publichealth-1 E

Transcriber:	Yvonne Cherne
Brief Bio:
Date finished:	5-3-2007
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file: hph_lec1e.mp3

A History of Modern Public Health: Introduction (continued)

So a critique of medicine led to the reformulation of public
health and a new impetus for public health from the 1970s
onwards. And I think it is fair to say that public health
practitioners generally accept that this new public health is the
paradigm under which they work, although we will go on to
criticisms of the new public health itself.

But the new public health provides a framework for programs such
as the Healthy Cities Program run by the World Health
Organization. This Healthy Cities Program includes for example
environmental projects such as recycling, screening programs, and
so on, and it combines health promotion with health consumerism
and returns also to the tradition of local public health action.
So it draws in different sectors of the community in terms of
business, in terms of social welfare providers, in terms of
government, and in terms of health care providers, and it deals
with health problems at a local level. A program effectively for
healthy cities is adoptable in any locality, and currently more
than 1500 urban areas globally have signed up to the Healthy
Cities Program. So it is very much a flagship program for the new
public health.

And the new public health with its harking back to traditional
ideas about the importance of the environment is well-placed to
deal conceptually with topics such as re-emerging infectious
diseases. It also, when it considers healthy behaviors and
lifestyles, it also enables a role for the prevention of
epidemics of chronic diseases such as coronary heart disease and
cancers, and these traditionally - certainly in the 19th and
earlier 20th centuries - had been considered beyond the role of
public health. The new public health with its emphasis on
lifestyles and individual habits has enabled to incorporate
chronic disease into its preventive program.

That is not to say that it is not without its critics. In
particular, sociologists have criticized the new public health,
and they draw parallels between the new public health and the
situation of medicine in the 1950s, 60s and 70s. Sociologists
argue that the new public health is still dependent on the
sciences of epidemiology, biostatistics, and so on. And this
dependence on science parallels medicine as a whole. It draws on
scientific knowledge, it emphasizes the role of expertise and
technology to improve health status. It is bureaucratic and
technocratic in its nature, and as such, it does not disrupt the
power relations that exist between science and the general
public.

The new public health's rhetoric on empowerment, sociologists
argue, the way that is suggests that health problems are
localized and that local populations can be empowered to deal
with those health problems actually disguises the way in which
society is medicalized. They suggest that the new public health
with its dependence on science and expert knowledge still
controls and regulates and does not allow for individual
autonomous action because it imposes particular programs that are
drawn from science and epidemiology and expert knowledge. And
this expert knowledge is a crucial thing to which we are going to
return to consistently throughout this course on the history of
public health.

But what they also argue in relation to history is that the way
in which the new public health harks back to a golden age of
sanitary reform is idealistic and progressionist. In other words,
what they are saying is by expropriating this golden age of
environmental health, what the new public health is doing is
ignoring the profound moral, political, and social implications
that public health and development has exhibited over time, and
it is these profound moral, political, and social implications
that hopefully I am going to be able to draw your attention to as
we go through this course.

One of the things that we can point to is the fact that the new
public health is not the first new public health. The turn of the
20th century for example saw a re-evaluation of public health -
as we will see as the course progresses - from a concern with the
environment to a concern with individuals. There is a recognition
in the new public health of the early 20th century that
bacteriology had impacted on the ideology and practice of public
health, and that helped in the shift from environments to
individuals.

So you can see here a 1949 publication of the new public health.
Here we have a 1920 publication of another new public health that
was first produced in 1916. And in this publication, Herbert
Winslow Hill argues that public health is a term which includes
all knowledge and all measures tending to (a) foster health or
(b) to prevent disease. It subdivides public health into the
hygiene of the individual and the public environment. That is in
many ways resonant and parallel to the new public health of
today. But Winslow Hill in this publication does tend to
subordinate the role of the environment to the role of the
individual. He accords greater importance to individual behaviors
and personal habits in the production of ill health than he does
the role of the physical environment. So the environment in
Winslow Hill's conceptualization provides the root of infection:
it is the individual that is the source.

So in this sense Winslow Hill is fairly disparaging of the old
style. Even by then, by 1916, there was an old style of public
health which sought the origins of disease in the soil, the air,
climates, and the topography of localities. He argued that the
old public health failed to find the sources of infection and in
most cases the sources of transmission, except for water, because
it looked at the environment rather than looking at human beings.
So it is in this way that we can see how today's new public
health uses the golden age of sanitary reform in a way that is
essentially misleading. It is not necessarily a golden age. The
sanitary reform period was based on a set of circumstances and a
set of beliefs about disease causation that over time were proved
to be misplaced. We will be looking at that in our class on
sanitation.

The next sequence of slides just here to provide you with some
idea of the persistence of this dichotomy between the environment
and the individual and the tension between these two themes that
characterizes the history of public health.

Here you have a picture of Jacob's Island which is a part of the
district of Bermondsey in London in the mid 19th century. You can
see the houses are built with privies at the back and that these
privies empty into basically a stream or a river, and so human
excrement just goes directly into the local water supply. Rather
similar is this image of a favela in Ecuador from the early 21st
century; the similarities really striking in terms of the
appearance of the buildings in terms of the environmental
conditions under which people lived in the early 21st century and
how comparable they are to an industrializing nation in the
middle of the 19th century.

And this is just an example of the importance of individual
behaviors and the transmission of disease. On the left-hand side,
you can see an image of the protection that people were
encouraged to take during the SARS epidemic in terms of covering
their mouths and preventing the airborne infection of the
disease. On the right-hand side you can see a very similar,
almost identical example of a mother and a child covering up
their faces with a mask during the influenza epidemic just
towards the end of the First World War. So here public health is
trying to have been influence over the behaviors of individuals
for the good of the wider community. And that is an issue that
strikes at the very heart of the history of public health, and it
is an issue that we are going to come back to again and again
throughout this course.

So on that note of the tension between the environment and the
individual that we can trace in public health historically is
where we will leave it for this first class. I hope that you have
been stimulated by what I have said and that you will be
encouraged to come back and learn a lot more in the coming weeks.