Introduction

This chapter and the others that follow have the study of population health as their focus (as opposed to a focus on individual care and treatment). Clearly, however, we are concerned with the way in which population health is influenced by biomedical theories and practices, and the way population health is funded and influenced by the importance placed on therapeutic medicine. The discussions that follow include a brief overview of the ancient history of public health and the modern history of Western public health dating from 1850. This date signifies the beginnings of a more organised, collective effort to protect the public’s health. These discussions will help you further expand your definition of public health.

You will have an entertaining journey through public health achievements and less successful outcomes by examining historical developments that have led us to a modern understanding of public health. The ancient Greeks and Romans, for example, had public health measures to ensure the safety and health of their populations, for a range of social and economic reasons. Convicts arrived in Australia with many health problems and were put to work to satisfy the needs of a fledgling colony. It is important to understand the historical journey of public health and the way it is critically analysed, as it is a window into the present and the future.

The importance of the past in public health

Examining the historical evolution of public health is important because, as George Rosen said:

In a similar vein, Tosh (1984), in the Pursuit of History, commented that to know the past is to understand that things have not always been the same, and that they need not remain the same in the future.

History is also relevant because we need to be able to ‘observe public health over a long period of time in order to be able to evaluate progress, or the lack of progress, in improving it’ (Scally & Womack 2004 p 751). In an interesting article, Ogilvie and Hamlet (2005) present a dialogue between Socrates and Panacea, the goddess of healing, in the year 2055 about the history of the Western obesity epidemic. Socrates and Panacea discuss why information to the public about this issue had little or no impact on the community; they talk about the shortcomings of environmental changes and the expectations of society regarding advancing economic development and access to healthy foods. At the conclusion of the article Socrates asks Panacea why the discipline that was ‘fond of phrases like “primary prevention” and “going upstream” never came up with a serious challenge to obesity’ (Ogilvie & Hamlet 2005 p 1547): a sobering thought for us to contemplate in the early part of the twenty-first century.

An understanding of how public health practitioners can influence the health of the population requires knowledge of how the discipline has evolved, and its successes and failures. The threat of infectious diseases, that as a public health community we thought had mostly been eradicated, for example, severe acute respiratory syndrome (SARS), are re-emerging as threats to the population worldwide.

Historical awareness ‘helps us to be alert to the resurgence of practice that has held sway in the past but been out of fashion in more recent times’ (Scally & Womack 2004 p 752). It is important to be able to appreciate why particular approaches to public health lost favour in the past, and to determine the relevance of old approaches and their likely usefulness in thinking about new approaches. For example, the rise of coronary heart disease and cancer in the period between the two world wars led to an emphasis on adult risk factors. In more recent years a return to a concept prevalent in the first half of the twentieth century, that of lifecourse epidemiology where early life experiences influence adult mortality risk, has become more important.

Historical accounts of public health until the past 40 years were strongly influenced by public health activity in the nineteenth century and by the heroic works of people such as Edwin Chadwick and John Snow. The work of Englishman John Snow, who had the handle from the Broad Street water pump removed leading to a rapid decline in the number of cholera cases, demonstrated the early use of epidemiological analysis to pinpoint more extensive outbreaks of the disease. Edwin Chadwick’s work on improving drinking water and sanitation actually marked the end of the era of social reform in public health in favour of advances in drainage systems and other more practical solutions (Berridge 2000). When the parameters of public health are confined largely to drawing connections between poor sanitation and disease and the control of infectious diseases, it is easy to argue that, although organised public health efforts did not appear until the 1850s, the foundations had been laid back through time, such as the Roman baths and aqueducts (Porter 1999). However, since the early 1960s a social history of public health has emerged where the focus is on ‘economic, political, social and ideological responses to disease and the exploration of complex ways in which change both caused and was determined by the impact of epidemics’ (Porter 1999 p 2).

Other more recent tensions evident in public health, such as the emergence of HIV/AIDS in the late 1980s, ‘revived the historical study of stigma … and forcefully added to new debates about the social construction of everyday life’ (Porter 1999 p 3). Placing current practice, organisational structures and political and public health philosophies within a historical framework can help us to resolve the tensions that exist within our field and increase our sense of identity and purpose (Scally & Womack 2004).

Historically, we can clearly see how strongly politics have influenced public health at different times. It is interesting to look back at the history of public health and to explore the political and social factors that have played a role in its evolution at various times during the past 160 years (Perdiguero et al. 2001).

The history of public health provides a useful vehicle for teaching the principles of public health. This is particularly so for health workers such as environmental health officers, nurses, general practitioners and public health workers who have a population health and prevention perspective in their work. It enriches our critical perspective of the ‘social effects of initiatives undertaken in the name of public health, shows the shortcomings of public health interventions based on single factors and uses a wider time scope in the assessment of current problems’ (Perdiguero et al. 2001 p 667). For example, there are similar issues between the story of opium at the end of the nineteenth century and its cultural and legal identification, and that of tobacco and smoking at the end of the twentieth century (Berridge 2000). If you look at the website for the organisation Action on Smoking and Health (ASH 2007), there are key dates in the history of anti-tobacco campaigning in the United Kingdom.

It is interesting to note how many years passed between significant developments. It was not until the second half of the twentieth century that significant progress was made on a range of fronts; however, the power of the tobacco industry still remains a major stumbling block to achieving the overall objectives of the anti-smoking campaign. The ups and downs of this story are a message to today’s practitioners to consider the timescale and effort entailed in dealing with vested interests (Scally & Womack 2004).

Scally and Womack’s (2004) quote is worth including in full here because it sums up why public health history is such an important aspect of our understanding of modern public health:

Advancing population health – medical intervention or collective action?

One of the most prominent authors writing about the factors that impacted on the changes to population health in nineteenth century Europe was Thomas McKeown. McKeown suggested that medical intervention, while playing a role in advancing health, was not responsible for the significant reduction in patterns of mortality and morbidity. He pointed out that medicine had not offered the nature of change that had resulted and that diseases were declining prior to the advent of effective therapy (Lewis 2003). Szreter (2002), among others, has seriously challenged McKeown’s thesis. Szreter (2002, 2003) indicated that McKeown was right that material living standards, such as food availability, and therefore economics, were crucial to the health of the population. However, he also argued vigorously that McKeown was wrong in failing to ‘foreground the importance of politics, ideologies, states, and institutions in producing the kind of societies that distribute their material wealth, food, and living standards in a health-enhancing way for all concerned’ (Szreter 2002 p 724, 2003 p 427).

McKeown’s critique of the medical establishment also found support in discourse emerging from the United States, Canada and the United Kingdom that focused on the importance of individual responsibility for health. (We discuss these issues later in the chapter.) (Colgrove 2002). However, Colgrove (2002) and Szreter (2002) have both suggested that McKeown had allowed his assumptions about the limited value of medical interventions and the need for social reform to predetermine his analytical categories and thus bias his interpretation of evidence.

What is clear in McKeown’s argument is that nutrition and public health clearly have roles in the explanation, along, however, with living and working conditions, urbanisation, education, aetiology of diseases, doctors and medical knowledge, mothers’ attitudes, knowledge and behaviour, politics, reformers and climate (Lewis 2003).

However, McKeown’s research has continued to hold a place in public health history because his research posed a fundamental question:

In answering this question, Colgrove (2002) concluded that the choice of targeted interventions versus social change should not be viewed as dichotomous or opposing choices, but as complementary to each other. The challenge for health workers is to find ways to ‘integrate technical preventive and curative measures with more broad based efforts to improve all of the conditions in which people live’ (Colgrove 2002 p 729).

For the sake of the public’s health? The ancient history of public health

The ancient history of public health is permeated with examples of efforts to protect health. However, it was unlikely that many of those efforts were actually designed to protect the public’s health but to enable other activity that would deliver a social or economic benefit to the State, through having relatively healthy individuals and communities. In ancient societies collective action to advance the health of populations was reserved for promoting the comfort of elites (Porter 1999).

Actions to protect the health of the public emerge throughout history, especially those activities relating to sanitary measures to ensure safe water and food supplies. For example, the earliest records of Chinese public health practice include providing drinking wells, building ditches around houses, protecting drinking water and killing rats. Two centuries before the birth of Christ, the Chinese had invented rudimentary sewers, water spray carts and toilets. There was an emphasis on providing personal hygiene and preventive practices. In addition, herbal medicines, diagnostic procedures and preventive concepts, such as feeling the pulse and acupuncture, were in use.

In Egyptian and Babylonian societies there were systems for sewage disposal and rainwater collection. Hygiene customs included personal cleanliness, frequent bathing, simple dressing and the use of ‘earth closets’ (the forerunner of the modern-day toilet). The Code of Hammurabi, adopted by Babylonian society, guided the conduct of physicians and prescribed healthful practices. Temperance was recommended for all, at least three thousand years ago.

For Greek civilisation, the emphasis was placed on the individual. Consequently, the Greeks focused on the harmonious development of all faculties where exercise and personal cleanliness were important. Little attention was afforded to environmental protection. The Hippocratic Oath (attributed to Hippocrates) still guides the ethical practice of medical practitioners. Hippocrates is also credited with a treatise on environment and health. Hippocrates in the fifth century BC, and Galen in the second century AD, described what were called the four humours: phlegm (phlegmatic), blood (sanguine), black bile (melancholy) and yellow bile (choleric) (Lawson & Bauman 2001). When in harmony, these four humours were believed to be responsible for health.

By contrast, in the Roman Empire, the State, not the individual, was considered more important. This meant that the regulation of building construction, sewage disposal and the destruction of decaying goods and buildings were of fundamental concern. Town planning, street and gutter paving, establishing drainage networks and public bathing were very important aspects of Roman society because they reinforced their philosophy of the importance of the State. Both the Greeks and the Romans protected the health of the wealthy, and their military, by providing fresh food, water supply aqueducts and environmental protection laws.

Unlike the Greek and Roman eras, the Middle Ages marked a dark period in the history of public health. Throughout Europe there were major epidemics of infectious diseases. During these times, the emphasis on spiritual aspects of life increased substantially and if people were unwell, they were often thought to have done something against the will of God. Islam rose to prominence during the sixth and seventh centuries and a series of pilgrimages to Mecca saw several cholera epidemics emerge; leprosy flourished in Egypt, Asia Minor and Europe.

Between 1096 and 1248, there were six great Crusades. These events all contributed to the spread of disease, as men were travelling together in large groups where diseases spread easily, and, with limited means to treat such outbreaks, large numbers of men were lost to disease rather than to war. In the period up to 1453, a number of pandemics and epidemics emerged. Diseases that flourished during the time included cholera, bubonic plague and pulmonary anthrax. A variety of factors contributed to the spread of epidemics and pandemics, including poor personal hygiene, inadequate nutrition, clustering of population groups and increased contact through trade. Quarantine was the major form of intervention and prevention of further spread of disease because there was no scientific understanding of the cause and the nature of diseases, or how they were spread.

During the Renaissance, the period from 1453 to 1600, the emergence of individual scientific endeavour led to some understanding of the cause and the natural history of infectious disease. This increasing scientific knowledge enabled treatment and prevention activities to be put in place that were more closely linked with an understanding of disease processes. Although these processes were not at all sophisticated, their implementation marked the beginnings of scientific medicine and the development of the medical dominance over public health. The Renaissance was also a time of increasing social density, the expansion and further development of trade between countries and general population movements, all which encouraged the development and spread of disease.

The changing history of definitions of disease

An understanding of the history of public health would not be complete without some consideration of definitions of health and disease. The occurrence of death and disease can only rarely be described as a matter of chance. They are influenced by a number of determinants, including: the social and spatial organisation of a population; the individual’s genetic endowment and exposure to a range of risk factors; the physical environment; patterns of relationships and mobility; and access to health services (Perdiguero et al. 2001; Scott 2004).

As the nineteenth century emerged, a number of disease theories formed the framework for the debate about causes of ill health. The germ (or contagion) theory held that for every disease there was a corresponding pathogen. From a modern point of view, it is difficult to understand that the phenomenon of contagion was not recognised with the first contagious disease (Fleming & Parker 2007). It was only in the nineteenth century that this theory gained further prominence when the theory of microorganisms could be substantiated with the aid of suitable medical apparatus such as a rudimentary microscope. By contrast, the environmental theory supported the sanitary reforms that represented the first great revolution in public health. Unfortunately, that support was based on the incorrect belief that illness was a sign of dirty air, or, as it was known at the time, ‘miasma’. While the theory of divine retribution suggested that a person’s illness was a punishment for sinning, disease as a personal defect was another prominent theory on the cause of disease that suggested illness was attributable to an individual’s social class or behaviour (Pickett & Hanlon 1990).

What becomes clear to us from the preceding discussion is the complexity related to defining disease and the ways it was perceived at different times in history. The germ theory supported the development of scientific medicine and treatment of the individual, although, with the recognition of contagious diseases, public health measures such as quarantine were introduced. The divine retribution and personal defect theories cited the cause of illness as either spiritual or the individual’s class or behaviour. The personal defect theory had as its core the notion of individual responsibility for illness.

Edwin Chadwick supported the environmental theory of disease and pushed for sanitary reform; the culture of nineteenth-century Britain gave him the opportunity to write about the poor as the population group most often exposed to disease. They were ‘… less susceptible to moral influences, and the effects of education are more transient than with a healthy population; these adverse circumstances tend to produce an adult population short-lived, improvident, reckless and intemperate, and with habitual avidity to sexual gratification …’ (Pickett & Hanlon 1990 p 28).

Only the environmental theory of disease can be clearly linked with sanitary reform measures; however, even though this strategy improved the health of the population, its use was initially based on incorrect assumptions about the cause of disease. As time passed, it became clear that changing patterns of mortality and morbidity and significant decreases in the rate of death due to infectious diseases were clearly attributable, in part, to sanitary reforms. In addition, the militancy of the nineteenth-century working class resulted in improved wages and working conditions, and improved living standards and nutritional status, which significantly heightened people’s resistance to microorganisms in air, food and drinking water. The interrelationship between the two theories of disease is evident when one considers that clean water and proper sewerage are environmental changes that work, in part, because they reduce or eliminate exposure to microbes (Fleming & Parker 2007).

In Chapter 1, we examined concepts of health and illness in contemporary society and the diversity of perspectives that exist between, for example, professional and lay definitions. The ways in which professionals define health and illness are different from the ways in which other members of society conceive of them. Across time and cultures, depending on people’s concerns, there have always been varied conceptions of health and illness (Waltner-Toews 2000).

The colonial era: colonisation and health

The colonial period extended from around 1600 to 1800. In the UK, for example, boards of health were established to examine prevalent health problems, and to protect the population from the spread of diseases caused by unsafe drinking water and tainted food supplies. Boards of Health were the first employers of public health professionals. However, the ineffectiveness of the original boards of health in controlling infectious disease was partly due to the limited strategies they had at their disposal. Treatment options were minimal and often dangerous to the patient, and prevention consisted primarily of quarantine. These quarantine measures were resented by the merchants, who understandably wanted to retain the flow of goods and customers. The religious orders also resented the boards and their powers to ban public congregations during an epidemic (Lewis 2003).

Improved understanding of the causes of ill health and advances in the scientific basis of medicine further increased the possibility that people might recover from an illness when treated with procedures that were based on increasing evidence. Community sanitation legislation was introduced in England in 1837 as a mechanism to ensure at least fundamental public health activity was being pursued. Edwin Chadwick was the author of the Report on the Sanitary Condition of the Labouring Population of Great Britain (1842) and the initial driving force behind public health reform. In 1848, the Public Health Act came into being as a mechanism to remedy unsanitary conditions and to provide adequate drainage and sanitation. This Act was primarily due to the efforts of Edwin Chadwick (Porter 1999). By 1872, a new public health act required every statutory authority to appoint a medical officer of health.

In the colonial era, despite improved understanding of the causes of disease, actions designed to protect the public’s health often came after an epidemic had established itself in a population. Isolation and quarantine were still the major mechanisms to deal with outbreaks. Public health advances in the eighteenth century included developing rudimentary occupational hygiene practices, considering the safety and health of workers, introducing procedures to improve infant hygiene practices and some attention to mental health issues (Lewis 2003).

Certainly, the public health movement was essential for the survival of the burgeoning cities created by nineteenth-century industrial capitalism (Susser 1981). Public health remained progressive, even though at times social and economic reforms were absent. The pursuit of community health at a population level was new, and the assumption of State responsibility for maintaining community health was equally so (aside from acute emergencies such as plague or other epidemics). The originality of public health was to attack disease and poverty – in the community at large – at their perceived source in the environment.