publichealth-3 A

Transcriber:	Chen Li-Chen
Brief Bio:
Date finished:	04-06-2006
Proofreader:	Paula Trever
Brief Bio:
Date finished:	04-06-2006

The History of Public Health

Lecture 3: The Sanitary Idea

 Part A

Welcome back everybody.  We're going to be talking today about the sanitary idea. There are a number of themes in the structure of the lecture that I'd like to draw to your attention.  We're going to begin by looking at the modern legacy of the sanitary idea.  And we're going to be examining how the new public health, the dominant paradigm in public health practice today, uses the sanitary idea to justify recent practice.  And to do that, what we're going to do is we're going to examine exactly what the sanitary idea was, and what it consisted of, and we're going to look at the origins of the sanitary idea, in terms of the importance of urbanization and industrialization.  We're going to be looking at how the environmental problems were caused by the migration of people into towns and cities, and how that migration and how that increasing population pressure in towns and cities was managed. We're going to be looking at the importance of that for the development of the sanitary idea and for the development of the notion that it was important to clean up the environment in order to improve people's health.  So, as well as the social process of urbanization and industrialization, we're going to be considering the Enlightenment origins of the sanitary idea. And when I talk about the Enlightenment origins, effectively, what we're thinking about are philosophical and political developments from the mid-18^th century onwards that made sanitary intervention and environmental interventions attractive to reformers and politicians.  And finally, when we get towards the end of the class, we're going to look at what the sanitary idea tells us about the practice of public health in the past, but also more recently. 

So let's begin in Section A, with the discussion of how today's public health practice uses rhetorically the sanitary idea. The most recent incarnation of public health that we've discussed in the introductory class reserves a special place in its heart for the British sanitary reform movements of the mid-19^th century.  And those who shaped government interventions in that period to improve water supply, drainage, and the removal of sewage, are presented in today's public health, if you pick up any textbook today on public health practice  There's usually an introductory section about the history of public health, and that introductory section tends to present those who implemented the sanitary idea as exemplars for current efforts to improve population, health, and well-being.  And it is that sort of rhetoric that I want to look at in this first section.  It may seem a strange question to ask, at the beginning of the 21st century, why urban conditions such as these, that you can see in this slide, should be the focus of interventions to improve health.  But, as you can see, the similarity of the two images that you have in front of you is striking.  The first image is from an Ecuadorian favela at the end of the 20^th century, and the second image is taken from a northern British city in the early 19^th century.  And the apparent health risks that are caused by unregulated urban growth-they're similar, they're manifold, and they're obvious, even when you look very briefly at these two images. Poorly planned housing-thus, if you can call it housing-which is located on marginal land, very overcrowded living conditions, and minimal if any utility provision, such as clean running water and excrement removal, the health-threatening factors that immediately come into view, are common to both of these scenes.   What you can see from the image from the northern city-in particular, behind the houses you can see hut-like structures, and these are actually privies.  People would use the privies, and their excrement would just basically come out of the back of the privy into the open sewer that is at the back of the houses.  You can see from the image of Ecuador, probably, it's very likely, that similar processes are going on in terms of the ways in which people behave sanitarily.  Well, to our minds, the case for intervention in both of these cases are overwhelming. 

It's important to realize that there was a time when the links between these sorts of conditions and the health of the population were either denied, they were unclear, and they were subjects of intense debate.  Indeed, in earlier periods, certainly the beginning of the 19^th century and at the end of the 18^th century, cases were made that no intervention at all should be made.  And part of the point of this class is to look at how there was a shift from the laissez-faire attitude of no intervention to an attitude whereby it was felt there should be legislation, government, and state intervention to improve the sorts of environments that are so palpably health-threatening that you see in these images.  And one outcome of these debates over the relationship between the environment and health in the mid-19^th century was the sanitary idea. 

In his book, Healthy Cities, John Ashton lists twelve points that we can take from historical study of the sanitary idea, and apply to the new public health today.  He suggests the sanitary idea illuminated the legitimacy of working at the local level.  He argues that the sanitarians who implemented environmental reforms in the early and mid-19^th century were very resourceful and pragmatic. They had a very humanitarian approach and a strong moral tone.  And these are features of the sanitary reform program that should be taken into public health practice today.  He also says the sanitary idea recognized the need for special skills and qualifications, and there's a suggestion there that the new public health needs to draw today on skills from all forms of disciplines, and that there's a need for formal qualification [at] a certain level, entry level into the public health profession.  He also argues that the sanitary idea illuminated and illustrated the appropriateness of research and inquiry, and the value of producing reports on the state of the population, and that these could be used to focus on positive health.  He also suggested that populism and health advocacy were crucial in this period, in the mid-19^th century, to convince legislators, politicians, and vested interests that sanitary reform was a valuable and necessary project.  He argued that there was a need to work with trends and to be desistent (?), and it was better if the reform movement was highly organized at a variety of levels, both the national level and the local level.   And in turn, this organization, the local level, was related to the fact that the public health needs to be the responsibility of a democratically accountable body.  He argues that the group of upper middle-class men who were involved with the sanitary idea are now seen to have left behind them an approach and a menu of measures which flowed from that sanitary idea and helped legitimate [legitimize] public health practice today.  But some sociologists have argued, historical sociologists who are interested in health, that this list that you see before you has little to do with how and why the sanitary idea came into being.  Histories of public health and public health textbooks tend to present a progressive chronology of achievement and have an undeveloped understanding of fundamental assumptions of why the sanitary was promoted in the first place. 

So part of this class is about looking at the sanitary idea in a rather more critical way than has been the case in the past.  And that more critical approach has been summarized by Peterson and Lipton in their book on The New Public Health.  They suggest that, in their failure to appraise critically the narratives of progress that underlie and support many of the projects of the new public heath, public health advocates can be accused of leaving unexamined and intact the power relations that these narratives both produced and helped to sustain. Before we go on to discussing in greater detail a critique of the sanitary idea and how it came about and its origins, it would be useful just to summarize very briefly what the sanitary idea was all about.  Effectively, it encompassed the idea that mortality and ill-health are determined by physical conditions. 

So in that respect, the environment is crucial to the determination of people's health status.  And, if you assume that ill health is determined by physical conditions, then sanitation becomes important.  Human existence can be improved by the removal of disease, which can be achieved by the constructions of massive drainage, and sewage removal systems, by the provision of constant supplies of water, by widening and paving streets to make them easier to clean, and by removing cesspools and all of the noxious nuisances.  However, for that level of intervention to be achieved successfully at the local level required central direction and legislation.  The central direction, implementation, and monitoring of localities was deemed to be crucial to the success of the sanitary idea.  In effect, what we're saying here is that the central government had to have a stronghold on the legislation that was produced, and it had to be in a condition to control and monitor what local authorities and what local areas were doing in terms of implementing infrastructural and utility improvements. 

And all this seems eminently sensible to us today, but a number of questions remain. And these are, put briefly, I've separated these questions into three main themes. First of all, I'd like to ask the question of why Britain, in the early 19^th century, what was it about conditions, about social life, about political and intellectual life in Britain in the early 19^th century that made that time and that place so associated with the emergence of the sanitary idea?  Secondly, there's a question about the etiology of disease. What was it?  What theory of disease causation was dominant in order for the sanitary idea to emerge as the most prominent form of preventive intervention for the health of the population?  And thirdly, it's important to ask questions about why and how correlations were made between environment and health in the first place.  And this links back to the emergence of a political and intellectual philosophy, that depended on its ideas, that valued human rationality and the ability of humans to improve their social wealth and their social health.  And in that respect, it becomes important to consider the rise of statistics and the rise of epidemiology, and how they fitted into the sanitary idea.  So that concludes the section on our summary of the sanitary idea. And when we come back, we'll be having a look at the first of those questions--why Britain in the early 19^th century?-- and we'll be focusing on the role of urbanization and industrialization.