PRINCIPLES OF PUBLIC HEALTH AND EPIDEMIOLOGY

BY

DR. NSIKAK AKPA

 CONCEPT OF PUBLIC HEALTH
Public health deals with the protection and improvement of the
health of people and their communities. This is achieved by
promoting healthy lifestyles, researching disease and injury
prevention, and detecting, preventing and responding to infectious
diseases. It focuses with protection of the health of entire
populations. These populations can be as small as a local
neighborhood, or as big as an entire country or region of the world.
According to World Health Organization, Public health aims to
provide maximum benefit for the largest number of people

Definition: In 1920, Charles-Edward A. Winslow defined public health as "the science

and art of preventing disease, prolonging life, and promoting physical health and efficiency
through organized community efforts for the sanitation of the environment, the control of
community infections, the education of the individual in principles of personal hygiene, the
organization of medical and nursing service for the early diagnosis and preventive treatment
of disease, and the development of the social machinery which will ensure to every individual
in the community a standard of living adequate for the maintenance of health.

TERMINOLOGIES IN PUBLIC HEALTH

Isolation: Isolation is separation of a person who has the disease from the healthy
population
quarantine refers to the separation of an individual who has possibly been exposed
to disease

EVOLUTION AND HISTORY OF PUBLIC HEALTH

Hunter-Gatherers ERA

Ten thousand years ago humans were hunter-gatherers and their primary need was just
finding enough food to eat. Hence, they lived and traveled in small groups and hunted and
foraged for food. Their mixed diet was probably fairly balanced and nutritionally complete.
Since they lived in small groups and moved frequently, they had few problems with
accumulating waste or contaminated water or food, thus little or no problem with
communicable diseases.

Superstition and Religious Era

As human population increased, interaction among humans in one hand and with the
environment in the other hand ensued; leading to occurance, transmission and spread of
diseases. Early explanations for the occurrence of disease focused on superstition, myths,
and religion. Primitive peoples believed in the divine and demonic theories of disease
occurrence which were were sometimes mischievous or vengeful. Of importance was the
belief by the Greek that the god Jupiter could be angry about man accepting the gift of fire.
The story is long and complicated, but Zeus crammed all the diseases, sorrows, vices, and
crimes that afflict humanity into a box and gave it to Epimetheus, the husband of Pandora.
Mercury was very tired from carrying his burden and gave it to Epimetheus for safe keeping.
Pandora wanted desperately to know what was in the box. She waited until Epimetheus was
gone. She opened the box, and all of the ills of the world flew out and spread throughout the
human world.

The Agricultural Revolution Era

Expansion in population resulted in People living in a larger group and staying in the same
place, with tendency of trnasmitting infectious diseases among themselves. The subsequent
movement of people from one place to another shifted their attention from mere hunting to
agriculture for secured food supply and rearing of animals and co-inhabiting with these
animals for food, means of transportation and labour. These animals unknown to man were
transmitting zoonotic diseases. At this point, generation of agricultural, animal, food wastes
and liquid waste (including human metabolic wastes) became paramount with little or no
attention on proper disposal. These wastes attracted rodents and insect vectors to human
settlements, providing sources of disease but then, these diseases were linked to
religion, myth and superstitions

The Hippocratic Corpus

Many centuries past and disease occurences were still based on unexplained religious and
cultural superstitions with no scientific basis. The Hippocratic Corpus (a collection of
around seventy early medical works collected in Alexandrian Greece) was an early
attempt to think about diseases, not as punishment from the gods, but as an imbalance of
man with the environment and imbalances in diet or personal behaviors. The Corpus looked
at disease as an imbalance in natural forces or an imbalance in humours (or fluids):
melancholy, phlegm, bile, and blood. Health depended on a proper balance of these
humours. this concept of humours provided some sort of rationale for understanding health
and disease and the possibility of intervening to prevent disease or possible treatment. This
was the beginning of breakthrough in public health. This enable Greek physicians prescribed
changes in diet or lifestyle and sometimes concocted drugs or performed surgery. An excess
of the humour blood, for example, became the rationale for bloodletting, a practice that was
followed for centuries (without any evidence of its efficacy).

Despite the contributions of the Corpus, medical and scientific progress in Europe was
stagnated for centuries and there was little or no attention on waste disposal and sanitation,
culminated to for endemic disease and periodic epidemics.

Outbreak of Bubonic Plague (1347-1700s)

Around 1347, there was outbreak of bubonic plague in Europe which lasted until the late
1700s, but the cause was unknown but with different propositions. The plague originated from
Asia and traveled along trade routes into the Black Sea and then into the Mediterranean Sea
and then swept through Sicily and Italy and then France and the northern European countries
all the way up into Scandinavia. There were subsequent multiple outbreak in Europe until the
late 1700s.

The most popular proposition on the cause of plague was that it was caused by "miasmas,"
(obnoxious vapors that emanated from swamps or cesspools and floated around in the air,
where they could be inhaled). Others thought it was spread by person to person contact, or
perhaps by too much sun exposure, or by intentional poisoning. The miasma theory was the
most popular, however, burning and inhalation of aromatic herbs was one of the measures to
counteract miasma by plague Doctors. There were also crude medicines that were concocted
to prevent or cure the bubonic plague; one of them was known as theriac.

Non of these methods was effective, because the plague was primarily spread by flea bites
While most believed that plague was caused by miasmas, the primary mode of transmission
was actually via flea bites due to accumulations of garbage which attracted rats and enabled
the rat population to explode. Rats had harbored fleas and Yersinia pestis for many years
without major difficulty, and plague epidemics in humans didn't occur until human behaviors
created environments that brought people into proximity with rats, fleas, and Yersina pestis.
These were the real causes of the plague epidemics.

Quarantine and Isolation

Quarantine comes from the Italian quarantena, meaning forty-day period. Quarantine is one
of the oldest public health measures and can be traced back to the 14th century when the
Black Death ravaged Italy and Europe. Travelers potentially exposed to disease were
isolated for a period of time (usually the incubation period) to ensure that they were not
infected. Physical barriers were created (cordon sanitaire). This practice persisted into the
late 19th century and early 20th century. Quarantine was a very useful public health tool when
plague threatened San Francisco. The Chinese section was quarantined by encircling it with a
rope with armed guards to ensure that unauthorized individuals did not pass through. A
cordon sanitaire was also used during an outbreak of bubonic plague in 1899-1900 in
Honolulu's Chinatown. Fourteen blocks of the city were literally cordoned off and 10,000
people were isolated. Quarantine is still very much in use today. During the SARS
epidemic, Toronto quarantined individuals who had potentially been exposed by
confining them to their homes for the period of incubation until it was certain that they
were not showing signs and symptoms of SARS. However, quarantine is less useful
for diseases like influenza, when an infected person can spread the disease even
before they begin having symptoms.

Contributions of Girolamo Fracastoro to Evolvement of Public Health

(1546)

Girolamo Fracastoro was an Italian physician, poet, astronomer, and geologist, who
unknowingly proposed germs theory of disease 300 years by writing about ‘disease seeds’
before it was proven by Louis Pasteur and Robert Kock. Fracastoro outlined his concept of
epidemics in his "De contagione et contagiosis morbis" and concluded that each disease
was caused by a different type of rapidly multiplying 'seed' and that these could be
transmitted by direct contact, through the air, or on contaminated clothing and linens.

He believed that life forms could arise spontaneously. Maggots, worms, bacterial and fungal
growth could be found "arising" from food that was left for long. In 1699 Francesco Redi
boiled broth and sealed it; no growth occurred, suggesting that Fracastoro was correct.

John Graunt - The Bills of Mortality (1662)

Beginning around 1592 the parish clerks in London began recording deaths. In 1662 John
Graunt, a founding member of the Royal Society of London, summarized the data from these
"Bills of Mortality" in a publication entitled "Natural and Political Observations Mentioned in a
Following Index, and Made Upon the Bills of Mortality."

Graunt analyzed the data extensively and made a number of observations regarding common
causes of death, higher death rates in men, seasonal variation in death rates, and the fact
that some diseases had relatively constant death rates, while others varied considerably.
Graunt also estimated population size and rates of population growth, and he was the first to
construct a "life table" in order to address the issue of survival from the time of birth.

Robert Hooke (1665)

Robert Hooke published "Micrographia" in 1665. Hooke devised a compound microscope and
used it to examine and describe the structure of nature on a microscopic level, including
insects, feathers, and plants. In fact, it was Hooke who discovered plant cells and coined the
term "cells".

Anton van Leeuwenhouk (1670s)

Anton van Leeuwenhoek of Holland was "the father of microscopy." He began as an

apprentice in a dry goods store where magnifying glasses were used to inspect the quality of
cloth. Van Leeuwenhoek was fascinated by the lenses and experimented with new methods
for grinding and polishing more powerful lenses. He was able to achieve magnifications up to
270x diameters. He used these to create the first useful microscopes. Using his inventions, he
was the first to see bacteria (1674), yeast, protozoa, sperm cells, and red blood cells.

John Pringle and "Jail Fever" (1740s)

John Pringle was a Scot who served as physician general to the British forces during the War
of the Austrian Succession (1740–48). In London he became physician to the Duke of
Cumberland and to King George III. Pringle published "Observations on the Diseases of the
Army" in 1752, in which he proposed a number of measures aimed at improving the health of
soldiers including improvements in hospital ventilation and camp sanitation, proper drainage,
adequate latrines, and the avoidance of marshes. He wrote extensively on the importance of
hygiene to prevent typhus or "jail fever," which was a common malady among soldiers and
prisoners in jails. Pringle incorrectly believed that typhus was caused by filth. In fact, it is
caused by a small bacterium (a rickettsia). Lice are vectors for the disease; when infected lice
defecate on the skin of lice-infested soldiers or prisoners, the bacteria can gain entry through
small scratches or abrasions in the skin. The bacteria then multiply and cause a severe febrile
illness which is often fatal if not treated. Pringle also coined the term 'influenza'.

James Lind and Scurvy (1754)

Scurvy is due to a deficiency in vitamin C that results in weak connective tissue and
abnormally fragile capillaries that rupture easily, causing bleeding, anemia, edema, jaundice,
heart failure, and death. Scurvy was a huge problem in sailors several centuries ago, because
of the chronic lack of fresh fruit and vegetables during long sea voyages. James Lind, a
Scottish naval surgeon, suspected that citrus fruits could prevent it based on some anecdotal
observations. In 1754 Lind conducted what may be the world's first controlled clinical trial on
12 sailors with scurvy. Lind divided the 12 sailors into pairs, and each group received a
different treatment (sea water, various other concoctions, and lemons and oranges. The two
who received lemons and organs were cured, but the others were not. Lind concluded that his
hypothesis was correct, reported his findings, and recommended that sailors receive a ration
of lime or lemon juice.

Unfortunately, 50 years passed before the British navy acted on Lind's recommendations and
began to provide lime juice to sailors at sea. (This led to the nickname "Limeys" for British
sailors.) It is also noteworthy that Lind was able to correctly identify a means of preventing
scurvy even though he misunderstood the cause. He believed toxins within the body were
normally released through pores in the skin and that scurvy was the result of damp sea air
causing pores to close, thus trapping toxins within the body.

Francois Broussais & Pierre Louis (1832)

Bloodletting to Treat Cholera

Francois Broussais was a prominent Parisian physician and a strong proponent of

bloodletting with leeches. He used bloodletting to treat many diseases, including cholera. It is
believed that his vigorous use of bloodletting to treat victims of a cholera epidemic in Paris
substantially contributed to the mortality rate

Pierre Louis was a contemporary of Broussais's who believed in using numerical

methods to evaluate treatment. Louis studied bloodletting and found it ineffective, but many
dismissed his conclusions. Bloodletting was a therapy that had been practiced for centuries,
although it had never been tested for efficacy. It had become embedded in medical practice.

The Industrial Revolution brought an explosion of development. There were new jobs,
(particularly in the cities), new goods, and increased trade. However, it also brought new
problems to Europe.

Further expansion of the population and mass migration caused explosive growth of cities.
The maps to the right illustrate the concentration of population into the cities of England that
occurred over 200 years beginning in 1700 as shown in these maps of population density in
1701 and 1911.
Poor workers were often housed in cramped, grossly inadequate quarters. Working conditions
were difficult and exposed employees to many risks and dangers, including cramped work
areas with poor ventilation, trauma from machinery, toxic exposures to heavy metals, dust,
and solvents. Consequently, progress brought a whole new set of health problems that were
widespread in Europe and in America.

The Enlightenment (1700-1850)

The Enlightenment was a period that saw an embrace of democracy, citizenship, reason,
rationality, and the social value of intelligence (the value of information gathering). These
ideas provided important underpinnings for public health. In the early 1800s Jeremy
Bentham and his disciples (the theoretical radicals) developed the philosophy
of utilitarianism which provided a theoretic underpinning for health policy and wider social
policies. One theme was that the reduction of mortality and improvements in health had an
economic value to society. Healthy workers were more able to contribute to the economy of
the state. Implicit in utilitarianism was the notion that one could measure 'evil' by the degree of
misery that was created (or relieved) by a particular action. To Bentham the welfare of both
the wealthy and the poor could be achieved most efficiently with good governance.

Ignaz Semmelweis and Oliver Wendell Holmes (1840s)

Ignaz Semmelweis was a Hungarian physician who practiced in the maternity department of
the Vienna General Hospital in the 1840s. Postpartum sepsis (puerperal fever) was a
common occurrence and was almost invariably fatal. There were two maternity wards in the
hospital, one where births were attended by medical students, and another where births were
attended by midwives. The students often came directly from the dissecting rooms where they
had been working with corpses with their bare hands. Puerperal fever was much more
common in the ward tended by the medical students, but no one knew why.

A colleague of Semmelweis cut his hand while performing an autopsy and developed a
similar clinical picture of overwhelming sepsis and died. Semmelweis began to wonder
whether contagion could be carried on the hands and transferred to the women during
childbirth.

He decided to require all attendants to wash their hands in chlorinated lime water before
attending to a birth, and the rate of infection plummeted. Some were impressed by these
findings, but others, including Semmelweis's superior, ignored them.

Oliver Wendell Holmes, Sr. was an American physician, professor, lecturer, and respected
literary author. He received his M.D. from Harvard Medical School in 1836 and served as
professor and chairman of anatomy and physiology at Dartmouth Medical School and later at
Harvard Medical School. He advocated for medical reforms and was a strong proponent of
the idea that doctors and nurses could carry puerperal fever from patient to patient.
In 1843 he presented a paper entitled "The Contagiousness Of Puerperal Fever" at the
Boston Society for Medical Improvement This was a controversial position. Holmes was
opposed by a number of members of the society, including Dr. Charles Meigs, a prominent
obstetrician. With regard to puerperal fever, Meigs's position was:

"I prefer to attribute them to accident, or Providence, of which I can form a conception,
rather than to a contagion of which I cannot form any clear idea, at least as to this
particular malady." (Quote from Professor Charles D. Meigs)
John Snow - The Father of Epidemiology
Cholera is an infectious disease that became a major threat to health during the 1800s. In the
1800s there were large epidemics of cholera in Europe and America that killed thousands of
people. John Snow was a physician in London who spent several decades studying cholera
in a systematic way. He is most often credited with solving an outbreak of cholera that
occurred in London in 1854. The first cholera epidemic in London struck in 1831, when Snow
was still an apprentice. Another large epidemic occurred in 1848 and lasted through 1849.

The prevailing opinion was that cholera was spread either by miasmas or by person-to-person
contact, Snow began examining the victims and found that their initial symptoms were always
related to the gastrointestinal tract. Snow reasoned that, if cholera was spread by bad air, it
should cause pulmonary symptoms, but since the symptoms were gastrointestinal, perhaps it
was transmitted by water or food consumption. In fact, cholera is caused by the
bacterium, Vibrio cholera, which is transmitted by the fecal-oral route, that is by ingestion of
water or food that is contaminated with sewage.

In August 1849 Snow published a paper entitled "On the Mode of Communication of Cholera"
in which he presented his theory that the disease was acquired by ingestion of contaminated
water, but his theory did not get much traction with the medical establishment. The epidemic
ended in 1849, but Snow continued to collect data on the pattern of of disease and began
finding evidence that linked cholera to specific sources of water. However, increasing
numbers of businesses and homes had water piped from the Thames River by private
companies. Snow learned from municipal records that two private companies supplied piped
in water to the areas that were primarily affected by cholera. Some consumers were supplied
by the Lambeth Company, while others were supplied by Southwark & Vauxhall. The map of
London below shows the areas of London supplied by these two water companies.

Southwark & Vauxhall pumped water from a more downstream location that was
clearly contaminated, and the rates of cholera were clearly higher in their customers
compared to those supplied by the Lambeth Company. Nevertheless, many were
unconvinced by his findings, since Snow had not actually demonstrated that the
water contained something that could cause cholera
In late August of 1853, cholera broke out in the Broad Street area, and the residents panicked
and many began to flee. A hand pump was located right on Broad Street, and Snow was
immediately suspicious. Water samples did not reveal gross contamination, but Snow
persisted and began to collect detailed information on where the victims had gotten their
drinking water. He obtained the names and the addresses of the first 83 victims who had died
by the end of the first week. He went to their homes and learned from relatives that the vast
majority of them had obtained their water from the Broad St. pump.

On Sept. 6 Snow appeared at the meeting of the local Board of Guardians and presented his
evidence that the pump was the source of the outbreak. He argued that the pump handle
should be removed in order to prevent further contamination. The board was not convinced,
but agreed to remove the pump handle as a precaution. The epidemic quickly subsided.

The investigation continued. Ultimately, Snow was able to track down 197 victims, the vast
majority of whom lived within walking distance of the pump. It was also noted that there was
an extremely low incidence of cholera at a nearby work house and also at the Lion Brewery,
and both of these businesses had their own water supply. The workers at another large
business used water from the Broad St. pump, and their workers had a substantial incidence
of cholera

An initial examination of the well failed to show any problems, casting doubt on
Snow's conclusions, and the pump was reopened without incident. However, some
months later an associate of Snow's stumbled upon the records of an infant who had
died of diarrhea at the very beginning of the outbreak. The timing of her death
indicated that she had been the first cholera case. Upon questioning, the mother said
that she had emptied a pail of the infant's diarrhea into a cesspool in front of their
house immediately adjacent to the water pump. The cesspool and the pump well
were than excavated, revealing that the cesspool, which was within three feet of the
well, was leaking, and the wall of the well was decayed, allowing the contamination
from the cesspool to seep in. In retrospect, it appeared that once the child died, there
was no further contamination of the well, and the epidemic ended.

In retrospect, Snow made several important contributions to the development of

epidemiologic thinking:

 He proposed a new hypothesis for how cholera was transmitted.

 He tested this hypothesis systematically by making comparisons between groups of
people.
 He provided evidence for an association between drinking from the Broad St. well
and getting cholera.
 He argued for an intervention which prevented additional cases (removal of the pump
handle).

The Sanitary Idea (1850-1875)

In many respects, public health as we think of it today took shape in London and Paris in the
wake of the devastating health consequences of the Industrial Revolution. However, the
circumstances that propelled the development of public health as a discipline are more
complex with many contributing factors. First, there was the notion of the importance of the
monarchy and the power of the state. The influence and power of the state could be assessed
in many ways including commerce and trade, but also by the size of the population and the
health and fitness of the working population.

This crude notion made the work of John Graunt quite compelling, and the importance
attached to "numbering the people" grew. Not surprisingly, the General Registrar's Office was
established in 1837 to record compulsory registration of births, deaths, and marriages in
England and Wales. Dr. William Farr was appointed Chief Statistician; Farr had trained at the
Royal Academy of Medicine in Paris. The General Registrar's Office established the
importance of surveillance with respect to health.

A second factor was the emergence of the Enlightenment in the 18th century, which
embraced democracy, citizenship, reason, rationality, and the social value of intelligence (the
value of information gathering). These ideas provided important underpinnings for public
health. In the early 1800s, Jeremy Bentham and his disciples (the theoretical radicals)
developed the philosophy of utilitarianism which provided a theoretic underpinning for health
policy and wider social policies. One theme was that the reduction of mortality and
improvements in health had an economic value to society. Healthy workers were more able to
contribute to the economy of the state. Implicit in utilitarianism was the notion that one could
measure 'evil' by the degree of misery that was created (or relieved) by a particular action. To
Bentham the welfare of both the wealthy and the poor could be achieved most efficiently with
good government.

Yet another factor was the recognition that poor health was a burden that fell
disproportionately on the poor. Villerme, a physician in Paris had noticed that mortality rates
varied widely among the districts (arrondissement) of Paris. He tried to correlate mortality with
the distance of the arrondissement from the Seine River, the relationship of the streets to the
prevailing winds, the arrondissement's source of water and local climatological factors such
as soil type, exposure to the sun, elevation and inclination of the arrondissement. None of
these things correlated. However, when he used tax rates as an indicator of wealth, Villerme
found a striking correlation with mortality rates

In 1842 Sir Edwin Chadwick, a social reformer, published a report entitled the 'Report into the
Sanitary Conditions of the Labouring Population of Great Britain' proving that life expectancy
was much lower in towns than in the countryside.
Chadwick argued that it was possible for the government to improve people's lives through
reform; he believed that a healthier population would be able to work harder and would cost
less to support. He concluded that what was really needed was not more physicians, but civil
engineers to provide drainage of streets and to devise more efficient ways of delivering clean
water and removing sewage and other noxious substances. These social, economic, political,
and philosophical developments all contributed to the emerging idea that the public's health
was a legitimate interest of government.

It is interesting to note that many of the proponents of the "Sanitary Idea," including Edwin
Chadwick were "miasmatists" who clung to the belief that disease was caused by breathing
foul vapors. Since sewage and garbage smelled bad, they were associated with disease, so
the miasmatists pushed to clean up the environment. And despite the fact that their belief in
miasmas would prove to be incorrect, the end result was that many of the sources of
infectious disease were removed. Chadwick was instrumental in creating a central public
health administration that paved the way for drainage, sewers, garbage disposal, regulation of
housing, and regulations regarding nuisances and offensive trades. This "sanitary idea"
resulted in remarkable improvements in health and well-being, as illustrated in the graph
below, which shows a remarkable decline in mortality from tuberculosis from the mid-19th
century until the mid-20th century.

Chadwick's report provided momentum for the establishment of a number of societies and
pressure groups consisting of politicians, civil servants, & social reformers lobbied parliament.
Among others, these included:

 The Health of Towns Association, 1844

 The Metropolitan Association for Improving the Dwellings of the Industrial Classes
 The Association for Improving Cleanliness Among the Poor, and others.

Through their efforts landmark legislation was passed including:

 1846 The Nuisances Removal Act was passed, giving local justices the power to
prosecute and fine landlords for infractions having to do with sanitation (poor housing,
garbage, cesspools and faulty drains).
 1848 The Public Health Act created a General Board of Health in London that could
direct localities to create local boards empowered to deal with environmental filth.

 In the 1850s The Epidemiologic Society of London was formed, consisting of local
physicians, ex-military commanders, and civil servants who presented papers related
to public health issues.
 1853: John Snow presented "The comparative mortality of large towns and rural
districts and the causes by which it is influenced". This intersection of statistics,
philosophy, and economy sparked a new agenda for social reform.

These efforts had an enormous impact. The graph below shows the remarkable decline in
mortality from tuberculosis in the United Kingdom from 1850 to 1960.The remarkable decline
in mortality from TB and other infectious diseases is believed to have been the result of the
many environmental improvements that occurred as a result of the implementation of the
"Sanitary Idea." Note the temporary up-surge in TB death rates during the World Wars I & II,
when nutrition suffered and many were forced to live in cramped, poorly ventilated quarters.

Louis Pasteur (late 1800)

Louis Pasteur was a French biologist and chemist who made enormous contributions to germ
theory, to prevention of food spoilage, and to the control of disease. In 1853 Pasteur began
studying fermentation in wine and beer and rapidly concluded that microorganisms were
responsible. He also discovered that microbes in milk could be killed by heating to about 130
degrees Fahrenheit, a process which is now known as 'pasteurization'. He discovered that
some microorganisms require oxygen (aerobic organisms), while others reproduce in the
absence of oxygen (anaerobic).

Pasteur pioneered the idea of artificially generating weakened microorganisms as vaccines.

Edward Jenner's work had demonstrated the principle with the naturally occurring cowpox,
which could be used to vaccinate against smallpox. Pasteur was able to artificially weaken
strains of anthrax and cholera in order to generate vaccines. It was, in fact, Pasteur who
coined the term 'vaccine' in honor of Jenner's discovery. Pasteur developed vaccines against
anthrax in sheep and cholera in chickens. In 1885 he developed a vaccine for rabies by
growing it in rabbits and then drying the nerve tissue that had been infected with the virus.
This vaccine was successfully used to save the life of a boy who had been bitten by a rabid
dog.

Public Health in the United States

Events in the US paralleled those in the United Kingdom. The US also underwent a rapid
transition from a rural, agricultural society to one that was intensely urban and industrial.
Inventions such as the cotton gin that promoted agricultural production, but also decreased
the need for farm workers, driving many to the cities for work. Economic growth and
inventions spawned factories and textile mills in US cities.

Many of the facts and images below come from the History of the Public Health Service from
the US National Library of Medicine.

The 1700s

 1798 - Congress passes the Act for the Relief of Sick and Disabled Seamen and
authorizes formation of the US Marine Hospital Service (MHS), which was the
forerunner of the Public Health Service. Seamen often became ill while at sea and
often were unable to find adequate health care in port cities. Their health was viewed
as essential to the developing country, and a network of marine hospitals, mainly in
port cities, was established by Congress in 1798 to care for sick and disabled
seamen. Seamen were taxed 20 cents a month in order to raise funds to pay
physicians and support the network of hospitals. This tax was abolished in 1884.
From 1884 to 1906 funds were raised by a levy on merchant ships, and after 1906
funds were allocated by the US Congress.
 1799 - Castle Island in Boston Harbor was chosen as the temporary site for the first
marine hospital. Dr. Thomas Welsh, a Harvard College graduate and participant in
the Revolutionary War battles at Lexington and Bunker Hill, was appointed as the
physician in charge.

 1799 - Boston establishes the first board of health and the first health department in
the United States. Paul Revere is named as the first health officer.

The 1800s

 1804 - The Boston Marine Hospital is established in the Charlestown section of

Boston. Dr. Benjamin Waterhouse was appointed the physician in charge from 1807-
1809.
 1800 - Dr. Benjamin Waterhouse introduced smallpox vaccination to the United
States
 1842 - Lemuel Shattuck, a Massachusetts legislator, established the first US system
for recording births, deaths and marriages. Largely through his efforts Massachusetts
legislation became the model for all the other states in the Union. Among Shattuck's
 many contributions were his proposal for a standard nomenclature for disease;
establishment of a system for recording mortality data by age, sex, occupation,
socioeconomic level, and location; the application of data to programs in
immunization, school health, smoking, and alcohol abuse.
 1849 - The Massachusetts legislature appointed a Sanitary Commission 'to prepare
and report to the next General Court a plan for a sanitary survey of the State', with
Shattuck as Chief Commissioner and author of its report. The report (1850) was
enthusiastically received by the New England Journal of Medicine, but the 50
recommendations in the report were otherwise ignored. Twenty years later the
Secretary of the Board of Health of Massachusetts based his plans for public health
on Shattuck's recommendations.

From from the US National Library of Medicine's web pages on The History of the Public
Health Service:

"The 1870 reorganization [of the Marine Hospital Service] also changed the
general character of the Service. It became national in scope and military in
outlook and organization. Medical officers, called surgeons, were required to
pass entrance examinations and wear uniforms. In 1889, when the
Commissioned Corps was formally recognized by legislative action, the
medical officers were given titles and pay corresponding to Army and Navy
grades. Physicians who passed the examinations were appointed to the
general service, rather than to a particular hospital, and were assigned
wherever needed. The goal was to create a professional, mobile, health
corps, free as possible from political favoritism and patronage, and able to
deal with the new health needs of a rapidly growing and industrializing
nation."
Epidemics of contagious diseases, such as small pox, yellow fever, and
cholera, had devastating effects throughout the 19th century. They killed
many people, spread panic and fear, disrupted government, and caused
Congress to enact laws to stop their importation and spread. As a result of
these new laws, the functions of the MHS were expanded greatly beyond the
medical relief of the sick seamen to include the supervision of national
quarantine (ship inspection and disinfection), the medical inspection of
immigrants, the prevention of interstate spread of disease, and general
investigations in the field of public health, such as that of yellow fever
epidemics."

 1874 - The Massachusetts State Board of Health instituted a voluntary plan for
weekly reporting of disease by physicians.
 1884 - Massachusetts passed legislation requiring the reporting of "diseases
dangerous to the public health" and imposed fines for not reporting
 1887 - A small "Hygienic Laboratory" was established at the marine hospital on
Staten Island to aid in the diagnosis of infectious diseases among passengers of
incoming ships. The laboratory later moved to Washington, D.C., and eventually
evolved into the National Institutes of Health.

The video below is a segment from a PBS documentary on public health. This particular
segment focuses on events at the dawn of the 20th century when bubonic plague threatened
San Francisco. Note the futile and inappropriate use of quarantine to deal with the threat of
plague. The last section of the clip describes a broad array of public health interventions that
eventually emerged.

Bubonic Plague Video Transcript

  1891 - The Immigration Act of 1891 required that all immigrants entering the US be
given a health examination by PHS physicians. The law stipulated the exclusion of
"all idiots, insane persons, paupers or persons likely to become public charges,
persons suffering from a loathsome or dangerous contagious disease," and criminals.
The largest inspection center was on Ellis Island in New York Harbor.

 1894 - The first epidemic of polio strikes the United States.

The 1900s

 1900 - Some estimates indicate that HIV was transmitted from monkeys to humans
as early as 1884-1924, but was either unrecognized or failed to initiate human to
human transmission until later.
 1902 - The US Congress expanded the scientific research work at the Hygienic
Laboratory and gave it a definite budget. The legislation required the Surgeon
General to organize conferences of local and national health officials in order to
coordinate state and national public health activities. The Marine Hospital Service
was renamed the Public Health and Marine Hospital Services (PHMHS) to reflect its
broader scope.
 1906 - Congress passed the Federal Meat Inspection Act requiring the Department of
Agriculture to inspect meats entering interstate commerce. They also passed the
Food and Drugs Act. The law forbade adulteration and misbranding of foods, drinks,
and drugs in interstate commerce, but contained few specific requirements to insure
compliance.

"The working environment and its effect on worker's health became a major
area of study for the Public Health Service starting in 1910. Investigations in
the garment making industry, as illustrated by these women making flowers,
revealed unsanitary conditions and an excessive rate of tuberculosis. Other
studies were done of silicosis among miners, sanitation and working
conditions in the steel industry, lead poisoning in the pottery industry, and
radiation hazards in the radium dial painting industry."

 1912 - The PHMHS was renamed the United States Public Health Service, and it was
authorized to investigate human diseases such as, tuberculosis, hookworm, malaria,
and leprosy), sanitation, water supplies and sewage disposal.
 1916 - Johns Hopkins University founds the first school of public health in the the
United States with a grant of $267,000 from the Rockefeller Foundation. The
Rockefeller Foundation later supported schools of public health at Harvard and the
University of Michigan.
 1918 - The influenza pandemic of 1918 struck. It is believed to have caused at least
25-50 million deaths worldwide.

 1925 All states begin participating in national reporting of disease

 1938 Congress passed the Federal Food, Drug, and Cosmetic Act of 1938, and major
amendments to the law were made in 1954, 1958, and 1960. Today the law requires
manufacturers to provide scientific proof of a new drug's safety. The law also makes
dangerous or falsely labeled cosmetics and therapeutic devices illegal. Enforcement
of these laws is the mission of the Food and Drug Administration (FDA), which is
tasked with ensuring that foods are safe and wholesome. It also ensures that drugs
and medical devices are safe and effective, and that cosmetics are harmless.
Provisions are also made to ensure accurately labeling and that radiofrequency
emissions from electronic devices is not hazardous to consumers.
 1948 Richard Doll and Bradford Hill conducted a landmark epidemiologic
investigation of the cause of the remarkable increase in lung cancer that had
occurred during the 20th century. They identified lung cancer patients in 20 London
hospitals and enrolled a comparison group of non-cancer patients and conducted a
case-control study. Somewhat to the surprise of Doll and Hill, the study found that the
 one consistent difference between lung cancer patients and the non-cancer controls
was that the cancer patients were more frequently smokers, and they were heavier
smokers. In retrospect, the study was quite carefully done and quite convincing.
Nevertheless, it initially stirred much controversy, even among the medical
community. Smoking was extremely prevalent, even in physicians, and many refused
to believe that it could be a cause of cancer. Other studies were conducted which
corroborated these findings, and eventually the importance of the study was
recognized, not only for establishing the link between smoking and lung cancer, but
for establishing the role of case-control studies. At the time, case-control studies were
infrequently done, and careful standards for their conduct had not been established.

 1948 The Framingham Heart Study began with the goal of identifying the factors that
contribute to cardiovascular disease by following its development over a long period
of time in a large group of disease-free participants. The researchers recruited 5,209
men and women between the ages of 30 and 62 from the town of Framingham,
Massachusetts, and began the first round of extensive physical examinations and
lifestyle interviews that they would later analyze for common patterns related to
cardiovascular disease. Since 1948, the subjects have continued to return to the
study every two years for a detailed medical history, physical examination, and
laboratory tests. In 1971 the Study enrolled a second generation - 5,124 of the
original participants' adult children and their spouses - to participate in similar
examinations." Click on this link to see an excellent PBS video on the history of the
Framingham Heart Study and its impact on heart disease.:

"Medical discoveries and public health campaigns have almost eliminated

deaths from the common diseases of childhood such as measles, diphtheria,
scarlet fever, and whooping cough. As a result of these successes nearly 20
years were added to the average life expectancy at birth between 1900 and
1950-from 47 to 67 years."
"As epidemic diseases were brought under control the Public Health Service
began to shift its attention to other areas such as cancer, heart disease,
health in the workplace, and the impact of environmental problems, such as
toxic waste disposal, on health. But the Public Health Service is still called
upon to investigate outbreaks of disease such as Legionnaire's, toxic shock
syndrome, and now the deadliest epidemic of our age -- AIDS. Much of the
work of the early plague fighters and sanitarians is now carried out by the
scientists at the Centers for Disease Control and Prevention (CDC) in
Atlanta, Georgia."

 1952 Polio cases surge in the US. Early testing of the vaccine developed by Jonas
Salk is encouraging.
 1953 Under President Eisenhower, Congress created the Department of Health,
Education, and Welfare (HEW).
 1954 A large scale clinical trial of the Salk vaccine begins
 Image of small boy with polio standing with crutches

 1959 Rene Dubos published a landmark book entitled "The Mirage of Health" in
which he convincingly argued that the decline in mortality since 1850 was not
primarily due to laboratory medicine; it was due to control of infectious disease as a
result of sanitation and improvements in nutrition. He also pointed out that Western
health was not optimal and that life expectation at age 45 had improved little.
Moreover, one out of four Americans spent at least some time in mental hospitals.
Increasing levels of drug dependency (all kinds of drugs) also indicated that health
was not optimal. Dubos took the position that medicine's concept of specific etiologies
(and therefore magic bullets that could cure disease) was misleading. He said that
disease is complex and tends to be rooted in social, physical, and cultural
environment in which people lived.
 1970 The Occupational Safety and Health Act was passed by Congress, and
the Occupational Safety and Health Administration was founded in 1971.
 1970 The Environmental Protection Agency (EPA) was established to consolidate
federal research, monitoring, standard-setting and enforcement activities to ensure
environmental protection.
 1979 HEW's educational tasks were transferred to the new Department of Education
and responsibility for health was given to the newly organized Department of Health
and Human Services (HHS).
 1979 Smallpox is declared eradicated by the World Health Organization. The
eradication of smallpox, one of the deadliest and most dreaded diseases, was the
result of a massive global effort utilizing case finding and vaccination. The last known
case occurred in 1977 in Somalia.
 1980 President Jimmy Carter signed into law the Comprehensive Environmental
Response, Compensation and Liability Act (CERCLA or Superfund). This historic new
statute gave EPA the authority to clean up uncontrolled hazardous waste sites and
spills.
 1981 Dr. Michael Gottlieb and his associates report on four previously healthy young
men who had developed Pneumocystis carinii pneumonia. They hypothesized that
this was a new syndrome of acquired immunodeficiency cause by a sexually
transmitted infectious agent.
 2002 The Institute of Medicine issued a report entitled "Who Will Keep the Public
Healthy?" The report concluded that "... public health professionals must have a
framework for action and an understanding of the forces that impact on health, a
model of health that emphasizes the linkages and relationships among multiple
determinants affecting health. Such an ecological model, the committee believes, is
key to effectively addressing the challenges of the 21st century."
 20th Century Public Health Achievements
According to the CDC, public health has been credited with adding 25 years to the life
expectancy of people living in the U.S. in the 20th century. But, how? Since it can be difficult
for the general public to understand the impact of public health interventions, the CDC
created Ten Great Public Health Achievements in the 20th Century as a very helpful overview
of all the great things public health has been able to achieve.

 Vaccination to reduce epidemic diseases

At the beginning of the 20th century, infectious diseases such as smallpox, measles,
diphtheria, and pertussis were widely prevalent. Since there were few effective measures
available, death tolls were high. Both the development and promotion of vaccinations against
preventable diseases has resulted in dramatic declines in morbidity and mortality and even
results in the eradication of smallpox.

 Improved motor vehicle safety

Since 1925, there has been a 90% decrease in the annual death rate due to motor
vehicle travel. This is particularly impressive given the number of motor vehicles, drivers,
and miles traveled in motor vehicles have all increased dramatically since 1925.Some of
the biggest interventions include regulations developed and enforced regarding safety
belts, alcohol-impaired drivers, young drivers, pedestrians, and child safety and booster
seats.

 Safer workplaces

Data from CDC's National Institute for Occupational Safety and Health (NIOSH) National
Traumatic Occupational Fatalities (NTOF) surveillance system indicate that the annual
number of work-related deaths decreased 28% from 1980 to 1995 with a 43% decrease
in occupational injuries during the same time.

 Control of infectious diseases

The leading causes of death in 1900 were pneumonia, tuberculosis (TB), and diarrhea
and enteritis whereas in 1997, 4.5% of deaths were attributable to pneumonia, influenza,
and HIV infection. Sanitation and hygiene, vaccination, and antibiotics are among the
control measures responsible for this marked decrease. Who knew handwashing could
be so powerful!

 Decline in death from cardiovascular disease

While deaths due to infectious death have gone down dramatically, heart disease has
been the leading cause of death for most of the 20th century. Since 1950, age-adjusted
death rates from cardiovascular disease have been cut by more than half. Some of the
key public health factors contributing to this decline include the decline in tobacco use,
changes in the U.S. diet, and better early detection and treatment of those at risk of
cardiovascular disease (e.g. individuals with hypertension, high cholesterol, etc.)

 Food Safety

Contaminated food and water resulted in many foodborne infections in early in the
20th century. Advances, such as refrigeration, pasteurization, pest control, animal control,
and food safety regulations that promoted better hygiene and sanitation practices all
contributed to decreases in foodborne infections.

 Improvements in maternal and child health

Childbirth use to come with great risk to many mothers and infants. Over the span of the
century, the infant mortality rate declined greater than 90% and the maternal mortality
 rate declined almost 99%. Improvements in nutrition, standards of living, access to health
care, and surveillance and monitoring of disease contributed to reducing risks to mothers
and infants.

 Family planning

Better family planning interventions have resulted in longer intervals between births and
smaller family sizes, both of which have been associated with improved maternal and
child health outcomes.

 Fluoridation of drinking water

At the beginning of the century, extensive dental caries was common in the U.S. with
tooth extraction being the main treatment option available. Several studies have
suggested that water fluoridation has contributed to reductions in dental caries when
compared to communities without fluoridated water.

 Reductions in prevalence of tobacco use

Smoking has been associated with a number of morbidities including cardiovascular

disease, cancer, chronic obstructive pulmonary disease, and low birth weight. According
to the CDC, it is the leading preventable cause of death and disability in the United
States. Due to massive public health efforts that include smoking cessation interventions
and regulation of the purchase and use of tobacco, there have been substantial
reductions in smoking.

Challenges in the Twenty-First Century

Dramatic events in the late decades of the twentieth century and the first
decade of the twenty-first have deeply affected public health. Since the
1960s, the capacity of public health has widened, with local, national, and
global perspectives. The public sector has come to work with private sector
influences on activities such as the global eradication of polio and the
control of AIDS and malaria in sub-Saharan Africa. New attention has come
to focus on many unmet human rights issues such as slave trafficking and
genocide, which are still inadequately addressed in the international
development agenda. Economic globalization is increasingly associated with
health and human rights in academic and public discourse. They have met
partial success and some failures in achieving global health goals in the
context of political, economic, and public health values. The global
recession that began in 2008 will undoubtedly have a negative impact on
such global health goals, but the clear advantage of cost-effective prevention
interventions will become more and more apparent.

The understanding of the enormous impact of smoking reduction, healthier

diets, improved road safety, improved medical care for hypertension, and
long-term management of chronic conditions, mainly in the developed
countries, is now being recognized as essential for developing countries at
all stages of the development process. Public health achievements are
reaching mid-level developing countries and the emerging economies such
as Brazil, India, China, South Africa, and South-East Asia. Despite powerful
economic growth, China and India especially still remain poor for the
majority of their citizens. The countries lagging behind in sub-Saharan
Africa still suffer from weak infrastructure, corruption, and political
instability, which prevent the use of their natural resources to build modern
economies and civil structures of public health. Political instability and
inadequate infrastructure and the mixed effects of globalization and
recession also negatively influence public health.

Scientific advances in the discovery of causes of some chronic diseases in

the late twentieth century are coming as public health advances in the
prevention of birth defects (by folic acid consumption before and during
pregnancy), cancers of the stomach (from H. pylori infection), liver (from
hepatitis B infection), and cervix (from HPV infection). These remarkable
discoveries hold out hope for further advances in immunology in the years
ahead. Similarly, advances in knowledge of nutrition, genetics,
nanotechnology and chronic disease are already contributing to reductions in
cardiovascular disease and cancer mortality, and perhaps incidence, with
more benefits to come in the years ahead. Success in reducing mortality
from HIV as a result of the wider availability and lower costs of
antiretroviral drugs has opened a new phase in HIV control by reducing
transmission, such as from mothers to infants, but also for preventive care
after exposure and prevention of infection in high-risk groups. Here again,
economic recession may hinder the sustainability of such programs, such as
in preventing maternal–fetal HIV transmission.

At the same time, malaria control is disappointingly difficult in many

countries where it is still a major cause of childhood mortality; the search
for an effective vaccine is one of the great challenges so far unsuccessfully
met in immunology. Drug-resistant diseases are also an increasing challenge
awaiting scientific advances.

The first decade of the new century saw the enormous effects of terrorism,
such as the 9/11 attack in New York and the 7/7 attack in London, and these
effects are not limited to the direct deaths and casualties. Major wars and
chronic low-grade warfare in Afghanistan and Pakistan have serious
consequences not only in military and civilian casualties, but in financial
burden and economic downturn. Recurrent civil wars such as those plaguing
some African countries have tragic local effects but also hinder the adequate
development of public health infrastructure and public policy. Disasters
such as the Thailand tsunami and floods in Pakistan and China in 2010, the
enormous earthquake in Haiti and the Japanese tsunami of 2011 caused huge
devastation, loss of life, and the subsequent effects of homelessness, poor
sanitation, and consequent disease and death.
The world now faces a long-term threat of weapons of mass destruction in
the hands of fanatically religious, transnational groups who may promote the
use of such weapons in genocidal acts following years of incitement, a
known precursor to genocide. The public health consequences may be
devastating and result in new genocides, perhaps on an unimaginable scale,
with weapons of mass destruction available to radical regimes and terrorist
organizations.

Climate change has serious and far-reaching health implications, now and in
the future. It is already changing the distribution of some infectious disease
vectors; of death, disease, and injury from heat waves; of floods, storms,
fires, and droughts. Climate change may also cause social disruption,
economic decline, and displacement of populations, all of which may impact
health substantially, affecting especially the very young and the elderly, the
physically and mentally disabled, the poor and economically disadvantaged,
and other marginalized groups. Local public health agencies are tasked with
showing leadership in dealing with the effects of disasters on this issue.
Budget and labor cuts in a time of recession can seriously jeopardize
emergency preparedness planning and preparation.

Great challenges and opportunities lie ahead for public health, including
access to future scientific and health technology achievements in genomics,
nanotechnologies, and other scientific advances in vector control, vaccines,
cancer prevention and management, and coping with diseases associated
with aging and mental illness. The economics of health care will be
challenged by rising costs, economic recession, and still prevalent
inequalities in health status. The economic crisis building since 2008 will
push more people into poverty and unemployment while reducing spending
on public services, including public health and social support systems.
Privatization of health care and public health services will reduce access to
needed care.

Migration, civil strife, and threats of genocide will continue to challenge

human rights and public health. Natural and human-made disasters now and
in the future will cause large-scale loss of life and social disruption. Yet
health technology and the widening use of currently available preventive
measures will increase longevity in more and more countries. The
translation of scientific and technical capacity to meet human needs will
continue to be a challenge for civil societies and public health. Human
resources for health continues to be a serious challenge for health systems,
and with aging societies, new health disciplines such as community health
workers will be needed to meet human needs. These and many other issues
in public health will raise important ethical questions and challenges for
health promotion in mandating risk reduction, such as in smoking and
dealing with apathy or opposition to essential programs of public health
protection such as immunization for population as well as individual health.
Inequalities will perhaps be the greatest ethical challenge to face.

History has shown that societies can achieve greater longevity and a
healthier quality of life by the application of public health and health
promotion measures. The achievements of the past can be equaled in the
future with the brilliant achievements of individual and systems research
and the application of findings. Many innovations face apathy and serious
resistance, with a high cost in unnecessary morbidity and mortality. These
and related issues will be discussed in the chapters that follow and in
recommended readings, and in specialized courses in the broad context of
public health.

Summary

MEDICAL SCIENCE AND PUBLIC HEALTH

Public health professionals try to prevent problems from happening
or recurring through implementing educational programs,
recommending policies, administering services and conducting
research—in contrast to clinical professionals like doctors and
nurses, who focus primarily on treating individuals after they
become sick or injured. Public health also works to limit health
disparities. A large part of public health is promoting health care
equity, quality and accessibility

Provision of portable water as an aspect of public health practice