Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (WHO, 2006). The concept of health is the main theme and focus of public health. The concept of “Public health” was defined by the American public health leader, Charles-Edward A. Winslow, in 1920 as, “the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health” (Winslow, 1926) and also adopted as the definition by The Acheson Committee on Public Health in England, which reported in 1988, at their first meeting which is cited in the Health Second Report of the House of Common (2001). What does this definition tell us about the meaning of public health? It means it is ‘the organised efforts of society’, implying some ‘collective responsibility for health and prevention’ (Beaglehole et al, 2004)
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Public health is an aspect of health services concerned with threats to the overall health of a community based on population health analysis. It generally includes surveillance and control of infectious disease and promotion of healthy behaviours among members of the community in contrast to medicine which is focus on the overall health of the individual. Public health deals with the population while medicine deals with the individual. The population can be as small as of people who lives in one community or as large as all the people of several continents in the case of a pandemic. As public health become popular to this modern time tensions sometimes arise between medicine and public health. Each discipline has its distinct priorities. Medicine aims at cures for individual diseases and primarily dealing with individuals while public health emphasizes the prevention of disease of the population and health promotion.
The Health Second Report of the House of Commons (House of Commons, 2001) mentioned in the paper that Public health”, according to the Proprietary Association of Great Britain, is not a term understood by the majority of the public and “one of the difficulties with the term ‘public health’ is that it means different things to different people. In addition according to the report that Public Health can span everything from a medical specialty to a specialty which is an awful lot broader than medicine and to almost a philosophy” and “Public health” can be variously defined so as to cover trends of disease in a population, the provision of preventive and health improving care, or a range of health-impacting factors including or excluding the NHS”.
According to Brieger (1999) and Kumar (2007) the history of public health has been a flourishing field in the last three decades. Yet despite a spate of excellent monographs about various epidemic diseases and many good collections about health and disease in Africa, Asia, the Middle East, Latin America, as well as Europe and North America, the most recent textbook on the history of public health is four decade old. George Rosen’s venerable, A History of Public Health, was first published in 1958.
In many ways, public health is largely a modern concept, although it has roots in antiquity and public health impact and influence has waxed and waned over the past 150 years (House of Commons, 2001). Tosh (1984) cited by Womack and Scally (2004) in his book The Pursuit of history wrote, “To know about the past is to know that things have not always been as they are now, and by implication that they need not remain the same in the future” and according to Carr (1987) cited by Womack and Scally (2004), “history offers a dual function, to enable men and women to understand society of the past and to increase the mastery over the society of the present”. The importance of the history, knowledge and understanding of the past public health and how it evolved, its success and failures, its highs and lows enable us to increase our understanding of the present. In this paper public health history is revisited to see how past shaped the public health today.
Past and Present
Throughout the human history, community attempts to prevent and limit the spread of diseases which are the main early historical ideas of public health. Evidence of the existence of the idea of public health can be found in the earliest evidence of communal living and existence of diseases similar to what we have today. Evidences of activities connected with community health were well documented by Rosen et al (1993) in the book A History of Public Health these community health activities have been found in the very earliest civilizations dated as early as four thousand years ago in India, where evidence showed that these early Indian cities where consciously planned in which the bathrooms and drains are common in excavated buildings, the streets were broad, paved and drained by covered sewers. In Middle Kingdom (2100-1700 BC) archaeologist discovered the ruin city of Kahun in Egypt and there is an evidence that care was taken to drain off water by means of masonry gutter in the centre of the street. During the pre-Christian era, about two thousand years ago, the problem of procuring drinking water supply for larger communities had already been solved. In the book it was mentioned about the impressive engineering works of the Incas. They established well-drained cities that were adequately supplied with water, thus providing a good basis for the health of the community. In Greece, for example, the Cretan-Mycenean culture had large conduits, and in the Palaces, such as that of Konosos on Crete, which dates from the second pre-Christian millennium, there were not only magnificent bathing facilities but also water flushing arrangements for the toilets (Rosen et al, 1993). Kumar (2007) mentioned that Romans believe that ill health could be associated with, amongst other things, bad air, bad water, swamps, sewage, debris and lack of personal cleanliness. In some places, Rome included, it is impossible to avoid all of these unless something is physically done to alter the environment. The Romans resolved these problems by the provision of clean water through aqueducts, removing the bulk of sewage through the building of sewers and development of a system of public toilets throughout their towns and city’s and personal hygiene was encouraged through the building of large public baths. These historical evidences of public health community activities are the source of early information and strategies on the importance of housing and sanitation in public health.
Rosen et al, (1993) discussed the concept of cleanliness and it was very evidence during early days. Cleanliness and personal hygiene are to be found among present-days primitive and very unquestionably practiced by pre-historic and early historic men. Primitive people dispose generally their excretions in sanitary way, although their reasons are quite different to the reasons of today’s generation. During early days these practices are connected to religious practices. People kept clean to be pure and clean in the eyes of the gods and not for hygienic reason. An interesting example cited by Rosen et al (1993) was the connection between the cleanliness and religion in the Inca feast, Citua. Every year, in September, at the beginning of rainy season which is associated with diseases, the people led by the Inca carried out health ceremony. In addition to prayer all homes were thoroughly cleaned. Religious traditions against eating pork among Hebrews and Muslims reflect the special hazards of eating those foods when inadequately preserved or prepared. As often happens in public health, even without an understanding of the underlying etiology, effective preventive measures can be taken. Successes in prevention reinforce the concept that disease can be prevented through human action other than prayers and sacrifices to the gods, which in turn encourages additional attempts at prevention.
Other ancient practices which created a great impact in health of our modern time such as those that can be found among the Indian cultures with a well-developed system of health-related practices called Ayurveda (the science of living) that extensively used herbs and yoga (body and breathing exercises) based on three broad parameters, loosely translated as air (vata), bile (pita) and phelgm (kapha). While the exact date of the origins of these practices are unknown, it is variously estimated to have been in existence since before 1000 B.C. It is generally believed that invasive medicines were discouraged within Ayurveda, though some translations of older works suggest that occasional operations were performed on exceptional cases. Ancient Indian cultures also cultivated systems of healing such as Pranic healing (Mishra, 2003). The Ancient Greek would not have been too unfamiliar with some of the health and fitness regimes that are used by people today. The word ‘Regimen’ was used by the Greeks to describe people’s lifestyles: from which can be derived the word regimented (as in organised). The Greek philosophy of ‘Regimen’ covered what people ate, drank, the types and amount of exercise that they took and how much sleep they had. These ideas were very thorough: it demonstrates that the Greeks knew that lifestyle could affect the quality of life, as evidenced by their development and championing of the Olympics. Such is the quality of the remaining evidence that we can even see that doctors advice differed for those who were rich: and could therefore afford to spend time and money on relaxing, and those who worked or were poorer: and therefore couldn’t maintain as healthy a lifestyle as possible many of which are still visible in places today (Kumar, 2007). In China, although it is not traditionally known as public health, but health practices were visible already during the early days. The earliest known work on Chinese herbs appeared as early as 100 B.C.E., the acupuncture and moxibution, both of which have been practiced as therapeutic techniques in China for more than 2,000 years, the Qi Gong, as an art of healing and health preservation, dates back to the Tang Yao period, some twenty centuries B.C.E. which is about dancing and body movements, and various ways of breathing, exhalation, and exclamation were recognized as ways to read-just some functions of the human body and treat diseases (Koenig et al, 2001).
Public health problems are caused majority by diseases which are transmitted from one person to another. One example is tuberculosis. Tuberculosis was a very common problem all over the world until a good understanding of the disease helped scientists and doctors invent treatments. Less than 100 years ago, many famous people died from the disease, including artists, writers, philosophers, scientists, politicians and even some kings and queens. The history of diseases can be traced as early as the human existence. Paleopathology, the study of ancient diseases using fossils and other artifacts, reveals that early Homo sapiens, who were hunter-gatherers, suffered from essentially the same diseases that afflict people today for example, schistosomiasis, prevalent in Egypt today, has been found in Kidneys 3000 years old (Kloss and David, 2002) and skeletal remains show prehistoric humans (7000 BC) had TB (Hershkovitz et al, 2008), and tubercular decay has been found in the spines of mummies from 3000-2400 BC (Zink et al, 2003). According to Rosen et al, (1993) the first clear accounts of acute communicable diseases occur in the literature of classical Greece such as the writings of Thucydides and Hippocrates. In Hippocratic collection several known diseases of today were already mentioned such as malarial fevers, colds, pneumonia, inflammation of the eyes, suggestive statements of the presence of cases of diphtheria (although not known yet as diphtheria) and other unknown diseases in those time.
In the period of the Western European history from the fall of the West Roman Empire in the 5th to the 15th century is known as the middle ages (Dark ages) religion takes a firm hold on science (Koenig et al, 2001). During this time, the Western Europe experienced a period of social and political disintegration. Large cities disappeared, replaced by small villages surrounding the castles of feudal chiefs. The only unifying force was Christianity, and it was in the monasteries that the learning and culture of the Greco-Roman world was preserved. Furthermore, in many of these institutions, piped water supplies, sanitary sewers, privies, bathing facilities, and heating and ventilation were provided. In addition, some monasteries constructed hospices to shelter travellers and sick persons, though the medical care provided in them was primitive at best. In Eastern Europe and Asia Minor, however, feudalism did not exist, and medicine advanced and became centred in major secular hospitals established in Byzantium, Baghdad, and Cairo (Conrad, 2006).
The two most popular epidemics during the Middle Ages were Black Death and leprosy. Due to the specific environmental circumstances of medieval Europe and the religion of medieval people, these two epidemics had great social repercussions In early 1347, a fearful epidemic of bubonic plague broke out in Constantinople. From then on, this great plague would reach Europe and kill approximately from one-fourth to nine-tenths of the human population in the affected areas. Black Death or Plague from a modern medical point of view, it is a pneumonic type of an infection, highly contagious, which could be transmitted via inhalation, ingestion, or even slight abrasion of skin. Usually, lung lesions occur and death may occur from heart failure. The walls of blood vessels are attacked frequently causing haemorrhages and acute blood poisoning. It is fatal in almost all cases (Byrne, 2004). While leprosy spread in every civilized country in Europe during the Middle Ages. The Order of Lazarus was founded, and Lazarettoes built in a great numbers: the work and the purpose of the Order is to segregate and govern the afflicted and dangerous part of humanity. The disease was controlled through segregation and isolation of those who were afflicted of the disease (Rawcliffe, 2006), which is a very important concept of quarantine and isolation for the modern public health.
Successes in prevention reinforce the concept that disease can be prevented through human action other than prayers and sacrifices to the gods, which in turn encourages additional attempts at prevention. By the 1600’s, the practices of isolation and quarantine had begun to be employed to prevent the spread of certain diseases; by the 1800’s these practices had become common in the American colonies. Methods of smallpox inoculation also began to be used and apparently mitigated some epidemics, even before Edward Jenner’s introduction of a safe vaccine based on cowpox virus (Schoenbach, 2000).
In the early modern world, after about 1500, the West grew in wealth and world dominance, but it did not grow healthier. Infections that took a terrible toll on previously isolated societies, so-called virgin populations, became domesticated as world travel increased and urbanization progressed. Diseases that had been epidemic became endemic in urban centres (Brieger, 1999). During this period the development of crowded urban living, created the profoundest health problems. The contradiction between health and wealth of the nation was not lost. The promotion of fertility and personal hygiene education, the policing of sexually and socially transmitted diseases through policies of isolation and treatment and other major public health importance to the public health of modern time emerged during this period (Porter, 1994). In 1848, after studying a typhus epidemic, the German pathologist Rudolf Virchow stated that all epidemics had social causes-most typically poverty, hunger, and poor housing. Virchow believed that improving social conditions would have a positive effect on public health. This important early perspective plays a significant role in today’s thinking about public health, especially when there are major health disparities among social classes within an individual society or between rich and poor countries (Open Collections Program, 2008).
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The period from 1750 until the mid-nineteenth century was characterized by unprecedented industrial, social, and political developments, and the resulting societal impacts were immense, culminating in the Industrial Revolution (Porter, 1994). In the modern public-health advocates emerged in response to the slum and desperate working conditions of nineteenth-century Europe and North America. In centres like New York, London and Berlin the struggle for proper sewerage, decent housing, clean water, factory inspectors, district health officers and a regime of food inspections was born (Remington (chairman), 1988).
First major written contribution in the field of public health was in Germany, Between 1779-1816, Johann Peter Frank, a leading clinician, medical educator, and hospital administrator. Frank’s fame rests on his massive System einer vollständigen medizinischen Polizey (9 vol., 1779-1827; “System of a Complete Medical Policy”), which covers the hygiene of all stages of a man’s life. He undertook to systematize all that was known on public health and to devise detailed codes of hygiene for enactment. He was among the first to urge international regulation of health problems, and he endorsed the notion of “medical police,” whereby one of the duties of the state was to protect the health of its citizens (Frank, 2008). On the other hand in England 1788, Jeremy Bentham in the hope of making a political career, he settled down to discovering the principles of legislation. The great work on which he had been engaged for many years, An Introduction to the Principles of Morals and Legislation, was published in 1789. In this book he defined the principle of utility as “that property in any object whereby it tends to produce pleasure, good or happiness, or to prevent the happening of mischief, pain, evil or unhappiness to the party whose interest is considered.” Mankind, he said, was governed by two sovereign motives, pain and pleasure; and the principle of utility recognized this state of affairs. The object of all legislation must be the “greatest happiness of the greatest number.” He deduced from the principle of utility that, since all punishment involves pain and is therefore evil, it ought only to be used “so far as it promises to exclude some greater evil.”(Bentham, 2008). Through Bentham’s work Chadwick was influenced to produce his famous work General Report on the Sanitary Condition of the Labouring Population of Great Britain (1842). As secretary of the royal commission on reform of the poor laws (1834-46), Chadwick was largely responsible for devising the system under which the country was divided into groups of parishes administered by elected boards of guardians, each board with its own medical officer. Later, as commissioner of the Board of Health (1848-54), he conducted a campaign that culminated in passage of the Public Health Act of 1848. This legislation embodied his belief that public health should be administered locally so as to encourage the people to participate in their own protection (Chadwick, 2008).
In1854. London was in the middle of an outbreak of cholera. At the time, Europeans did not know what caused cholera. People saw that a lot of people were getting sick and dying, and they ran away to other places hoping they would not get sick too. The discovery owing largely to the work of a mid-nineteenth-century English doctor named John Snow. He watched who was getting sick very carefully. He made a map and put a mark on the map for each person who had got sick and died (Steven, 2006). Cholera is caused by a comma-shaped bacterium-Vibrio cholerae-whose role was identified by the German physician Robert Koch in 1883. By far the most common route of infection is drinking contaminated water. And, since water comes to contain V. cholerae through the excrement of cholera victims, an outbreak of the disease is evidence that people have been drinking each other’s feces (Steven, 2006). The classic investigations on the transmission of cholera by John Snow in 1854 and other diseases such as typhoid fever by William Budd in 1834, and puerperal fever by Ignaz Semmelweis in 1847 led to understanding and the ability to reduce the spread of major infections and other studies and researches and give rise to the birth of epidemiology (Schoenbach, 2000) which is a very important field in the modern public health.
Two major points can be drawn from historical perspective with the 19th century the dramatic advances in the effectiveness of public health “the great sanitary awakening” and the advent of bacteriology and the germ theory (Schoenbach, 2000). The rapid advances in the scientific knowledge about causes and prevention of numerous diseases brought tremendous changes in public health. Many major contagious diseases were brought under control through science applied in public health. The identification of bacteria and the development of interventions such as immunization and water purification techniques provided a means of controlling and preventing the spread of diseases (Remington (chairman), 1988).The advance in understanding of infectious disease that constituted the arrival of the bacteriologic era at the end of the century dramatically increased the effectiveness of public health action. In one dramatic example, mosquito control brought the number of yellow fever deaths in Havana from 305 to 6 in a single. Cholera, typhoid fever, and tuberculosis, the great scourges of humanity, rapidly came under control in the industrialized countries (Schoenbach, 2000).
However, with the decline in severity of infectious disease came a rise in mental illnesses, drug addictions, chronic diseases, cancer, and injuries and health damage associated with industrial labour and new emergence of infectious diseases associated with lifestyle such as HIV, Sexually Transmitted Diseases and re-emergence of diseases once thought defeated or least controlled like TB and malaria are back and have developed resistance to the drugs. Hospitals are today besieged by new forms of infection such as MRSA and C. dificiles that are resistant to most known antibiotics because of abuse and misuse of antibiotics. The changing demographic profile of the country such as increasing over 65 years population, the financial, health and care cost and provisions, ethnicity, diversity, the natural environment including source of water, types of food, clean air, different philosophies about animal use in research, technological advances such as bio-engineering, genetic engineering and human embryonic technology adds to the challenges of the modern public health.
Over the course of history such as the Sanitary movement of the nineteenth century and the development of bacteriology substantially lowered death rates from enteric diseases and other serious health problems still existed (House of Commons). Despite remarkable success in lowering deaths from typhoid, diphtheria, and other contagious diseases, considerable disability continuous to exist in the population. It also became clear that diseases, even for treatment was available, still predominantly affected urban poor (Remington (chairman), 1988). In the Twentieth Century, health, as measured by life expectancy, has improved for the population of Britain to a remarkable extent. Life expectancy in England and Wales has increased from 52 years for men and 55 years for women in 1910, to 74 years and 79 years respectively in 1994. Over the same period infant mortality has fallen from around 105 per thousand to six per thousand. Over the past twenty years, overall mortality rates have continued to decrease. However, health indicators such as mortality and morbidity rates have not improved at the same rates for everyone, with the result that health gap between the healthiest groups and the least healthy groups has now widened and is widening further (House of Commons, 2001). Health inequalities between develop countries and developing countries still exist at this modern time. Concern about health inequalities and other distributional aspects (disparity) of health status and service use has enjoyed varying degrees of attention over the years. During the 1970s and early 1980s, distributional concerns (i.e. a concern for about the health status of different socio-economic groups within society as distinct from the overall societal average) were dominant in thought about international health. These concerns then receded for about a decade, from around the mid-1980s to the mid-1990s, as attention turned from equity to efficiency. Now, the pendulum has begun to swing back, and distributional concerns are on the rise (Gwatkin, 2002). Those who are most vulnerable to evolving health crises tend to be the poor and marginalized who already suffer from numerous inequities and lack of opportunities. Another striking example of the disparity in emerging health issues is found in environmental health. While the industrialized world, representing 15% of the world’s population, consumes more than 60% of world energy, the developing world shoulders the greater health burden from modern environmental hazards. According to the World Health Organization, more than 40% of the total disease burden (in disability adjusted life years lost – DALYs) due to urban air pollution occurs in developing countries. Children are especially vulnerable to chemical, physical and biological hazards in their environments because they are in a very active growth stage and the ability of their bodies to detoxify is not fully developed (Global Health Council, 2008). Despite progress over the last decades, health conditions in many developing countries are still unsatisfactory and, in most instances, health outcomes in these economies remain below those attained in the developed countries, with a significant share of the populations suffering from reventable and/or easily treatable diseases. To a large extent, global inequalities in health outcomes eflect the enormous socio-economic disparities that exist between rich and poor countries. Simultaneously, inequalities in health outcomes are prevalent between or among different socio-economic, ethnic, racial, cultural groups in a country: for example, between male and female, between urban and rural populations, between rich and poor groups, the old and the young, etc. (CDP Working Group on Global Public Health, 2009)
The world is entering a new era in which, paradoxically, improvements in some health indicators and major reversals in other indicators are occurring simultaneously. Rapid changes in an already complex global health situation are taking place in a context in which the global public-health workforce is unprepared to confront these challenges (Beaglehole et al, 2004).
Modern technologies give rise to modern public health problems such as high rates of occupational diseases and industrial injuries led to programs for industrial hygiene and occupational health. Mental health (stress and depression) was identified as a public health issue, and specific nutritional deficiencies were recognized as risk factors for a spectrum of diseases and other health nutritional related diseases such as obesity and malnutrition. The urban development patterns and global trade policies have had a direct impact on the emergence of preventable injuries and tobacco use as major public health threats.
In 2000, unintentional injuries (e.g. road traffic injuries and poisoning) and intentional injuries (e.g. interpersonal violence and war) accounted for 9% of the world deaths and 12% of the global burden of disease and according to WHO’s Tobacco Free Initiative, tobacco use accounted for 6% of the world deaths in 1990; however, if current use patterns persist, deaths due to tobacco use are expected to increase to 18% by the year 2020 (Global health Council, 2008). Another modern public health issue is the concept of Drug abuse is a major public health problem that impacts society on multiple levels. Directly or indirectly, every community is affected by drug abuse and addiction, as is every family. Drugs take a tremendous toll on our society at many levels (National Institute of Drug Abuse, 2008) and the problem of infectious diseases is another issue of present public health. According to the World Health Organization’s 2004 World Health Report, infectious diseases accounted for about 26 percent of the 57 million deaths worldwide in 2002. Collectively, infectious diseases are the second leading cause of death globally, following cardiovascular disease, but among young people (those under the age of 50) infections are overwhelmingly the leading cause of death. In addition, infectious diseases account for nearly 30 percent of all disability-adjusted life years (DALYs), which reflect the number of healthy years lost to illness. Today’s infectious diseases can be a newly emerging disease, is a disease that has never been recognized before, such as HIV/AIDS is a newly emerging disease, as is severe acute respiratory syndrome (SARS), Nipah virus encephalitis, and variant Creutzfeld-Jakob disease while Re-emerging, or resurging, diseases are those that have been around for decades or centuries, but have come back in a different form or a different location. Examples are West Nile virus in the Western hemisphere, monkeypox in the United States, and dengue rebounding in Brazil and other parts of South America and working its way into the Caribbean. Deliberately emerging diseases are those that are intentionally introduced. These are agents of bioterror, the most recent and important example of which is anthrax. Newly emerging, re-emerging, and deliberately emerging diseases are all treated much the same way from a public health and scientific standpoint (Fauci, 2006).
To tackle the major global health challenges effectively, the practice of public health will need to change. It is not sufficient to focus only on urgent health priorities, for example, HIV/AIDS, tuberculosis, and malaria in Africa, or the narrowly focused Millennium Development Goals. Programmes and policies are required that respond to poverty-the basic cause of much of the global burden of disease-prevent the emerging epidemics of non-communicable disease, and address global environmental change, natural, and man-made disasters, and the need for sustainable health development. The justification for action is that health is both an end in itself-a human right-as well as a prerequisite for human development (Beaglehole et al, 2004) and it is important to recognised the potential value of historical research for studying health services and for influencing health care policy. Responsibility for the lack of use of history in formulating policy lies both with policy-makers and historians. History can help them realize the constraints they face and help them plan accordingly, a situation well expressed by Antonio Gramsci in the 1920s: ‘man can affect his own development and that of his surroundings only so far as he has a clear view of what the possibilities of action open to him are. To do this he has to understand the historical situation in which he finds himself: and once he does this, then he can play an active part in modifying that situation.’ history’s contribution complements those from other disciplines. It has an additional unique role. It can help policy-makers understand the limitations they inevitably face and, in doing so, can help them maintain realistic expectations. Carefully formulated policies to shape the future are always going
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