publichealth-1 A

Hello everybody,

Welcome to this introductory class on the history of modern
public health. Hopefully already you should have a reasonable
idea about what this course is going to deal with. We are going
to be looking at the development of public health from around
about the period of 1750, and we are going to be tracing its
development to the late 20th century. We are going to be doing
that by looking at specific themes within the history of public
health.

But what I want to do in this class is try and talk to you about
the current situation in public health in terms of the main ideas
and the main themes that dominate the discipline today and relate
that back to its historical development but particularly relate
it back to critiques of public health and medicine that took
place between the 1950s and the 1980s. And so what we are going
to be looking at essentially is what has been termed in the late
20th century the "new public health." And we are going to be
looking at how this new public health is actually a
reconstitution and a reformulation of old forms of public health
plus additional concepts and methods that relate particularly to
the late 20th century.

So, it's great to have you along, and I want to begin this
session simply by outlining some contemporary ideas about what
public health actually is today. When I teach this class on site,
I usually ask the students what they think public health is, what
they think the main preoccupations of public health are, and what
sorts of topics and themes public health should be concerning
itself with in the modern world. And quite often, we come up with
a number of ideas and themes and topics that can be fitted in to
these 3 requirements of prevention that have been identified by
Tolchinski and Varovikova. They argue that prevention has 3 core
requirements:

First of all, we have definition. And here, what they mean is
that we need to define health itself and what it is that public
health should be expected to achieve.

Secondly, a second requirement of prevention is that of
measurement. Public health needs to use epidemiological methods
to identify problems and evaluate the effectiveness of
interventions. What is also important here is the measurement of
population itself, and in that respect, what we are talking about
is defining populations at risk, defining those segments and
sectors of the population who might become the focus of specific
interventions.

And thirdly, they argue that one requirement to prevention is
that we develop effective interventions. Now the definition of
health and measurements are part of defining what actually is an
effective intervention. But here, we are looking at interventions
on different scales and different levels. So what is effective in
terms of health promotion? How do we foster individual and
community standards of behavior that are conducive to good
health? What about interventions at the primary level? How do we
go about effectively preventing a disease from occurring in
particular situations? And then we have the question of
effectiveness at the secondary level. Early diagnosis is
important. Interventions such as the notification of diseases
help facilitate prompt and effective treatments.

And at a fourth level, we can look at effective interventions in
terms of tertiary prevention. How do we go about preventing long-
term impairments or disabilities and promoting functional
rehabilitation?

So these are the key requirements of prevention. And one of the
points of this introductory class is to highlight for you and
illustrate for you how these different topics and themes do not
remain constant over time, and hopefully you begin to get a feel
for the historical development of these themes and how we are
going to use these historical developments to examine the
development of public health over the period of 1750 to 2000.

One of the key points about defining public health and what
public health should be expected to achieve is establishing the
causal mechanisms of disease. And when I talk about causes of
disease, I'm not simply talking about the biological causes of
disease, we are also looking at the modes of transmission, the
social and economic conditions that foster disease, and so on. So
we are not just thinking about purely medical ideas about
causation. We are thinking rather more about wide aspects of
disease generation in terms of the environment and society and so
on.

And this illustration shows how public health conceives of the
cause of disease. And here we are looking on the left-hand side
of this diagram at a typhoid case who is in bed. And that typhoid
case has possibly been caused by the transmission of infected
milk from rural areas to the city, and that infected milk is
brought into the home, and eventually what you have is a typhoid
case that fills the city hospitals with victims. And what you
have here, you can see here very clearly the relationship between
the domestic environment and the rural and city environment in
terms of the provision of milk supplies and how that has an
effect on the demand for health services within a city, and
certainly how public health becomes to be interested with health
services in relation to the provision of institutional space for
typhoid victims. What this in effect is all about is tracing the
origins of disease and the causation of disease in a particular
supply and attempting to break that causal link in order to
reduce the demand on hospital services and on public health
administration. So we are talking about wide concepts here of
causes of disease and not just simply, as you can see in this
slide, the bacteriological and the biological causes of disease.

Nonetheless, we are concerned historically about how spaces such
as bacteriological laboratories fitted into concepts of disease
theory and of disease causation, in other words, how public
health laboratories came to be important for defining and
identifying specific bacteriological causes of disease that
enabled public health authorities to move away from concerns
about the wider public health environment and consider in more
detail the role of individual behaviors, the role of lifestyles,
and the interaction of people and individuals who might transmit
germs and specific germs through a variety of mechanisms, be that
airborne, water- and food-borne, and so on.

So again, laboratories are important for identifying the specific
germs that cause disease, but they are also important for
changing the ways in which public health addresses the problems
of disease either from an environmental or an individual
perspective.

Another aspect that I think we can draw on in addition to the
causation of disease and the different ways in which disease is
transmitted, the different ways in which disease moves around in
a population, is how knowledge of prevalent diseases comes about.
Clearly, this is part of what we were looking at earlier in
relation to definition and knowledge of disease.

On the left-hand side of this slide, you can see a copy of the
front of the Bills of Mortality. These were basically a list of
all the deaths that occurred in London, and this particular
example is taken from 1665, and each of the deaths were
categorized into a specific cause. And it is in these sorts of
ways, the collection of information about individual deaths and
the categorization of those individual deaths into specific
causes that enabled public health authorities to garner and
accumulate information about epidemics that were either breaking
out, about epidemics that might be concentrated in specific
geographical areas, and also to accumulate information over a
long period of time so that epidemic diseases could be looked at
in relation to their seasonality, in relation to the way in which
they came and went in long cycles over periods of years, and also
to get some idea about how severe an epidemic was in relation to
the number of deaths it was causing on a daily, weekly, monthly
or annual basis. And this tradition, which has its roots
historically - we are going back here to the 17th century - you
can see this tradition continues today.

On the right-hand side of this diagram you have the front cover
of the journal "Emerging Infectious Diseases." And this journal
was begun in the 1990s, and effectively it is a forum by which
academics and scholars and public health officials and
administrators can discuss and debate issues around infectious
diseases that are emerging globally, internationally, and in
specific locations. And this particular issue is about the
reemergence of tuberculosis. What you have on the front cover is
a representation of the artist Modigliani. This is a self-
portrait painted in 1919, just one year before his death from
tuberculosis.

Just as an aside, the picture was obviously being used on the
front cover of this journal to reemphasize the fact that
tuberculosis was clearly a disease that was at one point
considered to be a disease of the past. It had pretty much
disappeared from Western industrialized societies, but with the
emergence of HIV/AIDS and problems of homelessness - as I am sure
many you are aware - tuberculosis was reconceptualized in the
1990s as a public health problem.

But I think this cover of the artist close to death with his thin
face, his eerie pallor and calmness,  -  and has been interpreted
as being due to tuberculosis - is evocative of the ways in which
history can be used to reframe a contemporary problem. So central
to public health is the knowledge about how disease is caused,
central is knowledge about where disease occurs, how many cases
occur - questions of incidence and prevalence are very important
- but what is also significant is how this knowledge about
epidemiology and about health itself links to medical notions and
medical ideas of the body. What is particularly important
historically is the way in which the ideas about the body and the
ideas about how the body fits into and has a relationship with
the wider environment are crucial for public health and public
health intervention.

And from the 7th to the 5th centuries B.C., the Hellenic
tradition of medicine emerged. New schools of philosophy were
created in Asia Minor, Sicily, Rhodes, and Corse. And in this
Hellenic tradition, secular conceptions of medicine absorbed
influences from the Mediterranean, from Asia, and from Oriental
cultures. And eventually these conceptions were translated into
the Hippocratic Corpus which stressed that disease was a natural
event not caused by supernatural forces.

What you have in this slide is the representation of the 4 humors
of the Hippocratic Corpus.
As you can see, these are at the center of this circular diagram.
First of all, you have fire which is represented by yellow bile.
Secondly you have air which is represented by blood. Thirdly you
have water which is represented by phlegm, and finally, earth is
signified by black bile. And so the humeral constituents of the
body itself are reflective of the environment. The blood, the
phlegm, the yellow bile and the black bile correspond to the
fire, the air, the water, and the earth. So the body exists in
harmony with the environment, and the body's well-being is
mediated by the environment and by the seasonality of the years.
So in the Hippocratic sense, the human body has a very close
relationship to its environment, and disease is part of the
result of the interactions of human beings and their physical
living conditions.

As medicine develops and becomes more rational, ideas about the
body change. Knowledge of the body shifts as anatomy becomes more
important. And this is an example. It is an anatomical
illustration of a woman taken from the later Middle Ages. The key
point here is that the representation of the squatting figure is
used to show diseases, it is used to show wounds and the
influence of the zodiac on the body. In this concept, realism
tended to be irrelevant. The aim here was to illustrate the
standard conclusions about bodily parts that had been arrived at
by learned physicians.

And moving on from philosophers in the Hippocratic period to
learned physicians in the Middle Ages, we have a shift now where
self-knowledge of the body is increasingly important. There is a
greater degree of responsibility placed upon individuals to
monitor, detect, and manage their own health.

And it is these important shifts that we can detect, as hopefully
we will see throughout this course, in the history of public
health where we move from a point where the dominant concern is
about the environment and about the physical conditions of
existence towards a point in which  individualistic modes of
health, individual behaviors and lifestyles become a legitimate
focus for public health. So knowledge of disease and disease
causation and knowledge of the body and internalist ideas of how
the body works are important for the development of public
health. What is also important of course is the effectiveness of
interventions and therapies, and we will consider those points
when we come back in the next section.