration and sewage treatment which led to the decline in deaths caused by infectious waterborne diseases such as cholera and intestinal diseases.[152] The federal Office of Indian Affairs (OIA) operated a large-scale field nursing program. Field nurses targeted native women for health education, emphasizing personal hygiene and infant care and nutrition.[153]
Mexico
See also: Healthcare in Mexico § Public healthcare delivery
Logo for the Mexican Social Security Institute, a governmental agency dealing with public health
Public health issues were important for the Spanish Empire during the colonial era. Epidemic disease was the main factor in the decline of indigenous populations in the era immediately following the sixteenth-century conquest era and was a problem during the colonial era.
The Spanish crown took steps in eighteenth-century Mexico to bring in regulations to make populations healthier.[154]
In the late nineteenth century, Mexico was in the process of modernization, and public health issues were again tackled from a scientific point of view.[155][156][157][158][159][160] As in the U.S., food safety became a public health issue, particularly focusing on meat slaughterhouses and meatpacking.[161] Even during the Mexican Revolution (1910–20), public health was an important concern, with a text on hygiene published in 1916.[162] During the Mexican Revolution, feminist and trained nurse Elena Arizmendi Mejia founded the Neutral White Cross, treating wounded soldiers no matter for what faction they fought.
In the post-revolutionary period after 1920, improved public health was a revolutionary goal of the Mexican government.[163][164] The Mexican state promoted the health of the Mexican population, with most resources going to cities.[165][166] Concern about disease conditions and social impediments to the improvement of Mexicans' health were important in the formation of the Mexican Society for Eugenics. The movement flourished from the 1920s to the 1940s.[167] Mexico was not alone in Latin America or the world in promoting eugenics.[168] Government campaigns against disease and alcoholism were also seen as promoting public health.[169][170]
The Mexican Social Security Institute was established in 1943, during the administration of President Manuel Avila Camacho to deal with public health, pensions, and social security.
Cuba
See also: Timeline of healthcare in Cuba
Since the 1959 Cuban Revolution the Cuban government has devoted extensive resources to the improvement of health conditions for its entire population via universal access to health care. Infant mortality has plummeted.[171] Cuban medical internationalism as a policy has seen the Cuban government sent doctors as a form of aid and export to countries in need in Latin America, especially Venezuela, as well as Oceania and Africa countries.
Colombia and Bolivia
Public health was important elsewhere in Latin America in consolidating state power and integrating marginalized populations into the nation-state. In Colombia, public health was a means for creating and implementing ideas of citizenship.[172]
In Bolivia, a similar push came after their 1952 revolution.[173]
Ghana
Though curable and preventive, malaria remains a huge public health problem and is the third leading cause of death in Ghana.[174] In the absence of a vaccine, mosquito control, or access to anti-malaria medication, public health methods become the main strategy for reducing the prevalence and severity of malaria.[175] These methods include reducing breeding sites, screening doors and windows, insecticide sprays, prompt treatment following infection, and usage of insecticide treated mosquito nets.[175] Distribution and sale of insecticide-treated mosquito nets is a common, cost-effective anti-malaria public health intervention; however, barriers to use exist including cost, household and family organization, access to resources, and social and behavioral determinants which have not only been shown to affect malaria prevalence rates but also mosquito net use.[176][175]
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