file: hph_lec1c.mp3
A History of Modern Public Health: Introduction (continued)
So what is the new public health? Well, the main feature of the
public health that you will be practicing as public health
professionals is a focus on the health status of populations.
That is a traditional concern, an ideal of public health
throughout history. There is also, however, an accent on
lifestyle and individual choice. Here what we are talking about
in terms of lifestyle is the relation with body shape, with
diets, and with exercise and habits in relation to alcohol and
tobacco consumption that are considered to be harmful to health.
The new public health also emphasizes that risks to health exist
that are beyond the control of individuals. These risks might
include pollution, hazardous chemicals, global warming, the
greenhouse effect, and the loss of biodiversity.
So the new public health is therefore comprehensive in scope. It
has the potential to intervene in all spheres of both public and
of private life. It is concerned on the one hand with populations
and with lifestyles, behaviors, and individuals on the other. On
top of that is a layer of risk that individuals cannot control.
And what this new public health does is consciously emphasize
continuity with what has been termed the old public health.
The old public health has been defined as the golden age of
sanitary reform in Western Europe in the 19th century when
governments struggled with the environmental problems of large
cities. Typically, this period is seen as one of scientific and
technical breakthroughs in relation to the control of filth,
odor, and infections, and this control contributed to the rise in
life expectancy and well-being.
But it is important to understand why this formulation of public
health emerged in the late 20th century. It is very much related
to a reappraisal of medicine that became important by the early
1960s. It was in this period that the success of the therapeutic
era of medicine was beginning to be questioned, and this was
combined with a concern over the spiraling costs of health care
and an aging population that would offer no respite from those
spiraling health care costs. The attack on medicine came from
three distinguished sources: Rene Dubos, Thomas MacEwen and Ivan
Ilich. We are going to spend much out of the rest of this class
in looking at the arguments of these three individuals.
First, however, I think it is useful to look at the
epidemiological landscape that was beginning to concern
epidemiologists around about the 1960s. Effectively what you have
here are two scenarios: you have a pattern of mortality trends on
the left-hand side of a population
with a relatively young age structure, and on the right-hand side
a population with a relatively old age structure. It was this
representation on the right-hand side that was being considered
as potentially problematic in the future. With higher proportions
of older people in the population, you can see that the
percentage of all deaths that are taken up by chronic conditions
such as cancer and circulatory diseases is much greater than it
is for a population with a relatively young structure. And for
epidemiologists and heath care specialists in the 1950s and
1960s, this presented a problem in terms of maintaining the
health of elderly people, in terms of social welfare and social
care into old age in terms of keeping people with chronic
conditions alive for longer.
This slide shows the comparison of health care expenditures as
shares of the gross domestic product in economically developed
countries between 1970 and 1992. The general point here is that
overall costs are going up. You can see from Australia at the top
to the United States at the bottom, over this 20-year period, it
was not uncommon for health care expenditures as a share of
GDP to increase by at least 20 or 30 percent. In the case of the
United States, the amount of GDP that was spent on health care
actually doubled in this 22-year period.
So the causes of this increased expenditure were partly the aging
population, it was partly the result of increasing specialization
within medicine, and it was also the problem of increasing
technological costs. What this did was it shifted the arguments
away from therapy and away from hospital medicine towards a new
and reformulated idea of preventive health.
One of the first commentators to notice and identify this problem
was Rene Dubos. He was born in France in 1901. He studied there,
and he also studied in the United States, and he became a
naturalized US citizen in 1938. He was professor of comparative
pathology and professor of tropical medicine at Harvard Medical
School. He wrote a book, the "Mirage of Health" in 1959 that had
four key themes: he looked at the decline of mortality, he argued
that Western health was not optimal, he argued that disease
outcomes were a result of multifactual etiologies, and he
considered the role of human adaptation to environment as being
crucial.
Let us take each of these in turn. First of all, the decline in
mortality: Dubos argued that reductions in mortality from 1850
were not due to advances made in laboratory medicine. He argued
that the tide of infectious and nutritional diseases was rapidly
receding when the laboratory scientists moved into action at the
end of the past century. So what Duboss is doing here is
challenging the notions that were popular in the 1950s and early
1960s that medicine had made the most substantial contribution to
the reductions in mortality that had taken place in the previous
century.
In terms of optimal health, he argued that Western health could
not claim to be the best in the history of the world. He said
that life expectation at age 45 had improved little over the
previous decades. (Remember, he was writing in the 1950s.) He
argued that one in four Americans spent at least some time in a
mental asylum. And thirdly, he pointed to the increasing levels
of drug dependency as being indicative of the fact that health
was not at its most optimal state. You can see here on the right-
hand side an image from the mid-1940s, an advertisement for
Philips milk of magnesia which is being marketed as an ideal
laxative antacid. It is this sort of advertisement that Dubos was
pointing to in relation to the increased dependency of the
American population on drugs.
A third point he made is that whilst medicine is constructive and
a force for good overall, biomedicine's doctrine of specific
etiology and magic bullets was problematic. The idea that
specific diseases were caused by specific germs that could be
eradicated by a specific drug was not helpful because diseases
have multiple causes. He argued that most disease states are the
indirect outcome of a constellation of circumstances rather than
the direct result of single determinant factors. You can see here
a picture of Alexander Fleming from 1943 who discovered
penicillin in a mold in 1928. Dubos was effectively saying that
yes, penicillin was important, but the idea that you can have a
magic bullet that will cure every specific disease was misleading
and tended to ignore the causes of disease that were rooted in
the social, physical, and cultural environment where people
lived.
And finally, his fourth theme was that human adaptation to the
environment was crucial. The ways in which human beings adapted
to the environment from agricultural societies through to
urbanized societies changed the patterns of disease that could be
observed in populations. And this shift from a predominantly
rural to a predominantly urban global population is demonstrated
in this slide where we can see that 2000 years ago, village
farming was predominant, the assumed density per square kilometer
was around about one (a person per square kilometer), and the
total global population was about 133 million. By 310 years
before Dubos's writing, we have the shift from village farming
and urban to farming and industrial. Assumed density had
increased to 3.7 people per square kilometer, as the total
population had increased to 545 million. This represented a shift
as human settlement offered greater opportunities for the
constant contact with intestinal parasites which were carried
through human excrement as the settlement and domestication of
animals and plants and urbanization altered the disease
environment of the human species forever.
And so he argued that it was important for research to move away
from treatments and cures to the environmental causes of disease.
However, and what is important is that he did not call for
radical social organization. He suggested that it was not the
function of medicine to become identified with political action.
So while he is saying here that medicine is a problem in that it
does not allow for researchers to concentrate on the social,
economic, and cultural causes of disease, he is not saying here
that medicine should become a force by which those causal factors
should be changed.
What I want to go on to in the next two sections is to have a
look at two protagonists, Thomas MacEwen and Ivan Ilich, who did
suggest exactly that.
