The public health movement. What goes around comes around. Allan Hildon Lecturer in Primary Care The good old days Life expectancy in England since the C17th 90 80 70 Life expectancy 60 50 40 30 20 10 From family reconstitution From vital registration (mostly rural) 0 1600 1650 1700 1750 1800 1850 1900 1950 2000 Year
The early public health movement The industrialization of Europe which started in the 18th century produced urban slums which were swept periodically by epidemics of typhoid and typhus. Life expectancy in many urban areas declined in the early C19th. As epidemics of Cholera spread through Europe, Rudolf Virchow (1821 1902) studied the connection between poor sanitation and disease, and challenged his fellow physicians to look beyond clinical manifestations of disease to recognize and treat the poverty and other social factors that underlay illhealth. Virchow s beliefs were later echoed in the slogans and practices of the sanitary reformers who gave birth to modern public health. John Snow and the cholera map Famous anaesthetist who administered chloroform to Queen Victoria. Observed the spread of cholera during a number of outbreaks in London between 1830s and 1850s. Famously mapped the cases and made the link between the sources of the water supplies in the Soho area. Concluded (along with Budd) that an unknown agent was responsible for transmission, but the significance of this observation was not appreciated until... Robert Koch isolated and cultivated Vibreo cholerae in 1883. Overcoming the urban penalty, Sweden, 1860s 1920s 64 Deaths /1000 / year 57 51 45 42 40 30 28 22 16 16 21 17 18 17 1861 1871 1881 1891 1901 1911 1921 16 12 9 8 9 9 Stockholm Gothenburg & Bohus 3 comparison counties*
C19th technology to the rescue Major sanitary reforms 1842 - Report to House of Lords on 'Sanitary Condition of the Labouring Population' 1848 - Public refuse removal in London 1865 - London Metropolitan Board of Works develops new network of sewers 1869 - Extension of franchise for local Gov't 1875 - Filtered water supplies 1900 - Chlorination of water supplies The public health movement The C19th model of public health was primarily directed to the control of filth, odour, and contagion, based upon the miasma theory of disease. Not unsurprisingly, the emphasis for many decades was on infectious disease due to the high mortality among the urban working population, and the fear that the poor living conditions could lead to social unrest. As mortality due to infectious diseases declined, attention turned to non infectious diseases (such as cancer and heart disease) in the mid C20th.
What a difference a century makes Source: WHO Top 10 infectious disease events of the C20th Category Vaccine Antibiotic Epidemic Bacterium Virus Controversy Anti-viral Public Health Basic Science Clinical Research "Event" Eradication of smallpox in 1977 Discovery of penicillin in 1927 Influenza epidemic of 1918-19 Tuberculosis (century) HIV 1981 - H. pylori: 1983 AZT (Zidovudine): 1986 Chlorination of water Plasmids: 1970 The RCT: 1945 Results of a Survey of Physicians asked to Name the Top 10 Infectious Disease Events of the Past Century 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Eradication of smallpox Discovery of penicillin Epidemic of HIV Epidemic of influenza 1918-19 Polio vaccine Childhood immunization Antibiotic resistance Treatments for Tuberculosis Cultivation of infectious agents Chlorination of water Survey conducted at The Harold C. NeuInfectious Disease Conference, May 18-20, 2000, Dallas, TX
Historical trend in Tuberculosis mortality Historical trend in Diphtheria mortality Historical trend in Measles mortality
HIV infections in gay men: England 8000 7000 6000 5000 Major public health campaign launched 4000 3000 2000 1000 0 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 Not such an exact science Sanitary reforms were associated with the recognition of the effects of the contamination of the body via the environment. Hygiene reforms emerged following the discovery of micro organisms. Lifestyle reforms focussed on the identification of risk behaviours. Environmental reforms revisited the premises associated with the contamination of the body. Genetic fundamentalism appears to revisit the Darwinian concept of survival of the fittest. The new public health movement Late C20th revival of interest in public health lead to the emergence of the new public health movement. Key events: Alma Ata conference, and Ottawa Charter for Health Promotion. Inherent in the new paradigm is the notion that public health research and practice must actively engage political and social injustice. Ironically, the roots of this radically new vision for public health are, in fact, more than a century old. The new public health attempts to recapture the population focus of the early sanitary movement, framing contemporary health issues as primarily being social rather than individual problems that require a social and political response.
What lies ahead? A key challenge to the new public health model lies in the ascendancy of the notion of health as a commodity that individuals purchase through a market place. This is starkly illustrated in the tensions between the aim of the Blair Govt health service reforms to empower individuals with choice, and the less than robust reforms outlined in the public health white paper (again emphasising the notion of individual empowerment to make the right choices). Emerging public health movements Healthy Communities Movement A fusion of urban planning and public health, predominantly addressing health in urban populations in developed nations. The Peoples Health Movement Aims to develop health, social justice, and equity in global economic development through social mobilisation.???