The Cult and Science of Public Health

A Sociological Investigation

Kevin Dew

• Publisher: Berghahn Books
• Year: 2012
• ISBN:
  9780857453402
• Edition: 1
• Topic: Sozialwissenschaften
• Subtopic: Soziologie

In contemporary manifestations of public health rituals and events, people are being increasingly united around what they hold in common—their material being and humanity. As a cult of humanity, public health provides a moral force in society that replaces 'traditional' religions in times of great diversity or heterogeneity of peoples, activities and desires. This is in contrast to public health's foundation in science, particularly the science of epidemiology. The rigid rules of 'scientific evidence' used to determine the cause of illness and disease can work against the most vulnerable in society by putting sectors of the population, such as underrepresented workers, at a disadvantage. This study focuses on this tension between traditional science and the changing vision articulated within public health (and across many disciplines) that calls for a collective response to uncontrolled capitalism and unremitting globalization, and to the way in which health inequalities and their association with social inequalities provides a political rhetoric that calls for a new redistributive social programme. Drawing on decades of research, the author argues that public health is both a cult and a science of contemporary society.

CHAPTER 1

Myths, Morality and Modern Public Health

Introduction

In German states in the eighteenth century, national policies and public health became closely entwined in the development of the ‘medical police’ (Rosen 1993). The medical police were state bureaucrats whose goal was the regulation of all aspects of human activity to foster the health of the nation. It was, as Rosen puts it, a form of enlightened despotism: all spheres of human activity, even the most private of individual affairs, were to be regulated for the benefit of the state. Johann Peter Frank, a leading advocate of medical policing, lobbied for bachelor taxes to encourage marriage, and for legislation that would enforce periods of rest for new mothers. The mothering and education of children were to be under police supervision, and Frank also prescribed in great detail the necessary diet, clothing, sanitation and recreation required to produce a population of healthy individuals. The goal of medical policing was to regulate health practices from the womb to the tomb through a systematic and comprehensive health policy (Rosen 1993: 164). Importantly, the justification for such measures was to improve the health of the state as a whole, and it was to this end that individual health was important.

The concept of medical police openly acknowledges the relationship between social control and public health. In order to bring about communal changes in health, individual freedoms may have to be limited, and non-conformists punished. Similar measures were adopted in other parts of the world: a course on medical police appeared in the Edinburgh medical school curriculum in 1809 (Smith 2007) and the policing of climate, physical education, and medicine were advocated. The Metropolis Management Act 1855 made the appointment of ‘inspectors of nuisances’ compulsory in London – and these inspectors were known as the medical police. In some jurisdictions the medical police’s powers included prosecuting for obscene language (Wood 2005). They had the powers to enter premises and even comment on domestic spaces such as the positioning of privies in houses (ibid.). In the eighteenth century their roles could include occupational hygiene and administration of hospitals, but by the nineteenth century this narrowed down to the control of epidemic diseases, the oversight of environmental sanitation and the implementation of sanitary surveillance.

This concern with the health of individuals so that the state itself is empowered has been a recurrent issue in public health up to the present day, yet is not a prominent feature of what have become its ‘founding myths’. This chapter will begin with a brief overview of such myths, which tend to focus mostly on public health’s discovery of scientific principles and commitment to individual well-being. This chapter will then go on to show, however, that the development of public health reveals that, unsurprisingly, it has been far more complex and riddled with conflict and tensions than such myths would indicate. There was in many cases a reluctance to adopt public health measures, either because there was doubt about their efficacy, or it conflicted with prevailing ideologies. When public health measures have been adopted, it has often been for reasons that cannot be reduced to paternalistic benevolence. As public health has developed, it has constantly brought about novel social and material relations. These have presented new, often unpredicted challenges and prospects for action. This chapter demonstrates some of the ways in which public health can come into conflict with business enterprise and with the general public. Drawing on a Durkheimian framing we can see how public health can act to restrain the state, particularly in relation to its free market ideologies, and restrain the individual.

As noted in the introduction, the foundation story of modern public health and epidemiology dates back to 1854 when Dr John Snow hypothesized that a cholera outbreak in London was caused by drinking water contaminated by sewage. John Snow’s ‘study’ has been hailed as ‘a model of the scientific, investigative approach to medical research, and clearly identified water as the medium by which the disease was transmitted’ (Halliday 2007: 77). In this story, John Snow marked on a map of London where all the deaths from the cholera outbreak had occurred. From this he identified the particular area of trouble and developed his theory about the cause of the outbreak. To prove his theory he removed the handle of the Broad Street pump where the contaminated water was coming from, and so the epidemic disappeared (Brody et al. 2000). The power of this story for public health lies in a number of factors. John Snow believed that cholera was caused by some organism in contaminated water, a theory that we now accept but which was hotly contested at the time. Current theories of cholera identify faeces-contaminated water as the means of spread, along with flies that have hatched in diseased faeces (Halliday 2007). But in the early 1800s, speculation about the cause of such diseases as cholera was rife. The Lancet noted that people had escaped a cholera epidemic ‘by rubbing their bodies with a liniment containing wine, vinegar, camphor powder, mustard, pepper, garlic and ground beetles’ (ibid.: 59). There were theories that cholera was the result of an emanation from the earth, from atmospheric electricity or from a shortage of ozone. A commonly held theory, articulated by Justus von Liebig, Professor of Organic Chemistry at the University of Giessen, was known as the zymotic theory. This theory posited that disease was the result of the putrefaction of organic material giving rise to contagious miasmas that spread infection through breathing (Halliday 2007). This became better known as the miasmatic theory of disease, and it was believed that foul odours, bad air, or a noxious atmospheric influence could be the source of a miasma and cause disease.

Miasmatic theories of disease causation were popular in the nineteenth century, and were at odds with the germ theory being promoted by Snow. Snow’s actions showed that this miasmatic theory was incorrect. His achievement is thus held as embodying the progressive nature of public health. Rather than being driven by theory, Snow simply applied a method of careful observation that drew him to the logical conclusion – the same conclusion anyone would come to if they followed the same logic. In addition, Snow is seen as being a founder of epidemiology, the study of patterns of disease and their causes.

There are many elements of this story of John Snow that have been contested by medical historians. Snow did not derive his theory from what he had found in his map, but drew his map to illustrate the prior theory that he had been working on for many years. In other words, he drew the map to support his theory, and made various editions of the map with changes in detail, such as altering the political boundary lines to highlight the areas where deaths occurred (Brody et al. 2000). Choices in representation were made to support an argument. Snow himself did not remove the handle, but after his report on the epidemic to the Board of Guardians of St James Parish, where the Broad Street pump was located, the handle was removed. Despite this, the story suggests that public health and epidemiology are not driven by theories, but by observation. Another important element of this story is that it shows that public health is about engaging in action. To paraphrase a famous saying by Karl Marx and apply it to public health, public health is not only about understanding the world, but changing it. John Snow did not simply locate the source of the problem; he sought to ameliorate it by removing the pump handle.

More recently, John Snow has come to be framed as a founder of community engagement. The story goes that during the epidemic there was one person affected by cholera that did not live in Broadgate, but lived in an affluent area some distance away. Snow found out from this person’s maid that she drank the water from the Broad Street pump because it was sweeter. Consequently, Snow’s detective work and active involvement is held as being the origin of the public health physician’s engagement with ‘ordinary people to find out about their habits and practices’ (Orme et al. 2007b: 11).

Logical argument, empirical observation, community engagement and action are then seen as the heart of public health. In the foundation story of John Snow these can be opposed to superstition, tradition, ideology and mere description or analysis of the world. In more recent and contemporary times, public health advocates have focused on the various success stories of public health, particularly the eradication of infectious disease.

Public health measures have been credited with some remarkable achievements. Vaccination is extolled for bringing about a dramatic decline in mortality rates for diseases such as measles, diphtheria, whooping cough and tuberculosis, which in the late nineteenth and early twentieth centuries caused many deaths. Public health vaccination campaigns, along with the use of antibiotics to fight bacterial infections, were deemed to be so successful that it was claimed that as a cause of death, infectious diseases have been reduced to insignificance (Davis 1981). Such claims were obviously made before the emergence of HIV/AIDS.

From this perspective, the fall in death rates from infectious diseases can be seen as an outstanding success in public health. However, apart from smallpox and polio, infectious diseases were well into their decline before vaccines were developed for these diseases. Whooping cough was a disease that could kill hundreds or thousands of people during an epidemic, but from the early 1900s epidemics would rarely cause death. Measles caused severe mortality in ‘developed’ countries, even through the interwar years, but since then it has been a relatively mild disease (Maclean 1964).

Thomas Mckeown has provided a challenging and provocative argument in relation to this decline. He has argued that medical science was not responsible for the major decline in death rates from infectious diseases that occurred in the late nineteenth and early twentieth centuries. Improved diet and a rising standard of living were responsible for improving resistance to these diseases and so lowering the death rates. The only real exceptions here, Mckeown argues, are vaccinations for smallpox and sanitary improvements reducing the impact of diseases such as cholera and typhoid (Hardy 2001). Otherwise direct human intervention accounted for little in the way of influence on measles, scarlet fever, whooping cough and many other diseases. Vaccines for these diseases were not available when the remarkable drop in death rates occurred, and a vaccine was never developed for scarlet fever. Mckeown’s thesis has subsequently been contested – and others have argued that public health interventions have had a greater role in reducing death rates and improving health than Mckeown claims (ibid.).

However, while what accounted for the rapid decline in morbidity from infectious diseases is not absolutely clear, changes in sanitation and sewerage measures and nutritional changes would have had a major part to play in this (McKeown 1979; Szreter 1995). Improvement in the health of children or changes in the virulence of the disease were also seen as possible explanations (Maclean 1964). It should be noted however, that even with the reduction in death rates during the late 1800s, health gains in terms of morbidity were small (Hardy 2001). Health experience was dominated by ‘the miserable run of chronic respiratory, rheumatic and digestive illness’ (ibid.: 46).

The reality of public health, then, has not been as clear and logical as the picture that is often presented. But these foundation myths persist as important elements in the moral authority that public health exercises in contemporary society.

Modern Developments in Public Health

Early precedents of public health can be found in ancient Greece. In around 400 BCE, the medical discipline of hygiene was developed. In the name of the goddess Hygieia, this discipline ‘attempted to control every aspect of the human environment – air, diet, sleep, work, exercise, the evacuations, passions of the mind’ (Smith 2007: 74). Hygieia is a concept which conceptualizes health in terms of a perfect human body set within a perfect environment – a wholesome life extending the lives of patients under Greek physicians (ibid.). Perfection was not found in extremes, but in moderation and a balance of opposites (ibid.).¹

The Protestant Reformation ushered in other views about the care of the body, with diet and cleanliness again being central and a continuing Greek influence leading to the strong promotion of exercise (Smith 2007). The ‘reformed body’ was kept pure not only through religious practices and demeanour but also through diet (ibid.). Exercise and fitness, however, particularly in relation to sports, was not always an important part of the health and care of the body. While physical prowess, strength, and fitness were prized by the Greeks, sports and games were repressed during the Old Commonwealth in England. These were revived in the Restoration, and in 1724 George Cheyne, the author of the best-selling Essay on Health and Long Life, insisted that exercise should be part of a patient’s religion (ibid.). This relation between physical and moral health was a popular theme within Christian movements. The Christian mission has historically been associated with helping the poor and indigent, as well as with the mission of healing. William Buchan, the author of the best-selling British health manual – Domestic Medicine – published in 1769, wrote: ‘There cannot be a more noble, or more god-like action, than to minister to the wants of our fellow creatures in distress … to instil into their minds some just ideas of importance of proper food, fresh air, cleanliness, and other pieces of regiment necessary in diseases, would be a work of great merit’ (cited in Smith 2007: 255).

It is around this time that Johann Peter Frank was advocating the establishment of medical police in the German-speaking states. The view was emerging that population health was vital to the health of the state as a whole: a healthy, fit population of men and fertile, healthy women create a strong, productive and competitive state. For the next two hundred years or so, this was to become a strong argument for adopting public health measures.

George Rosen argued that the development of medical police was symptomatic of a centralized and despotic form of governance common to the German-speaking states. In contrast, medical police would be in conflict with the more laissez-faire approach to governance of eighteenth- and nineteenth-century Britain (Rosen 1993). In comparison with the German-speaking states, the development of public health in Britain was characterized by a great deal of tension with commercial interests. On one hand, there was anxiety that any centralized form of public health would infringe upon the liberal tradition and the individual, and the commercial rights it championed. On the other hand, there was considerable disquiet over the appalling living conditions of a large section of British society.

These appalling living conditions were in part a result of the rapid urbanization that accompanied the industrial revolution. The industrial revolution brought about a spectacular growth in urban centres, with London experiencing a six-fold increase in the population (Halliday 2007). During the nineteenth century the growth of cities and the impacts of industrialization led to shifts in thinking about responsibility for health. It was no longer considered a wholly private matter, but now increasingly regarded as requiring government action (Hardy 2001). This was clearly seen in the development of compulsory vaccination legislation, but also in the increasing use of epidemiology to describe national disease pictures and encourage public health interventions. Prior to the Public Health Act of England and Wales in 1848 governments had responded to public health issues by using decrees, whereby in response to epidemic diseases beds could be burnt, houses fumigated, towns whitewashed and so on.

In England in the late 1800s towns were not kind to human health: ‘Their skies were black with coal smoke, their streets strewn with horse manure; in summer they were alive with flies, in winter dank and damp with fog’ (Hardy 2001: 13). Sickness at this time came at a great cost. It has been estimated that 72 per cent of pauperism in England in 1871 was the result of sickness (Hardy 2001). For those who found themselves destitute the poor laws ensured that their experience was not a pleasant one, with recipients of poor relief being subjected to the harsh conditions of the workhouses, being politically disenfranchised and forfeiting ‘their normal rights as citizens’ (Sturdy 2002a: 243). In 1871 the Poor Law Board was abolished and a Local Government Board took over its function. This change heralded a shift from focusing on the poor law as a deterrent to receiving relief to a view that there was a public responsibility to provide medical services (ibid.). Research on the impact of poverty on health supported this change of focus. Charles Booth, a Liverpool shipowner, initiated his research into poverty in London in the 1880s, producing a ‘poverty map’ to illustrate the levels of deprivation suffered in different areas of the city (Halliday 2007). He concluded, to his dismay, that more than a third of the population lived in poverty (Hardy 2001). Similarly, Seebohm Rowntree, a Quaker industrialist, concluded that a third of York’s population lived in poverty and that the working classes received 25 per cent less than the necessary nutritional requirements for physical efficiency (Hardy 2001).

Many families in nineteenth-century Britain became reliant upon state relief measures after the male breadwinner died from acute infectious disease. Inadequate sewerage systems and water supplies were identified as possible causes for this state of affairs and therefore legislation was developed to deal with the problem (Hamlin and Sheard 1998). An added bonus to governments of introducing public health legislation was that such action might help to quell a working class that was becoming increasingly revolutionary. In addition to impoverished food, harsh working conditions, polluted waterways, poor sewerage systems, and industrial pollution and smog, city dwellers in the 1800s had to cope with an immense amount of animal traffic as they were brought to slaughter houses and markets. Cities had to deal with tons of animal droppings (Halliday 2007).

In 1836 the General Register Office (GRO) was established in the United Kingdom and this has been identified as a crucial development in providing an evidence-base and was an ongoing feature of public health discourse (Mooney 2008). This office provided for the registration of births, marriages and deaths, and more importantly from a public health perspective, the causes of deaths. Such an office provided the foundation for epidemiological studies that could have a profound impact on the development of social and health policy. Although there has been much debate over how best to use summary health measures over time, for example crude death rates, standardized death rates, or life expectancies, measures of this type have been consistently used from the mid-1800s to today (ibid.). Initially they could be exploited to provoke public health and policy action to improve the health of the population, and in turn could be used as a measure of progress in such interventions as sanitary reform (ibid.).

Early examination of this register revealed that 15 per cent of children did not survive to their first birthday in the nineteenth century (Halliday 2007). GRO data showed that Britain was also a divided nation in terms of the experience of health and premature death. Those in the south and in rural areas had lower death and illness rates than those in the north and in the cities (Hardy 2001). In addition, there was a difference in these experiences by social class – a finding that is as notable today.

GRO data provided important information on patterns of death and disease. At the same time some features of urban life came into focus, such as housing conditions. Poor housing was becoming the centre of public health debates. Heavy Irish immigration to Liverpool following the 1845 potato famine meant that it was not unusual to find up to sixty people sharing a four-room dwelling (Halliday 2007). During the late 1800s programmes of slum clearance were common in the major cities and legislation was introduced to improve housing conditions. But medical officers of health were conscious that to enforce such acts would merely shift the housing problem from one district to another. In 1847 Dr William Henry Duncan was appointed as Britain’s first medical officer of health in the city of Liverpool (Halliday 2007). The medical officer was to ‘inspect a...