1 The Historical Development of Public Health
Nicholas Fulton Phin
The association between human disease and the growth of centres of population has long been observed and the concept of action at a community or population level to influence health is not new; the Romans incorporated aqueducts and sewage systems into the design of their cities. However, for this chapter, the historical focus will be on the emergence of the modern public health movement from the 1830s onward.
- Early public health work focused on the prevention of infectious diseases; the focus is now on other determinants of health.
- Many of the greatest successes of public health were achieved when the public health department was within and able to influence local government.
- Is the health service, with its emphasis on treatment and care, the right base for a modern public health service?
The Industrial Revolution created an unprecedented migration of people from the countryside to towns, resulting in rapid urban growth; between 1801 and 1831, Liverpool’s population grew from 77,000 to 202,000 and Manchester’s from 75,000 to 182,000. The absence of planning or building controls during this period meant that little consideration was given to either population density or the need for
adequate drainage and access to clean water. The ensuing insanitary conditions and overcrowding resulted in infectious diseases, such as smallpox, tuberculosis, cholera and typhoid, becoming significant causes of death and morbidity; life expectancy in the worst industrial towns was as low as 19 years.
There was therefore an inevitability about the emergence of epidemics such as cholera and it is likely that the first cholera epidemic of 1831–32, which killed over 22,000 people in England, was a key element in the emergence of the sanitary movement – the forerunner of the public health movement. At this time it was believed that disease was caused by poisonous, foul-smelling vapours from decomposing matter (the ‘miasmic’ theory). Improved sanitation to remove these smells and hence the source of the disease was considered the solution; a view supported by the observation that cholera was commonest where overcrowding and squalor, and hence smells, were most intense and strongest.
In 1842, Edwin Chadwick, the secretary of the Poor Law Commission, published The Sanitary Condition of the Labouring Population of Great Britain describing the appalling conditions under which many people lived. Chadwick, heavily influenced by the Utilitarian philosophy of ‘the greatest happiness for the greatest number’, argued strongly and passionately that disease could be eliminated if social conditions were changed. Chadwick’s report, the emerging sanitary movement and the outbreak of the second cholera epidemic in 1848 were the main drivers for the introduction of the Public Health Act 1848 and the beginning of the modern public health movement.
The Public Health Act 1848 required towns where the death rate was over 23 per 1,000 to establish local Boards of Health responsible for cleansing, adequate water supplies, sewerage, drainage and the regulation of slaughterhouses. The main officers of the board were a surveyor, an officer of health and an inspector of nuisances. Implementation was patchy as the Act was permissive where the death rate was less than 23 per 1,000 and therefore influenced by local attitudes and vested interests. It needed a further two epidemics of cholera and the death of Prince Albert from typhoid to convince the government of the day to introduce the Local Government Act 1872 requiring all districts to provide public health services led by Medical Officers of Health (MOH) and to consolidate all existing public health legislation into the Public Health Act 1875.
The Public Health Act 1875 was important for a number of reasons:
- Local authorities were required to provide public health services such as meat inspection, the provision of water supplies, sewerage, drainage and cleansing and required to regulate and inspect common lodging houses.
- Local authorities had the power to provide hospitals (fever hospitals) and medicines for epidemic control and a variety of powers to control infectious diseases.
- The appointment of an MOH became obligatory.
This Act was a milestone and gave local authorities far-reaching powers to intervene on behalf of the health of their population.
The scientific basis of public health action was strengthened by the work of John Snow, Louis Pasteur and Robert Koch. In 1854, John Snow demonstrated that the pattern of disease in a cholera outbreak in Soho was consistent with infection caused by drinking faecally contaminated water from the Broad Street pump, and not with miasmic transmission. In 1857, Louis Pasteur was able to demonstrate that the toxins thought to cause certain diseases were in fact living organisms and by 1864 had developed the germ theory to explain his findings. Robert Koch provided further support for the germ theory by identifying the bacteria causing tuberculosis in 1882 and cholera in 1884. The debunking of the miasmic theory of disease transmission and the acceptance of the germ theory of disease was a significant step forward in the development of public health; it established the importance of the study of epidemiology and microbiology in public health and was an effective basis for public health action.
The Boer War provided the unlikely stimulus for the next developments in public health; the rejection of over 28 per cent of army volunteers on health grounds in 1900 caused such alarm that a series of measures were introduced to improve the health of children. The 1906 Education (Provision of Meals) Act permitted local authorities to provide school meals and is the basis of the current school meals service. The 1907 Education (Administrative Provision) Act introduced the schools medical service led by the MOH, the aims of which were to ensure all schoolchildren had regular medical examinations in order to identify disease at an early stage. However, since many of the children’s ill health problems were present before school age and infant mortality was still very high (it had not improved in the 50 years before 1900),
action was directed at improving care during pregnancy and in the period after birth.
Before the 1902 Midwives Act, many midwives were untrained and this Act required midwives to be certified and registered with a Central Midwives Board; the local supervision of registration was the responsibility of the MOH. The importance of health visiting, started in the 1860s by a group of women from Manchester and Salford to encourage higher standards of child care, was recognised in the 1907 Notification of Births Act. This Act encouraged the notification of all births to the MOH so that a trained health visitor could visit the mother; notification became compulsory after 1915.
During the early twentieth century, public health continued to grow and develop as local authorities were delegated more powers: for example the Local Government Act 1929 transferred the functions of the Poor Law Authorities to county and borough councils, as well as responsibility for vaccination, hospitals and other institutions. It would be fair to say that public health was at its most influential from 1930 until the formation of the National Health Service (NHS) in 1948.
The introduction of the NHS saw the transfer of fever hospitals and infirmaries from local government to the health service. The school health service, health visitors, district nurses and social workers remained with the MOH and the development of community services became a priority. During this period, renewed attention was given to the environment with the Clean Air Act 1956, the Noise Abatement Act 1960 and the Control of Pollution Act 1970. The effects of this were most noticeable in the elimination in the early 1970s of the smogs that had affected many large cities.
Following the 1974 reorganisation of the NHS, many of the services associated with the MOH transferred across into the health service, and community medicine emerged as a medical speciality within the NHS. Social services and environmental health services remained within local government, the latter with support from the new community physicians.
Over the next few years, public health went into decline as the new community physicians found themselves increasingly drawn into the problems of acute medical care and the recurring financial problems of the health service. The public health agenda also changed and infectious disease was no longer perceived to be the problem it had been; cancer and heart disease were now the main causes of death and significant morbidity. However, it was two infectious disease incidents – an outbreak of salmonella at Stanley Royd Hospital and legionnaires’ disease
at Stafford Hospital – which led to the renaissance of public health. The Acheson Report, Independent Enquiry published 1998 attempted to clarify roles and responsibilities in relation to communicable disease and environmental hazards and the other aspects of public health. The term ‘public health’ was reintroduced and became formalised in health service guidance in 1993.
The 1990s saw a brief resurgence of interest in the concepts of public health but the managerial focus was on hospital activity and waiting times. The eventual demise of health authorities and the establishment of Primary Care Trusts (PCTs) in 2002 should have seen the resurrection of public health, given the emphasis in general practice on prevention and promoting health. Instead, PCTs rapidly became commissioning organisations focused on meeting healthcare targets and many within PCTs questioned the added value of public health. In 2003, the creation of the Health Protection Agency took the leadership, but not the responsibility, for infectious disease and other environmental issues away from the health service, further fragmenting public health in PCTs.
Information has been summarized from the Health Protection Agency (HPA) website (www.hpa.org.uk
2008) and typifies the evolving and dynamic focus of public health in the UK and the role of the HPA in the context of current public health issues.
The Agency’s roles are ‘to protect the community (or any part of the community) against infectious diseases and other dangers to health’ (HPA Act 2004). This is provided by the HPA via an integrated approach to protecting UK public health through support and advice to the NHS, local authorities, emergency services and others who also have health protection responsibilities. The Agency was established as a special health authority in 2003 and then as a non-departmental public body in 2005, with radiation protection as part of its remit.
The Agency’s services are provided through:
- The Centre for Emergency Preparedness and Response – prepares for and co-ordinates responses to potential healthcare emergencies and undertakes basic and applied research into understanding infectious diseases.
- The Centre for Infections – includes infectious disease surveillance, providing specialist microbiology and epidemiology services, coordinating the investigation and cause of national and uncommon outbreaks, helping to advise government on the risks posed by various infections and responding to international health alerts.
- The HPA Centre for Radiation, Chemical and Environmental Hazards – comprises the Radiation Protection Division and the Chemical Hazards and Poisons Division.
- Local and Regional Health Protection Agency services – work alongside the NHS providing specialist support in communicable disease and infection control, and emergency planning. They also oversee some laboratory services.
The Agency continues to provide a range of specialist services and advice; training doctors, nurses, scientists, emergency services and others in emergency preparedness and response including potential bioterrorist incidents; surveillance of potential threats to public health; works across national and international boundaries to reduce the impact of threats to public health; leads on Port Health arrangements.
What does the future hold for public health? There is little doubt that many in power acknowledge and support the public health agenda; public health is now everybody’s business but no one’s responsibility and there is still a lack of an overall sense of direction. Is the NHS, with its preoccupation with healthcare delivery and targets, the right place for what remains of public health, with its emphasis on promoting health? Local authorities are still responsible for many services that...