Public Health

Historical Perspective
Dr. Anjum Odhwani MD, MPH
Public Health in Primitive
Societies
Have a sense of community hygiene
bury excreta
burial of the dead
tribal rituals for the diseased
temporary isolation for the sick
smoke for fumigation
Public Health in Ancient
Societies (Before 500 B.C.)
Northern India - excavations dating from
around 2000 B.C. have evidence of bathrooms,
drains and sewers
Middle Kingdom Egypt (2700-2000 B.C.)
showed the presence of drainage systems
Code of Hammurabi (earliest written record
concerning public health), King of Babylon in
1900 B.C. included laws pertaining to
physicians and public health practices
Public Health in Ancient Societies
(Before 500 B.C.)
Sumerian clay tablet from 2100 B.C.
contains prescriptions for drugs
Minoans lived on Crete (3000-1430 BC)
drainage systems, toilets, water flushing system
Myceneans 1430-1150 BC
same as Minoans
Egyptians knew more than 700 drugs and
were some of the healthiest of ancient
civilizations.
Public Health in Ancient
Societies (Before 500 B.C.)
Hebrews wrote Book of Leviticus in about
1500 B.C.
first written hygienic code
• keep a clean body
• protect against contagious diseases
• isolation for lepers
• disinfecting of home after an illness
• sanitation of campsites
• protect food and water
• hygiene of maternity
Public Health in Classical Cultures
(500 B.C. to 500 A.D.)
Greeks began to travel to Egypt
Greeks took information from the Babylonians,
Egyptians, Hebrews and other people of the
Eastern Mediterranean
Included these in the Greek philosophy of health
and medicine
Active in the practice of community sanitation
Supplemented water from city wells by water
from the mountains if necessary
Public Health in Classical Cultures (500
B.C. to 500 A.D.)
Romans
Had extensive systems for public and private
hygiene
Brought clean water into their cities using
aqueducts
Had extensive bath and wash houses
Had system for getting rid of garbage and other
wastes.
Built the first hospital
Public Health of the Middle Ages
(500-1500 A.D.)
Dark Ages in Western Europe (500-1000
A.D.)
• saw the fall of Rome due to evil behavior
• went to the opposite extreme
– immoral to view one’s own body
– seldom bathed
– filthy clothes; used perfume
– diets were poor; used spices
– sanitation ignored; waste in streets
• many pandemics
Public Health of the Middle Ages
(500-1500 A.D.)

Both pagan rites and Christian beliefs

blamed disease on supernatural causes.
Christians generally believed that disease
was a judgement from God for sin
This led to a failure to prevent the spread of
communicable diseases
This is often called “The spiritual era of
Public Health”
Public Health of the Middle Ages
(500-1500 A.D.)
During the 7th century Islam appeared
religion stressed cleanliness
one problem---each Hajj (pilgrimage to
Mecca) was followed by a cholera
pandemic
crusades brought cholera back to
urbanizing Europe
Public Health of the Middle Ages
(500-1500 A.D.)
Leprosy spread from Egypt to Asia Minor to
Europe
lepers were banished
lepers succumbed quickly to starvation and
elements
inhumane measures ended leprosy in Europe
• One of the earliest recorded epidemic disease was
Leprosy
Public Health of the Middle
Ages (500-1500 A.D.)

Ghengis Khan brought plague west in 1219

Millions died in the known world
In some parts of France only 1in 10 survived
Known as the Black Death
Epidemics in Europe occurred periodically
1603, 1625, 1665, 1743, 1759, 1790
Control measures
quarantine of sailors at ports for 2 months
Public Health in the Renaissance
Period (1500-1700 A.D.)
Time of great trade
experience of the Dark Ages was not forgotten
People now asked how diseases arose
began to think that disease was not a
punishment from God
Careful record keeping showed that infections
killed the godly and the godless alike
Growing belief that it was environmental factors
that caused disease e.g. malaria= bad air
Public Health in the Renaissance
Period (1500-1700 A.D.)
In reality conditions did not change much in
the Renaissance period
Careful observations led to the recognition
of separate diseases
cholera, typhoid, TB, smallpox, etc.
Explorers, traders and colonists took
indigenous European diseases and spread
them to indigenous peoples in the New
World
Public Health in the Eighteenth
Century

Although there had been a recognition of the

role of the environment as a cause of disease,
living conditions were not conducive to good
health
This period had the beginnings of
industrialization and urbanization
Living conditions were poor and overcrowded,
water supplies were contaminated and working
conditions were unsafe
Public Health in the Eighteenth
Century
Significant milestone for both medicine and
Public Health occurred in 1796, when Dr.
Edward Jenner demonstrated the process of
vaccination as a protection against small
pox
Before this there had been only variolation
(inoculation with small pox material)
Public Health in the Eighteenth
Century
The first US census was taken in 1790
Average age at death in the US was 29
In 1798 Marine Hospital Service was
formed to deal with diseases on vessels
Public Health in the Nineteenth
Century
It was realized that social and sanitary
conditions impacted the economy
Industrialization led to the concentration of
populations in cities
Better agricultural methods produced better
nutrition
First sanitation legislation in England 1837
National Vaccination Board
Public Health in the Nineteenth
Century
Edwin Chadwick 1842
Report on an Inquiry into the Sanitary
Conditions of the Laboring Population of Great
Britain
General Board of Health for England 1848
John Simon - 1848
first medical officer of London
Public Health in the Nineteenth
Century
John Snow - 1850
deduced that cholera was caused by a small
entity in the water
used epidemiological data
Predated the discovery that micro-organisms
can cause disease
Predominant theory of contagious disease at the
time was the “miasma theory” (noxious
atmosphere or influence )
 Public Health in the Nineteenth Century
Ignaz Semmelweiss- 1850- decreased death-rate
of women from puerperal fever by introducing
hand washing
Theory of spontaneous generation (living organisms
could arise from inorganic or nonliving matter)
Pasteur in 1862 proposed the germ theory of
disease and later introduced pasteurization of
milk. Gave the death blow to the theory of
spontaneous generation.
Joseph Lister - 1867 - antisepsis
Public Health in the Nineteenth Century
Koch in 1876 demonstrated his postulates with
the anthrax bacillus
He formulated 4 postulates contributing to germ
theory
The disease agent must be found in all cases of the
disease
The disease agent must be isolated in pure culture
Inoculation of this disease agent must produce the
same disease in healthy animals/people
The disease agent must be re-isolated from the
inoculated animal/person
Public Health in the Nineteenth Century

Between 1877 and the end of the century

many bacteria that caused particular
infectious diseases were identified
1875 to 1900 The Bacteriological Period
of Public Health
Public Health in the Colonies
Massachusetts
first to record births and deaths - 1639
law against pollution of Boston Harbor - 1647
Isolation of smallpox patients and ships - 1701
hard to enforce
no agency to do it
Even the Federation of Colonies had little
luck really dealing with public health issues
Eighteenth century America
1790 George Washington ordered the first
census of the population to be made
1798 the Marine Hospital Service formed to
deal with diseases brought in by ships
1799 some cities (Boston, Philadelphia, New
York and Baltimore) formed Municipal Boards
of Health
19th Century America
Population increases
Country increases in size
Public health measures stationary
Epidemics common for
smallpox, yellow fever, cholera, typhoid,
typhus
Endemic diseases
tuberculosis, malaria
Shattuck Report - 1850
Lemuel Shattuck - legislator - MA
interested in public health
appointed to study sanitary problems in MA
document he wrote was ahead of its time
no national or state PH programs at the time
Shattuck's Recommendations
Establish state and local boards of health
Hire sanitary police or inspectors
Collect and analyze vital statistics
Exchange data and information
Sanitation programs for towns and buildings
Study health of school children
Recommendations continued
Study, supervise and/or control
TB, alcoholism, mental disease
Supervise and study immigrants
Erect model tenements, bath/wash houses
Control smoke
Control food adulteration
Recommendations continued
Establish nursing schools
Teach sanitary science in medical school
Include prevention in clinical practice
Get routine physical exams
Keep records of family illnesses
Preach health from the pulpit
Shattuck Report - 1850
Impact of this report was to start the
Modern Era of Public Health in America
Proposals took some time to implement
Massachusetts's State Board of Health was
founded in 1869 and by 1900 only 38 states had
state health departments
There were few county health departments
Public Health in the Twentieth
Century
At the beginning of the century
Life expectancy was less than 50 years
Leading causes of death were communicable
diseases (influenza, pneumonia, tuberculosis and GI
infections)
Vitamin deficiency diseases were common
including rickets, pellagra and scurvy
Deaths associated with pregnancy and
childbirth were also high
Public Health in the Twentieth
Century
Health resources development period
(1900-1960) is further divided into
The reform phase (1900-1920)
The 1920s
The great depression and World War II
The post war years
Public Health in the Twentieth
Century
Period of social engineering (1960-1973)
Period of health promotion (1973 to
present)
Public Health in the Twentieth
Century
The Reform Phase of Public Health
Involved both social and moral as well as health
issues
Public health nursing started with a school
nursing program in New York in 1902
In 1906 the passage of the Pure Foods and
Drugs Act
In 1910 New York passed Worker’s
Compensation Act
Public Health in the Twentieth
Century
First School of Public Health was
established in 1918 at Johns Hopkins
University
1918 was the birth of school health
education
Birth of first national level volunteer health
agencies
American Cancer Society 1913
Rockefeller Foundation established 1913
Public Health in the Twentieth
Century
The 1920s
Period of slow development in Public Health
Prohibition produced decline in alcoholics and
alcohol related deaths
Number of county health departments rose to
467
Life expectancy in 1930 risen to 59.7 years
Public Health in the Twentieth
Century
The Great Depression and World War II
by 1933 private resources could no longer meet
the needs of the people who needed assistance
Beginning in 1933, President Roosevelt’s New
Deal created agencies and programs for public
works
Building of hospitals and laboratories, control
of malaria and the construction of municipal
water and sewer systems
Public Health in the Twentieth
Century
The Great Depression and World War II
1935 The Social Security Act marked the
beginning of the involvement of the
government in social issues including health
World War II decreased the availability of funds
and resources for public health, but led to the
development of many important medical
discoveries that were made available once the
war ended
Public Health in the Twentieth
Century
The post war years
Antibiotic penicillin was made available
Insecticide DDT to kill insects that transmitted
communicable diseases was made available
Communicable Disease Center was set up in
Atlanta during the war, now known as the
Center for Disease Control and Prevention
(CDC)
Public Health in the Twentieth
Century
The post war years
Two major events in the 1950s
• Development of a vaccine to prevent polio
• President Eisenhower’s heart attack focused
attention on the nations number one killer,
heart disease
Public Health in the Twentieth Century

Period of Social Engineering

1965 passage of the Medicare and Medicaid
bills
• Medicare provides for health care to the elderly and
some disable people
• Medicaid provides health care for the poor
Period of Health Promotion (1974-present)
Recognition that the greatest potential for
saving lives is by education and life-style
changes by individuals
Public Health in the Twentieth
Century
Situation by the end of the Twentieth
Century
Life expectancy increased by 30 years
Major infectious diseases brought under control
Infant and maternal mortality rates decreased
by 90 and 99% respectively
Safer workplaces
Safer and healthier foods
Public Health in the Twentieth
Century
In 1970s, CDC conducted a study that
examined premature death
Study revealed that approx 48% of all
premature deaths were because of lifestyle
or health behavior-choices people make
This led the way for U.S. government’s
publication Healthy People: The surgeon
General’s Report on Health Promotion and
Disease Prevention
Major Eras in Public Health History
in the United States
Prior to 1850 Battling Epidemics
1850–1949 Building State and Local
Infrastructure
1950–1999 Filling Gaps in Medical Care
Delivery
After 1999 Preparing for and Responding to
Community Health Threats
Public Health in the Twenty First
Century
Problems to be faced
Health care delivery
Environmental problems
Lifestyle diseases
Alcohol and other drug abuse
New communicable diseases or old diseases
that have become resistant to drug therapy
Healthy People 2010
These are the governments goals for
improved health in the population
Also includes projected mechanisms to be
used to help to reach these goals
Healthy people 2010
Comprehensive, nationwide health promotion
and disease prevention agenda.
Designed to serve as a roadmap for improving
the health of all people in the United States
during the first decade of the 21st century.
Committed to a single, overarching purpose:
promoting health and preventing illness,
disability, and premature death.
Healthy people 2010
Can be used by many different people,
States, communities, professional
organizations, and others to help them
develop programs to improve health.
 Healthy People
Entering its Third Decade
1979 - Healthy People: The Surgeon General’s
Report on Health Promotion and Disease
Prevention
1980 - Promoting Health/Preventing Disease:
Objectives for the Nation
1990 - Healthy People 2000: National Health
Promotion and Disease Prevention
Objectives
2000 - Healthy People 2010
Healthy People 2010
Two overarching goals
28 focus areas
467 specific objectives
10 Leading Health Indicators
Goals of Healthy People 2010
1. Increase quality and years of healthy life.
(Health related quality of life, Global assessment, Healthy
days, Years of healthy life)

2. Eliminate health disparities. (gender, race and

ethnicity, income and education)
Bottom Line of
Healthy People 2010

A tremendous national resource

A remarkable intellectual investment
An important part of a national action plan