The Historical Origins of Public Health Dr Ann Hemingway Practice Development Fellow Public Health

1. The Historical Origins of Public Health Dr Ann Hemingway Practice Development Fellow (Public Health)

2. One of the problems with public health is that it can be everything - the air, the food or water, health behaviour and health sciences. Griffiths & Hunter (1999) Perspectives in P. Health Oxford: Radcliffe Medical Press

3. A definition of public health Public Health is the science and art of preventing disease, prolonging life and promoting physical health and efficiency through organised community efforts for the sanitation of the environment, the control of community infections, the education of the individual in personal hygiene, the organisation of services for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health. Winslow C.E.A. (1920) The Untilled Fields of Public Health Science 51, 23

4. ?Has public health existed as long as civilisation Brockington noted (1960) that, �public health in some form has existed as long as civilisation. Inoculation against smallpox was practiced in India and China more than two thousand years ago. Isolation of leprosy was enforced in the Roman Empire which built leprosaria; the first isolation hospitals, and many religious abstentions concerned food and excretal pollution�. Brockington F. (1960) The Health of Community Principles (2nd Ed) London: JA Churchill

5. The origins of public health: historical perspectives Classical Greek - two rival Greek medical traditions one based on disease classification and the other on emphasising the individual patient. Both based on observation, not divine causation. Hippocrates put great emphasis on the environment in relation to health and well-being

6. The Romans and Chinese engineered safe water and sanitary latrines dating from 4000 years ago. The Romans also created a military medical service who focused on the holistic well being of the troops.

7. Medieval and Renaissance Public Health A Greek text the Salernitan Programme of Health was re-discovered in Constantinople in the eleventh century. It emphasised hygiene, diet and exercise as the basis of good living. The church dominated medieval practices, relating to ill health. Plagues were caused by divine retribution and certain illnesses were stigmatised.

8. The origins of the Public Health movement The recurrence of plague in 14th and 15th Century Europe inspired concern for its control Italy set up permanent magistrates charged with overseeing moral and physical hygiene in cities These magistrates set up a system to isolate the sick and set up hospitals to do this Books of the dead were kept to record mortalities and plot the course of epidemics

9. Cities swollen in size by trading activities initiated public health measures, Bruges (Belgium/Flanders) became the first city in Europe to install an integrated water and sewage network. Leprosy was very common and sufferers were stigmatised, forced into ghettos and made to comply with distinctive dress codes and sound a bell when people came near.

10. From the middle ages to the early Victorian period two dominant theories of disease causation The miasmic theory, illness was due to miasma, toxic air from rotting debris, `a foul smelling vapour`. The humoral theory, the body was made up of different `humors` which needed to be kept in balance. However ultimately disease was seen as God`s punishment for the sins of humankind Lupton D. (1997) The Imperative of Health Sage

11. First International Public Health Conference In 1851 the first international public health conference was held with 12 nations debating for six months. Sardinia, Portugal and Russia supported the use of quarantine. England and France subscribed to the miasmic theory. By 1900 ten conferences had met and were most concerned with the spread of cholera.

12. In Europe and North America 3 phases of public health activity can be identified in the last 150 years First Phase This movement was triggered by the appalling toll of death and disease among the working classes in the mid 19th Century following the industrial revolution. In the 1830`s half of Manchester children died before their fifth birthday, and in Liverpool a labourer had a life expectancy of 15 years. Second Phase Public Health focuses were housing sanitation clean water The public health movement at this time resulted in Chadwick`s Public Health Act of 1848 (in Britain)

13. Third Phase  The germ theory of disease causation and the future potential of immunisation and vaccination became clear. Pressing environmental problems began to be dealt with. The therapeutic era began in the 1930/40`s in Britain with the advent of insulin and sulphonamides. Until that the therapeutic `arsenal` had proved to be of little efficacy. This period marks a weakening of the `public health` focus for health services and a shift of resources to hospital services, particularly teaching hospitals. Preventive efforts began to focus on the individual

14. ?Phase four The new public health movement goes beyond the understanding of human biology and recognises the importance of social and psychological aspects as determinants of health and well-being. The therapeutic era is being challenged; with most countries experiencing a crisis in health care costs, due to limitless demand and demographic changes.

15. The new public health movement Shifts responsibility for health from the individual back to the social, and the individual and acknowledges the wider determinants of health (see next slide) Can have a mixed workforce including staff from statutory and non-statutory organisations, local residents, voluntary organisations and local pressure groups Engages with state set targets, the current UK government has set over 600 health targets

16. The wider determinants of healthDahlgren G. & Whitehead M. (1991) in, Benzeval M. Judge K. & Whitehead M. (Eds) Tackling Inequalities in Health: An Agenda for Action London: Kings Fund Institute

17. WHO Global Commission on the Social Determinants of Health Closing the gap in a generation: Health equity through action on the social determinants of health (Final report of the commission Sept 2008)

18. Global change permeates through these determinants, for example; Population mobility patterns may affect the genetic make up of populations and their susceptibility to, or protection from genetically inherited disorders The spread of cultural values and beliefs through global marketing and advertising resulting in changed lifestyles The spread and adoption of policies across countries that affect access to health care

19. Global branding and public health and well being The global restructuring of the world economy that leads to `global brands` and the employment of workers without protection from health and safety legislation The widening of socio economic inequities within and across many countries, resulting in impoverishment and poor health

20. Globalisation and infectious disease An ancient public health issue Smallpox spread to Europe initially over two thousand years ago. Carried across the Roman Empire by troops returning from Mesopotamia (now part of Iraq). In the third century bubonic plague moved from its place of origin in the Himalayas between India and China to Egypt and Libya as a result of burgeoning trade.

21. In the sixth century bubonic plague reached Europe commencing a cycle of plague lasting until the middle ages. When plague killed between a quarter and a half of affected populations.

22. Infection V. Trade The history of epidemics tells us that the tension between effective disease control and the free movement of people and trade has always been a key feature.

23. International Co-operation The first international Sanitary Conference was in Paris in 1851 it aimed to set standard quarantine regulations for prevention of cholera, plague and yellow, fever. Notably the British delegate did not think that John Snow`s new theory that cholera was transmitted by faecally contaminated water worthy of mention!

24. World Health Organisation Created in 1948 to unify international health co-operation in a single body. It became responsible for the International Health Regulations (IHR). The purpose of which is to; �ensure the maximum security against the international spread of diseases with a minimum interference with world traffic�

25. Three preventable killers TB, Malaria, HIV/AIDS The International Health Regulations (IHR) were originally designed to apply to cholera, smallpox, plague and yellow fever. They do not provide a legal framework for other infectious diseases or threats from emerging infections. The IHR have no resources to ensure compliance with regulations

26. Top ten causes of death and disability (measured in DALYS) for adults worldwide 2002, WHO Cause of Death HIV/AIDS Ischaemic heart disease Tuberculosis Road traffic injuries Cerebrovascular disease Self-inflicted injuries Violence Cirrhosis of the liver Lower respiratory infections Chronic obstructive pulmonary disease Cause of disability HIV/AIDS Unipolar depressive disorders Tuberculosis Road-traffic injuries Ischaemic heart disease Alcohol use disorders Adult-onset hearing loss Violence Cerebrovascular disease Self-inflicted injuries DISABILITY ADJUSTED LIFE YEARSDISABILITY ADJUSTED LIFE YEARS

27. Deaths attributed to the top categories of infectious or parasitic diseases worldwide 2003 WHO Infectious/parasitic disease ranked by deaths Lower respiratory infections HIV/AIDS Diarrhoeal diseases Tuberculosis Malaria Measles Tetanus Meningitis Syphillis Other Infectious/Parasitic diseases % of all deaths 6.7 4.9 3.1 2.8 2.1 1.3 0.5 0.3 0.3 3.7 Total % of all deaths = 26.2

28. Globalisation and emerging infectious diseases 2 million people cross international boundaries each day. This leads to the movement of other life forms and traded goods around the globe which aids the movement of organisms and vectors (often insects) of disease.

29. Sudden Acute Respiratory Syndrome (SARS) In 2003 a novel coronavirus was identified as the agent responsible for SARS which spread to 30 countries and led to 8,422 cases and 916 deaths (WHO 2003, World Health Report, Geneva WHO). The SARS epidemic illustrated the speed with which an infection can travel around the world thanks to the increase in air travel.

30. Short and long term effects of the increase in global travel In the short term this means that unaffected populations are at greater risk from new infections. In the long term the `pooling` of organisms may reduce the likelihood that there are large populations completely na�ve to particular organisms.

31. Globalisation and non-communicable disease The obesity epidemic is rapidly becoming a global issue. 50% of European adults are now overweight. The international obesity task force estimates that around 300 million people worldwide are obese.

32. Predicted trends in obesity by 2030Lee & Collin (2005) Global Change and Health OU Press McGraw Hill Ed

33. Cardiovascular disease and global health Cardiovascular disease thought to be a quintessential `western disease` is fast becoming a threat in developing countries. It now causes four times as many deaths in mothers in developing countries than do childbirth and HIV/AIDS combined The INTERHEART study found that 90% of heart disease is avoidable World Heart Federation (2006) http://www.worldheart.org

34. What is causing the rise in global obesity rates? Is the global food industry the culprit, due to their use of high levels of salt, sugar and fat? Is advertising responsible? Do we only eat it because its advertised as cool, trendy or sexy?

35. The evidence base Much of the available evidence focuses on high income countries, with explanations for the rise in childhood obesity being linked to exposure to advertising. Although the lack of physical activity is also an obvious key factor. Lee K. & Collins G. (2005) Global Change and Health OU Press McGraw Hill Ed

36. Interestingly�.. A survey of Fijian adolescent girls was carried out one month and three months after television was introduced to their area. The number of girls who practiced self induced vomiting to loose weight increased from 0% to 11% in a three year period 1995-98 Study of eating disorders in S. Africa found that while 40% of the girls surveyed were overweight or obese, more than half of them had disordered eating patterns. These included self induced vomiting and the use of laxatives and diet pills BBC News World Ed (2002) `Eating disorders in zulu women` 4 Nov, http://news.bbc.co.uk/2/hi/africa/2381161.stm

37. Since the conception of the NHS in the UK in 1948 Only a small percentage of funds has been spent on the prevention of ill health. 1979 A royal commission on the NHS concluded that `a significant improvement in the health of all people in the UK can come through prevention` 1980 The Black Report recommended action within the health service and other agencies; with a particular emphasis on the need to abolish childhood poverty

38. Policy in the UK 1992 Health of the Nation Targets set by the government White Paper 1997 Our Healthier Nation Green Paper 1997 Minister for Public Health Appointed 1999 Saving Lives: Our Healthier Nation White Paper 2001/2 Emergency of health inequalities targets from the Dept of Health

39. Health inequities, what are they? How did we get them? England`s existing health inequities reflect economic and social failures, which have developed over a long period of time. These are unlikely to be redressed through single policy objectives and matching interventions. Sir Derek Wanless` report to HM Treasury Feb 2004

40. Wanless goes on to state that in the UK our current `national sickness service` will not refocus to become a `national health service` until public health actions and accountabilities are reflected in the performance and inspection regimes for both the NHS and local government.

41. The Gini coefficient The Gini coefficient measures inequality within and between countries. It is estimated that between the 1950`s and 1990`s 48 countries saw a rise in inequality (half of the worlds population), nine had less inequality and 16 showed no trend. Cornia G.A. (2001) Globalization and health: Results and Options Bulletin of the World Health Organisation 79(9) p 834-41

42. Per capita income growth for more globalised countriesDollar D. & Kray A. (2001) Growth is good for the poor? World Bank Policy Research working paper No. 2587

43. Is globalisation good for your health? Shiva (cited in Mander 2000) writes that; �Globalisation of the economy is a new kind of colonialism, visited upon poorer countries and the poor in rich countries�. Mander J. (2000) Corporate Colonialism Resurgence 179 at: http://resurgence.gn.apc.org/articles/mander.htm

44. Two opposing views of globalisation Firstly poverty is indeed the most pressing moral, political and economic issue of our time, and is made worse by some elements of globalisation. Secondly, to reverse the tide of globalisation would be in the words of an Economist Editorial, �an unparalleled catastrophe for the planets most desperate people and something that can be achieved only by trampling down individual liberty on a daunting scale�

45. Public Health Ideologies Collectivist and Socialist Perspectives Great emphasis is placed on the role of the state and collective arrangements in improving health. This group are cynical about the ability of isolated individuals to produce their own solutions to complex social problems.

46. Liberal individualistic perspectives Places great emphasis on negative liberty or the freedom to pursue one`s activities without interference from the state providing others are not harmed as a result. This group believe that the state is a hostile entity that coerces and disempowers citizens.

47. Environmentalist/Green ideology Greens argue for an holistic solution to the environmental and public health problems of industrialised societies. This group argues for sustainable development, balancing economic, social and environmental considerations. Importantly they also support precautionary principles believing that intervention on the basis of limited info rather than waiting for evidence of widespread harm is preferrable. Baggott R. (2000) P. Health policy and politics Macmillan Press

48. Dr Ann Hemingway Public Health Practice Development Fellow ahemingway@bournemouth.ac.uk 01202 962796