A History of Public Health

Science + Development of Interventions + Organization of public authorities = Public health

Pre-Eighteenth Century Public Health:

• Epidemics

• Rampant spread of diseases

• Plague

• Smallpox

• Cholera

• Disease = Poor moral and spiritual condition

• Proto-isolation and quarantine measures

Eighteenth Century:

• Quarantine measures

  • Isolation of smallpox patients by Massachusetts in 1701

  • Measures spread to coastal cities such as Boston, New York, and Philadelphia by the end of the century

• Establishment of public hospitals for physical illness and public institutions for the mentally ill

  • 1601 Poor Law (England)

  • First voluntary hospitals established in the following places:

    • Philadelphia (1752)

    • New York (1771)

    • Williamsburg, Virginia (1773, mental hospital)

The Nineteenth Century: The Great Sanitary Awakening

The great sanitary awakening: the identification of filth as cause and vehicle of transmission of disease

Cleanliness → Physical and moral health

Mental institutions → Moral treatment and cure

1 out of 10 people died from smallpox in London

Urbanization → Filthy conditions → Spread of disease

NY 16th Ward: >1,200 cases of smallpox and >2,000 cases of typhus

Massachusetts in 1850: 300 deaths per 100,000 people (tuberculosis), 200 infant deaths per 1,000 live births

Industrialization → Overburdened workforce + Crowded dwellings + Increased disease susceptibility → Disease spread to higher classes

Edward Chadwick: a London based lawyer, who served as a secretary of the 1838 Poor Law Commission

• “ … a damning and fully documented indictment of the appalling conditions in which masses of the working people were compelled to live, and die,” - General Report on the Sanitary Conditions of the Labouring Population of Great Britain

• Life expectancy for each social status in Great Britain:

  • Gentry: 36 years

  • Tradesmen: 22 years

  • Laborers: 16 years

• “Sanitary idea”: the assumption the diseases are caused by foul air produced by waste

  • Drainage network for sewage and waste removal

  • National board of health with local boards for each district

    • Run by district appointed medical officers

  • Ideas adopted into the Public Health Act of 1848

Chadwick’s Influence in the United States:

1. Lemuel Shattick’s 1850 book, Report of the Massachusetts Sanitary Commission

   1. Collected vital statistics on the Massachusetts population for mortality and morbidity rate differences by locality

2. Poor urban living conditions → Threat to the entire community

3. Drunkenness + Sloth = Poor health in the slums

4. Massachusetts board of health established in 1869

5. John Griscom’s 1848 report, The Sanitary Condition of the Labouring Population of New York

   1. Establishment of the first public health agency (The New York City Health Department, 1866)

   2. Other states pursued including Louisiana, California, the District of Columbia, Virginia, Minnesota, Maryland, and Alabama (1866)

6. Forty states had established health departments by the end of the 19th Century.

Bacteriology:

Louis Pasteur: a French scientist who proved that anthrax was caused by bacteria

• Progenitor of the germ theory

• Developed artificial immunization against the disease by 1884

New health knowledge → Scientific advancement → Laboratories run by state/local health departments

First laboratories established in Massachusetts in the 1890s between the State Board of Health and the Massachusetts Institute of Technology

W.T. Sedgewick Theory:

Fecal bacteria in water → Typhoid fever

Bacteriology solutions and successes:

• Theobald Smith: vaccines, antitoxins, and diagnostic tests against diseases

• New York City: produced antitoxins for physicians’ use

• “There was little more reason for health departments to assume responsibility for street cleaning and control of nuisances,” - Charles Chapin

• Decline of mortality rates from disease

• Evidence of yellow virus mosquito link found by Walter Reed

• 1907 law passed by Massachusetts requiring the report of individual cases of 16 different diseases, cancer treatment program in 1927

• Establishment of school health clinics:

  • Boston, 1894

  • New York, 1903

  • Rhode Island, 1906

  • Others in subsequent years

Federal Intervention in Public Health:

1. National Hygienic Laboratory, est. 1887 Staten Island, NY

2. Food and Drug Act of 1906

3. Physical and medical examinations of rural citizens and immigrants by 1918

4. Chamberlain-Kahn Act of 1914 

   1. U.S. Interdepartmental Social Hygiene Board for military and quarantined civilians

5. Children’s Bureau in 1912

6. First White House Conference on Children’s Health in 1919

7. National Hygienic Laboratory renamed NationalInstitute of Health in 1930

   1. NIH research expansion to include all studies of diseases and the National Cancer Institute

   2. National Mental Health Act in 1946 (National Institute of Mental Health as part of NIH)

8. Social Security Act (1935)

9. Medicare and Medicaid (1966)

10. Partnership Health Act (1966) - “block grant” approach to federal funding on health programs

11. Comprehensive Health Planning Act (1967) - established nationwide health planning agencies across the country

State Intervention in Public Health:

State health programs → Paralleled that of federal programs and Medicare

• Maternal and child health

• Family planning

• Immunization

• Disease control

National Health Service Corps Program: a federal program assigning physicians to serve underserved communities

Per capita health expenditures: $198 in 1965 → $334 in 1970 (25-37 percent of shares)

Increasing shares in healthcare spending → Health Maintenance Act of 1973

Current Health issues:

• HIV/AIDS and STDs

• Asbestos exposure

• Pertussis

• Alzheimer’s disease

• Alcoholism and drug abuse

• Hazardous health waste

• Growth of government spending in health

Summary: Public health has been around for millennia. At the start of human history, many communities have been affected by rampant diseases that reached epidemic levels or near such proportions. Before the eighteenth century, public health maladies were largely blamed on spiritual and religious grounds. The miasma theory and others have contributed to the rampant spread of diseases and multiple pandemics killing off significant populations across communities. Because of scientific and medical advances, those theories have been proven false and ultimately, replaced with the germ theory. Thanks to Louis Pasteur and Edward Chadwick, the germ theory prevailed over many others of the nineteenth century. Such measures of public health began in Great Britain and in Europe. Eventually, those influences spread to America and were proposed and utilized to counter the perilous effects of industrialization and urbanization. Despite huge success in reducing disease to local levels, other diseases have plugged the gap and reached epidemic proportions.