The development of public health began in ancient times. Health measures involved, for example, the quarantine of leprosy victims in the Middle Ages. Early international efforts in disease control occurred in national quarantines in Europe and the middle east. Over time, correlations between disease and environment were increasingly understood and refined, and from the 14th century onwards the plague epidemics spurred efforts to improve sanitation.
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During the last 150 years two factors have shaped the modern public health system:
- The proliferation of scientific knowledge about the source and control of disease
- Increasing acceptance of disease control as possible and as a public responsibility
This article presents a brief overview of the history of public health from the Middle Ages towards the present day, first beginning with a brief characterization of public health.
What is public health?
Public health pertains to the art and science of preventing disease and involves:
- prolonging life and promoting health ––both mental and physical
- sanitation
- personal hygiene
- control of infectious diseases
- organization of health services
Epidemics, such as the plague, spurred public efforts to shield people from disease, although such disease was often considered a sign of poor moral and spiritual condition. It was the poor and the common soldier or sailor who typically suffered the brunt of epidemic diseases, premature death, and squalid living conditions.
In England, since the late 16th century, the Poor Laws were formulated to help the deserving, but struggling, poor affected by:
- misfortune
- death of a breadwinner
- unemployment
- sickness
- inadequate wages
The level of maintenance was lowly and, sometimes, the able-bodied were required to work for their keep in a poorhouse or workhouse. Poor law support was deemed a last resort, for otherwise, it might negate the will to work.
Medical services did not comprise a large fraction of Poor Law provision for the unfortunate, but many Poor Law Guardians hired the services of local doctors.
18th century
By the 18th century, quarantine was commonly used for the containment of contagious disease. By this time, the right of each human being to health (and liberty and the pursuit of happiness) was brought into focus. Though the relationship between individual rights and the responsibility of the state was not always clear.
The Poor Laws were increasingly recognized as inappropriate and ineffective for the new economic circumstances of the age. In America as the population size of specific communities expanded, more formal arrangements were required for the care of the sick. In Europe, an increasing population size coincided with a heightened awareness of infant death and of the unsavory conditions to be found in prisons and mental institutions.
By the end of the 18th century in America, several cities including Boston and New York had established permanent measures for quarantine and isolation. These measures reflected a shift in understanding about disease from the individual, and as natural effects of the human condition, and more toward state responsibility ––where the disease was potentially controllable through public action.
19th century
The nineteenth century was a turning point in public health. From the 4th and 5th century BCE the causal relationship between disease and the environment was established for example in the work of Hippocrates, whose book Airs, Waters and Places remained the theoretical framework for epidemic disease until the 19th century when the new sciences of bacteriology and immunology emerged.
The 19th Century saw what has been dubbed “the great sanitary awakening” (Winslow, 1923) ––where filth was identified as both a cause of disease and a mode of transmission ––whereby social reforms became centered upon the issue of sanitation. Improvements in sanitary conditions occurred simultaneously in a few European countries as well as in the United States.
During the advance of the industrial revolution, the health and welfare of ordinary workers deteriorated. The increasing urbanization of populations exacerbated the occurrence of filthy environmental conditions, particularly in working-class areas, and thereby the incidence of disease. In London, for instance, smallpox, cholera, typhoid, and tuberculosis became widespread.
By the mid-nineteenth century, the hospital was a stable feature of the medical landscape. Though the limitations were that hospitals took in patients only after they succumbed to illness: they were curative rather than preventative.
In England Edwin Chadwick (1800-90) went beyond the known correlation between poverty and disease and argued that disease caused poverty too in his Report on the Sanitary Conditions of the Labouring Population of Great Britain (1842). Chadwick advocated for a clean system of water supply and the removal of refuge.
In England, the Public Health Act of 1875 touched housing, ventilation, sewage drainage, water supply, nuisances, dangerous trades, contagious diseases, and a plethora of other public issues thus providing the basis for the most successful health system in the world. The 1875 Act provided the standards for British sanitary administration until after World War I.
Advances in public health in England exerted a strong influence upon the US, where there was likewise a need for an effective administrative regimen for the supervision and regulation of community health. In Russia, after the communist revolution, rural medical services were massively expanded upon, to provide medical care for the entire population. The system has since inspired similar ventures in other European and Asian countries.
20th century
The beginning of the 20th century saw further advances in community healthcare. In the United Kingdom, the royal commission re-examined the Poor Law in 1909. This led to a proposal for a more cohesive state medical service ––a precursor to the 1946 National Health Service Act.
More recently, public health interests have turned to disorders such as cancer, cardiovascular disease, lung disease, and arthritis. The interrelationship between these disorders and the environment has been subject to investigation. Health education aimed at the prevention of disease became increasingly prioritized.
References:
- Bynum, W. (1994). ‘Medicine in the Community’ in Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press), pp. 55-91.
- Institute of Medicine (US) Committee for the Study of the Future of Public Health. (1988). A History of the Public Health System. [Online]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK218224/ (Accessed on 16 August 2021).
- Rhodes, P and J. H. Bryant (2021). Public Health. [Online] Encyclopedia Britannica. Available at: https://www.britannica.com/topic/public-health (Accessed on 15 August 2021).
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