PUBLIC HEALTH
An Introduction
In the past year, the world has learned a powerful and painful lesson: “public health” matters. Often treated as secondary to curative measures, the field has suddenly taken on primary importance, a matter of life and death, potentially for every person on the planet. We have begun to learn of the diverse approaches relied on by different countries, some of them more effective than others, with great and sometimes surprising disparities in outcomes. We can now put these agonizing experiences to positive use. At all levels, from individual to governmental to international, public health is a concern we can no longer ignore. The COVID-19 crisis has demonstrated with transparent clarity the field’s relevance, and the importance of developing a deeper understanding of the systems it involves — what does what, what works, how well, and why.
What Is “Health” and What Is “Public Health”?
“Health” can be defined narrowly or broadly. Narrowly, it is simple medical well-being; more broadly, it is physical, mental, and social well-being of all kinds. By any definition, health is fundamental to each of us and all of us. As Leigh Hunt wrote, “Health is the groundwork of all happiness.” Some people are fortunate, born with good genes into a physically and socially healthy society. Others may be disadvantaged, from birth, or later. If you are well, you may too easily take health for granted. If you are ill, you are reminded daily of its value. This is why throughout human history one of the most important things for any society to do has been to try to ensure the wellbeing of its members, both those in good health and those less fortunate.
To this end, “public health” is the study of health practices as they relate not just to individuals, but to wider groups, i.e. societies and nations. The subject, whether or not so labeled, has been pursued by every society to ever exist, each one paying close attention to the quality of their food, drink, shelter, sanitation, and medicine, often reflected in cultural and religious practices directly or indirectly. Periodically there have nevertheless been terrible outbreaks of disease that have especially driven efforts to better safeguard health, as with the plagues that periodically decimated huge swaths of humanity in previous centuries.
In the course of the long and complex history of public health, we have sometimes forgotten, to our cost, that there is still much to learn from the sufferings and solutions of peoples of the past. What we today more usually think of as public health is a product of the scientific and industrial revolutions of the last three hundred or so years, put into practice by modern systems of government, which these days are expected to take responsibility for the health and well-being of their people. Public health has evolved into a vast and multi-faceted field of study and practice, ranging from such mundane daily matters as diet, smoking, alcoholism or exercise to the most sophisticated medical and sociological studies of an enormous range of diseases and behaviors, all examined through highly computerized technologies and applied by specialized bureaucracies, private and governmental.
Origins of Public Health
What we today call “public health” has emerged from the idea that human life is sacred, at least as ancient as the mosaic principle of pikuach nefesh providing for the primacy of human life over religious rule (c. 5th century BCE). Sanitation, hygiene, nutrition and fitness practices, sometimes codified as part of civil and religious obligations, all played an important role in ancient societies, and laid the ethical and scientific foundations of contemporary Western medicine, through such figures as Hippocrates (4th century BCE).
Much of what determined human well-being, however, remained a mystery, and was often attributed to God’s will and nothing more, as with the Biblical inevitability that “in sorrow shall you bring forth children.” Nevertheless, over thousands of years humans sought remedies to the imperceptible threat of pathogens they had yet to uncover. Mediaeval waves of disease such as the “pandemics of leprosy, plague, syphilis, smallpox, measles and other communicable diseases” led to such public health measures as isolation of lepers, quarantine of ships and travelers, and closure of public bath houses. Preventative measures in Europe, as elsewhere, came to include both religious and charitable institutions offering some degree of care for the sick. Building on the remarkable progress achieved in Islam’s golden age of scientific and cultural development, Renaissance-era study and research, sometimes conducted despite civil or religious restrictions, began to reveal much information about the structure and functioning of the human body. With the Enlightenment in the eighteenth century, approaches to the study of illnesses such as typhoid, cholera, occupational diseases or nutritional deficiencies, and of solutions such as vaccination or diet or meticulous hygiene, became more systematic. Names like Jenner, Lister and Pasteur contributed to new fields of study, including epidemiology, immunology, microbiology, pharmacology and toxicology. Increasingly, governments became more involved in health issues, at local, provincial, national and even international levels (note the first International Sanitary Conference, regarding cholera, in Paris, 1851). At the same time there was growing awareness of the health implications of social reforms, such as the abolition of serfdom and slavery, or improving housing or the conditions of workers, or the provision of state-legislated health insurance as in Bismarck’s Germany in the 1870s or, later, Britain’s NHS (1948). There were also less dramatic reforms being quietly made, coming from increased consciousness of the need for prevention, for outreach and home care, often provided by community health workers.
Such changes in practice reflected developing thoughts and philosophies, sometimes knowledgeably based, sometimes not. Debated topics included issues of priorities and expenditure, general prevention and primary care versus hospitalization and curative specialization, the balance of focus on individual versus community, chemical treatment of food and water, sexual behaviors and reproductive care, universal health care, euthanasia, etc. In recent decades there has been growing consensus that among the increasing range of “rights” that have been identified over the centuries, there is a “right to health,” as asserted inter-nationally by the UN and WHO. In 1966 the UN endorsed an “International Covenant on Economic, Social and Cultural Rights,” further spelled out in the Alma-Ata “Health for All” promise (1978) of the “right of healthcare for everyone and the responsibility of governments to ensure that right.” Now, the UN’s inextricably interlinked 21st century “MDGs” (Millennium Development Goals) include poverty reduction, improved education and health standards, with special focus on clean drinking water, and women and children, and control of HIV/AIDS, malaria, and other diseases, all requiring constant vigilance — as the suddenness of the shock of the COVID-19 pandemic has proven. The SDGs (Sustainable Development Goals) which followed in 2015, replacing the MDGs, highlight the intricate interconnection of development areas: social justice, poverty, the planet and climate change, the ocean, water and sanitation, food security, gender equality and right to health and combat of diseases, right to education, green jobs and the economy … the whole framed in solidarity and empowerment of people..
Where We Are Today
Among the greatest issues of 21st century public health is the fundamental problem that different individuals and different societies have not benefited equally from the scientific and industrial developments of the last several centuries. Although humanity as a whole is healthier than ever before, people from poor communities and poor countries still by and large have very different outcomes from those coming from rich communities and rich countries. And even among the fortunate, some systems seem to work significantly better than others. Thus it is worth knowing what works, and what does not.
One striking fact about new post-decolonization governments is a renewed emphasis on health and education, the foundations of basic welfare for society in general. Accordingly, many LDCs (Least Developed Countries) have specifically sought to establish systems for the provision of elementary health care — systems which have sometimes been politicised, sadly undermining their value. Systems in both capitalist and socialist countries reflect an acknowledgement that all members of society have a right to healthcare, some by promoting the principle of universal medical care, others by supplementing privatization with social security and welfare programs. After a century of hot debate (see Theodore Roosevelt’s “New Nationalism” speech, Ossawatomie, 1910), the United States, for example, remains a mostly private, “employment-based” system, premised on private insurance companies which sell coverage against medical expenses to employees through their employers; gaps — the elderly, children, the poor, the unemployed — have gradually been covered (or not) by a patchwork of supplementary governmental programs.
The current pandemic has tested every element, functional and philosophical, of the many and varied systems of today. Conclusions must still be provisional, but among them we see that while we may be very different, we are all interconnected — “send not to know for whom the bell tolls,” a Chinese market can paralyze New York and London, kill in Delhi and Nairobi and Sao Paulo; that resources and preparation are necessary, but not sufficient; that wise and informed leadership is essential; that wealth does not in itself equal health; that large-scale medical issues become inextricably entangled with economic, social and political issues; that some systems do work better than others.
At international and governmental levels clearly there is much to be improved; and even at the individual level we have suddenly been alerted to grave dangers we had not thought much about, and to behaviors that we, singly or collectively, will need to change. Building on our long experience of the past, both of tragedy and of success, it will be the crucially important role of 21st century public health, making use of both private and public sectors, to “effectively and economically preserve, protect and promote the health of individuals and of greater society.”