|From past to present; the changing focus of public health
by Maria Joyce
Key sections include:
Environment, infectious disease, locating public health, the enlightenment, the Sanitarians, national provision of services, the inception of the National Health Service, ‘crisis in health’, The New Right, The Third Way, new public health.
Public health, the new ideology may be taken to mean the promotion of healthy lifestyles linked to behaviour and individual responsibility supported by government action; whereas traditionally the description tended to relate more to sanitary reform and ‘healthy conditions’. The chronological development of public health is mapped out, supported by the outlining and discussion of the emerging themes and influences pertaining to the study of public health. The approach to public health is positioned alongside the health of the population and the prevailing political/societal influence at the time. Public health is impacted on by poverty and environmental factors. Presently government policy to improve public health is delivered in a strategy that recognises the need for health improvement at times when the greatest impact on health is poverty and exclusion. The evidence reviewed demonstrates clearly that poor health without appropriate resources or intervention is cumulative and that the ‘right’ form of intervention can bring about long term health gains. Intervention from a national agenda needs to include individual’s health and the health of the community brought about through joint partnerships and multi-sectorial working.
Historically, the environment was seen to be causative of ill health and disease, precipitated by inadequacy of the air. Humid, marshy areas or toxic, rotting debris were thought to cause ‘miasmic disorders’, and it was thought best to reside in airy, well-ventilated places. The supposition being, miasma could be seen or smelt and disease produced by miasma was transported through breathing contaminated air or absorbed through the skin. The presence of disease was acutely observed in the summer season, when the smell would be particularly offensive. Unfortunately the corresponding link between rotting debris, flesh and heat with an increase in pests and rodents, which would inform later health initiatives, was not made at this time (Cipolla 1992). Belief systems were influenced by naïve sensory perceptions linking odour and miasma with overcrowded spaces as places of disease. Those financially better placed began to deodorise their environment with aromatic oils, flowers and herbs (Wear 1992). The environment was also seen as significant in humoral theories, where the body was thought to need a healthy balance of four humours: blood, phlegm, yellow bile and black bile with four elements: earth, air, fire and water and four qualities: hot, cold, wet and dry (Nutton 1992). Being cold or wet was often seen as the cause of colds or fevers; perspectives still present in popular lay discourse today.
In earlier times levels of understanding relating to infectious diseases was demonstrated with the Romans building isolation hospitals known as Leprosaria, quarantining their plague victims. Quarantine was associated with a contagionist understanding of ill health. Disease and isolation in this approach was separating the ill and infectious, to control the spread of disease (Lupton 1995). Quarantine stemmed from the belief that disease resided in places and bodies were responsible for the transmission of disease from infected to non- infected place (Armstrong 1993).
Fear and suspicion co-existed with ignorance and lack of education and the plague was construed, as a case of divine retribution in the absence of popularly understood causative indicators. The contribution of the church in leading a crusade against disease or indeed identifying causative behaviours was said to be welcomed when so little was known about the causes of these diseases. This resulted in an association between spiritual uncleanness and pathological condition, with the church prescribing segregation and exclusion to control disease, further reinforced by a system of notification, where those who fell ill were reported to the local authorities and isolated in their homes with all who had been in contact with them or removed from their homes when dead, through the window, into a barrow to be buried outside the city.
The onus on notification of infectious disease is still seen today in the Control of Disease Act 1984 and the Regulation of the Infectious Diseases 1988. This may have positive benefits to public health, limiting illnesses such as food poisoning and rapid identification of outbreaks of bacterial meningitis, measles and other illnesses through prompt notification and medical or environmental intervention. The role of ‘social conscience’ however and its manifestation in social control may have been responsible for dividing communities through encouraging individuals to report their apparently ill neighbours.
The tradition of public health and inherent understanding of the term, dates back as early as pre-Christian times, classified in five periods or bodies of thought: The Graeco-Roman period with emphasis on water and sanitation, the Medieval emphasis on epidemics, the Enlightenment emphasis on disease prevalence, the Industrialisation emphasis on working conditions and Modern era emphasis on bacteriology and virology (Rosen 1993 cited in Costello and Haggart 2003). A prevalent feature throughout the earlier periods being religious control, utilising methods ranging from diabolism which was thought to wreak bodily evil, sickness and ill health to the use of moral metaphors and victim blaming which gave way to rationalist, ‘scientific thinking’ during the enlightenment.
The perspective of public health over the past two centuries has been broken down into four major regimes and linked to mechanisms for social control by Armstrong (1993):
1) Quarantine – inclusion or exclusion and dominant up until mid 19th century,
2) Sanitary science – regulating the movement between different spaces environmental,
3) Interpersonal hygiene psychosocial attitudes and behaviours,
4) New public health (social and environmental patterns from the 1970’s).
Armstrong states that ‘new public health’ differs from the earlier three in the way it increases the scope of surveillance, gears behaviour to health targets and generalises danger. Armstrong’s use of the word ‘regime’ when categorising this period is also revealing. Bennett and DiLorenzo (1999) accuse ‘new public health’ of ‘nannying’ and imposing moral regulation on the population. A position further supported by commentators stating that:
‘The new public health can be seen as but the most recent of a series of regimes of power and knowledge that are orientated to the regulation and surveillance of individual bodies and the social body as a whole’ (Peterson and Lupton 1996, p3).
Some commentators suggest that the ‘old’ public health lasted only until the 1870’s when it was replaced by a more individualistic approach with germ theory and discoveries such as immunisation and vaccination (Ashton and Seymour 1988). Others state that ‘new public health’ emerged during the 1914-1918 war but accept that it goes further than a biological stance and recognises health problems linked to social conditions and lifestyles (Watterson 2003).
The concept of a ‘new public health’ is distinct from the ‘old public health’ in its departure from the biomedical model of disease and the adoption of a social model of health which
‘advocated a multi-causal approach that saw infectious and chronic degenerative disorders as being the result of a complex interaction between biophysical, social or psychosocial factors’ (Brown and Duncan p363).
Whether there is a reliance on the medical model in new public health may be disputed but public health policies that recommend preventative strategies seen in earlier Conservative government documentation such as Promoting Better Health (DH 1987) and Health of the Nation (DH 1992) increased the remit and power of health professionals (Peterson and Lupton 1996). The act of authority inherent in surveillance, screening and measuring targets is usually ascribed to a powerful medical model.