Public Health Concepts Explained

Section 1 : Introduction and General Concepts in Public Health,
Community Medicine & Preventive Medicine
Introduction, Definitions & General Concepts in RajVir Bhalwar, Mandeep Singh,
1 1
Public Health & Community Medicine J Jayaram
2 History of Public Health Leo S. Vaz 8
Theories of Disease Causation, Natural History
3 RajVir Bhalwar 17
of Disease & Levels of Prevention
Measuring the Level of Health in a Population : Epidemiological
4 RajVir Bhalwar 27
Measures (Indicators) of Health and Disease in a Community
5 Classification of Diseases Vijay K. Bhatti 35
Philosophy Behind “Health For All (HFA)”, “Primary Health Leo S. Vaz, Sunil Agrawal,
6 38
Care (PHC)” & “Millennium Development Goals (MDGs)” RajVir Bhalwar
Public Health in Developing Countries and Countries with
7 Amitava Datta 42
Transitional Economies - History, Development & Policies
8 Public Health in Developed Countries Amitava Datta 47
9 State of Health in the World : Disparities and Divides Sunil Agrawal 51
10 State of Health in India : National Health Profile Sunil Agrawal 59

the 20th century, many times more lives have been saved and
Introduction, Definitions & diseases prevented by simple public health measures as safe
1 General Concepts in Public Health water supply, sanitary excreta disposal, vaccination and insect-
& Community Medicine vector-control measures, than would have been saved by all
the dazzling advancements of curatives and diagnostics put
together! For instance, as per a report, the life expectancy in
RajVir Bhalwar, Mandeep Singh, J Jayaram
USA increased from 45 years in beginning of 20th century to
over 75 years in the next 100 years and only 5 out of these
The last two decades of the 20th century saw a renewal of 30 years increase can be attributed to the work of curative
the world population’s interest in public health, in disease medical care system, while the large majority of this gain has
prevention, communicable and chronic disease control, health come from improvements in public health, broadly defined to
protection and health promotion. Not that public health is a include better housing, nutrition, sanitation, immunization
new concept; great public health movements had already and occupational safety (4).
started in mid-nineteenth century by Edwin Chadwick in
UK (report on an inquiry into the sanitary conditions of the Definitions & Basic Concepts
labouring population in great Britain, 1842) and around the At the outset it would be worth-while to review the meanings of
same time in USA in 1850 by Lemuel Shattuck (Report of some terms in common use in the disciplines of public health,
the sanitary commission of Massachusetts) (1,2). These two preventive medicine & community medicine. In fact, meanings
reports initiated that brilliant movement - now known as public change with time. Terms which have been long in use acquire
health, of which preventive medicine is an essential component extended meanings (a case in point is the term “Preventive
and which has been responsible for saving billions of human Medicine” itself), while new terms are coined to signal a new
lives and reducing human suffering during the last 100 years. emphasis. The meanings of some terms may overlap and
The recent increasing interest in public health shown by different shades of meanings may be associated with use of
nearly all governments, whether from developed or developing the same term. In fact, Public Health, Preventive Medicine and
countries has been, therefore, due to the realization of the fact Community Medicine contain very overlapping ideas as would
that continued investment in clinical care brings diminishing be evident throughout this book; accordingly, their definitions
returns, while the gains can be maximized by resorting to are quite likely to overlap.
methods of health promotion and disease prevention among
populations at large. Health
The handicap that public health and preventive medicine There are many views as to what constitutes “health”. One view
always face is that its predominant focus on prevention makes puts it as “absence of disease”, i.e. there are no impediments to
it more abstract than curative medicine and its achievements an individual’s functioning or survival. This view is reflected
are therefore more difficult to recognize. The doctor who cures by Oxford English Dictionary (5) which defines health as the
a patient has achieved a real, recognizable benefit and the state of being free from illness or injury. Implicit in this view is
patient, as well as her near ones and even the community a set of abilities that favours growth and development and the
members, are all grateful. On the other hand, public health efficient performance of bodily function in the face of changing
cannot point to the people who have been spared of illness by environmental conditions, a capability known as “adaptability”.
it’s efforts. As the famous quote goes “---- If we had but the As a corollary, disease corresponds to failures or disturbances
gift of second sight to transmute abstract figures into flesh and in growth, development, function and adjustments of the
blood, so that as we walk along the street, we could say, “that organism, as a whole or any of its systems (6).
man would have been dead of typhoid fever”, “that woman The problem inherent in the “absence of disease” definition
would have succumbed to anaemia of pregnancy”, “that rosy is that it focuses only on disease. However, there is, in every
infant would have been in its coffin because of diarrhoea and disease, a long phase of transition from actual health to the
dehydration”, -then only would we have a faint conception overt disease process, as will be appreciated when one goes
of the silent victories of public health-----“. In fact, it is this through the chapter on “natural history of disease and levels
“silence” that accounts, in large part, for the lack of attention of prevention” in this book. Hence, health is something much
paid to public health by those who are in a position to mobilize more than the mere absence of disease.
community opinion or take public decisions. In developing The above ethos is echoed in the widely used definition of
countries not even one percent of the total national budget is health by WHO, which states “Health is a state of complete
spent on public health; the situation, even in the developed physical, mental and social well being and not merely the
countries is no better. For example, even in USA, just about absence of disease or infirmity (7). This definition is commonly
1% of the nation’s total health spendings go towards public seen as the statement of an “ideal” towards which nations
health. In 1992, when the average cost of medical treatment should aspire, rather than as a practical working definition. For
was $3,007 for each American, the amount spent on public this reason, an “operational” definition of health, one drawn
health was only $ 34 per person (3) ! from the above “ideal” definition, has been forwarded, by a
Despite the above-mentioned difficulties that public health technical study group of WHO (8). According to this definition,
including preventive medicine, as a concept and as a science, is the concept of health is viewed as being of two orders - first,
faced with, it has undoubtedly been a major force in furthering in a broad sense, health can be seen as a condition or quality
the cause of human health and development. Indeed, during of the human organism in given conditions : genetic and

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environmental. Secondly, in a narrow sense, more useful for To understand as to what preventive medicine has come to
working purposes, health means : represent as a movement within medical theory and practice, it
There is no obvious evidence of diseases and that the person is is necessary to follow historically the application of the concept
functioning “normally”, i.e. conforming within normal limits of and its interaction with other movements. As said earlier,
variations to the standards of health criteria, generally accepted preventive medicine, in its modern form, is not the same as
for one’s age, sex, community and geographic region and, the older discipline of public health, although the principles
and techniques of prevention are also widely applied by
That various organs of the body are functioning adequately in
public health professionals. Initially, preventive medicine was
themselves and in relation to one another, which implies a kind
identified with its most outstanding activity, i.e. contributing
of equilibrium or homeostasis.
to the control of communicable diseases. In fact, in its early
Medicine years, preventive medicine was equated with infectious disease
The noted medical historian Henry Sigerist (9) defined medicine control. Subsequently, by applying specific measures, as
as “Medicine, by providing health and preventing illness, demonstrated by the continuing emergence of “Epidemiology”
endeavours to keep individuals adjusted to their environment (one of the most important tools of preventive medicine & public
as useful and contented members of society; or by restoring health), the preventability of non-communicable diseases was
health and rehabilitating the former patient, it endeavours to demonstrated as well, with health education and counselling
readjust individuals to their environment. for behaviour change being added on to the armamentarium of
It is clear from the above-mentioned, widely accepted definition, preventive medicine.
that “Medicine” as a discipline, has two clear components - firstly Public Health
the “promotive and preventive” component, which is mainly the The perspective of public health is captured in statements
purview of preventive medicine; and the other, a “restorative contained in the report on “Higher Education for Public Health”
and rehabilitative’ component, which is the main purview of the Milbank memorial commission (10). In public health,
of curative medicine. However, there is no such sacrosanct problems are named within the context of the community as
dividing line in practice, since very often, a clinician may also a whole rather than occurring in a series of individuals. This
adopt ways and means of primary and secondary prevention, view leads to the establishment of priorities and permits
while a preventive medicine practitioner may very often focus rational choices on the use of resources. From this view also
on basic clinical care or rehabilitation. Finally, public health, as comes a commitment that is communal rather than personal,
a discipline, keeps a focus on both the components, i.e. health one in favour of solving problems for the benefit of the health
promotive / preventive as well as restorative / rehabilitative, of the population as a whole. Over the years, the unique feature
but distinguishes itself from curative or specific preventive of public health has been acknowledged to be “Organized
medicine in two very special facets - that in public health, the Community Effort” and “Systematic Social Action” and the
focus is on the “Public” (i.e. a community or a population) and classical definition of public health, which has stood the test of
not on any individual and that the approach utilizes “organised time, is the one forwarded by CEA Winslow (11) as :
community efforts”, as we shall appreciate a little later.
“The science and art of preventing disease, prolonging life and
Preventive Medicine promoting physical health and efficiency through organized
Preventive Medicine is that branch of medicine which deals with community efforts for the sanitation of the environment, the
promoting health and preventing disease. The cardinal goal control of community infections, the education of the individual
of preventive medicine is to avert the occurrence of disease. in principles of personal hygiene, the organization of medical
Achievement of this goal requires that actions be directed at and nursing services for the early diagnosis and preventive
the earliest stage of the natural history of disease, i.e. stage treatment of diseases and the development of social machinery
of susceptibility, using the methods of health promotion and which will ensure to every individual, in the community, a
specific protection; and to some extent, methods of secondary standard of living adequate for maintenance of health”.
prevention by early detection of disease when it may be Thus public health is best identified as a social movement
otherwise not detected using usual methods of diagnosis, often concerned with protecting and promoting the collective health of
by screening followed by appropriate intervention. However, in the community. This is its origin and this is its accomplishment.
a broader sense, preventive medicine refers to “limiting” the Thus, the province of public health is by no means limited to
progression of disease at any stage of its course. Thus, when prevention. While mostly public health activities are funded
a clinician, using the approach of curative medicine, diagnosis and regulated by the Governments (National or State), the
and treats a patient of pulmonary tuberculosis, she is practicing work of voluntary health agencies is also very much part
preventive medicine too, since she is “preventing” the progress of public health activities since they represent an organized
of the disease from the mild / uncomplicated phase to one of community effort and systematic social action. In fact, even
complications and more disability. Similarly, when we “treat” a small movement by a small village to purify their drinking
a patient of Colle’s fracture, by closed reduction and plaster water source or to stop alcohol drinking is also very much a
cast, we are actually limiting the progress of a disease to a public health activity. As has been very aptly stated by Mustard
more severe form which would have complications like mal- “A health problem becomes a public health responsibility if, or
union; thus we are practicing preventive medicine (preventing when, it is of such character or extent as to be amenable to
disability). solution only through systematized social action” (12).

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Preventive Medicine versus Public Health a governmental commitment and out of governmental (public)
The dividing line between preventive medicine and public finances, as is the policy in Russia.
health is actually a very thin, rather hazy one. Preventive Community Medicine
medicine is an overall science, public health is an approach As a professional movement, Community medicine (or
within this science. When preventive medicine starts focusing Community Health) is the most recent of the three fields to
on population groups rather than individuals and utilises the emerge in medical education and medical practice. As a
approach of ‘organised community efforts” it takes the shape discipline, it is defined as that branch of medicine, which
of public health. addresses certain selected aspects of health promotion,
The other approach of using preventive medicine is the disease prevention, health restoration (by curative steps)
“individualized” preventive medicine, for instance, immunising and rehabilitation of the former patients, in the community,
an otherwise healthy child, or the “clinical” preventive medicine, usually, from an “Institutional Community Base” which is
which can be very effectively practiced in clinical settings; for usually either an Academic Department in a medical college
example, a doctor who educates her ante-natal case about breast or through a curative centre. Community medicine, as an
feeding or a doctor who takes a pap smear from her patients approach, has borrowed heavily from the concepts, methods
who are attending a family planning clinic is actually practicing and approaches of its two elder sisters, viz. public health and
individualized or clinical preventive medicine, but, may be, preventive medicine.
not public health. On the other hand when the government or Community medicine is one pathway for representing an
even a Non Governmental Organization (NGO) working with institution’s commitment to improving health of its immediate
community members in a village, organises a health education (or adopted) community - generally a medical college, hospital
program in breast feeding for expectant mothers, or organises or a clinical department serve as the base. The health task is
a cervical cancer screening camp, the approach becomes that to define the health problems, propose solutions, maintain
of public health. surveillance, evaluate progress and monitor the use of
Social Medicine resources. The approaches employed range from tools of
The concepts of social medicine were formulated by some very epidemiology to the social skills, necessary for involvement
eminent physicians like Rudolph Virchow, Grotjahn and Rene with the community. Central to the approach of community
Sand, besides others. The fact that man is a social animal, it medicine, whether in academia or in practice, is the promise
is apparent that any effort at preventing or curing the disease that the main factors that determine a community’s health are
or making an assessment of the health problems has to take to be found within the community itself - in its social, cultural
social factors into account. This is, in essence, the concept of or biological features, or in its environment - natural and man
social medicine. Subsequently, the concepts of social medicine made.
merged with preventive medicine, to form the specialty of An understanding of the ways in which these factors interact
preventive & social medicine (see later). to cause disease or promote health in different communities, is
basic to the decisions to be made in the care and protection of
Preventive & Social Medicine
the community (13). For these reasons, community medicine
Beginning from somewhere around the mid twentieth century, must be concerned with and relate to, the community behaviour
it was realized that the art and science of preventive disease and its environment and not solely restrict itself to the health
and promoting health should be taught as an independent services, which, very frequently, is otherwise the principal
subject in the curricula of medical schools. Till then, most interest of the Institutional unit responsible.
of the medical colleges were conducting such training for
As a professional movement, in USA, community medicine
graduate level students under the subject nomenclature
first appeared when some medical schools began to establish
“Hygiene” usually as a part of General Medicine curriculum.
a new department (or rename an existing Dept of Preventive
It was also realized that every human disease has deep rooted
Medicine) and to charge it with functions of defining the
social causes and not simply a result of an infectious agent. For
health problems of a community (in the vicinity of the
example, everybody does not get infected with tubercle bacilli;
college, or an adopted community) and to suggest solutions,
and even out of those who get infected, only a small proportion
maintain surveillance and monitor progress. Many hospitals
develop the actual disease. Who gets the infection and who gets
also established department of community medicine to bring
the disease is actually decided by a wide array of social factors
together responsibility for the professional direction and
as poverty, ignorance, overcrowding, malnutrition and so on.
coordination of a range of ambulatory programs in OPD and
The considered decision was that preventive medicine should
emergency, personal health, outreach satellite elements and
essentially combine the social aspects of health and disease
other services. In UK, community medicine essentially includes
in its theory, practice and teaching. This led to the birth of
Epidemiology and Medical Administration and has been seen
academic departments and the specialty of Preventive & Social
as a successor to public health, providing information and
Medicine (PSM) or Social & Preventive Medicine (SPM).
advise on the health status and the services to the community
Socialized Medicine and to the local Self Govt / community organizations, as well as
Socialized Medicine is different form Social Medicine. It refers performing other planning and management functions. Thus,
to the policy of providing complete medical care, preventive in UK, the community medicine specialist is trained to function
and curative, to all members of a society (usually a nation) as as Medical Officer of Health (MOH).

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Evolution of Contemporary Public Health Contemporary Views on the Definition, Role,
From Shattuck and Chadwick in Mid-Nineteenth Principles, Core Activities and Components of Public
Century to Twenty-First Century (14, 15) Health
In the late nineteenth and early twentieth century, concern Definition : The Definition of Public health, as enunciated by
with control of epidemics was at the centre of medical and Winslow (11) and which has been presented earlier, though more
public attention. Measures for protection of the community than 80 years old now, has stood the test of time and is very
through “environmental health” appeared first and with the well accepted among the public health fraternity as the most
establishment of effective sanitary services, the modern era standard definition. Another definition given by the Institute of
of public health was born. Later, towards end of nineteenth Medicine (USA) also echoes the same ethos : “Public Health is a
century, microbiology expanded greatly and laid down new and mission for the fulfillment of society’s interest in assuring the
scientific basis of infectious disease control. When it become conditions in which people can be healthy, through organised
clear that an “organized effort” to apply these sanitary and community efforts aimed at the prevention of disease and the
bacteriologic techniques was needed, the responsibility of promotion of health, using activities undertaken within the
governmental health departments, to control the communicable formal structure of government as well as the associated efforts
diseases, was given the status of law; and since treatment of of private and voluntary organizations and individuals” (16).
infected individuals was also a part of control of infectious Role of Public Health (16) : As per international consensus,
diseases, this also become a responsibility of public health. Later the role of public health is to contribute to the health of the
public health responsibility was further extended for organized public (community) through :
maternal and child health services, thus extending public Assessment of Health Status & Health Needs : For making
responsibility into the realm of personal care of individuals. As assessments of health status and health needs and to reach
a result, organized “programs” for prevention (usually public a “community diagnosis”, with the ultimate objective of
funded but often by voluntary, non govt. organizations) become formulating health policies and planning appropriate health
more visibly identified. services, public health specialists draw heavily from the
In the first half of the 20th century, personal preventive “quantitative sciences” (Epidemiology, Research Methodology,
services in large numbers began to be publicly financed, while Bio-statistics, Information Technology); from “Environmental
the personal curative services, for the most part, remained Sciences”; from “Socio-Behavioural & Communication
privately supported. As a result the personal health services Sciences”; and, from “Bio-Medical Sciences”.
become compartmentalized into two different medical practice Development of Health Policies : For this purpose the public
settings - one largely preventive and the other largely curative. health specialist will need a good knowledge of Quantitative
However, later on, as the concept of “comprehensive health Sciences; Managerial Sciences; and of Socio-Behavioural &
care” came in, the traditional dichotomy between preventive Communication Sciences.
and curative medicine become less and less differentiable. Assurance of the Availability and Quality of Health Services:
One way of coping with the compartmentalization of activities To fulfill this role, sound knowledge of Basic Clinical Skills,
into the two practice settings (preventive & curative) is to Managerial Sciences, Bio-Medical Sciences and Quantitative
rationalize their inter-relationships. For example, the concept Sciences would be an essential requirement.
of prevention has been, in recent times, extended into curative In fact, the present text-book has been organized addressing,
settings in the form of “secondary prevention”, as one form of in a section-wise manner, the various core-competencies as
response to the rising frequency of chronic, non-communicable enlisted above. These major sciences required for the practice
diseases and diseases of special groups (mothers, children, of public health can be grouped into five major core competency
old people and industrial workers). Under this new strategy, areas, viz. Quantitative Sciences, Environmental Sciences,
clinicians are being urged to think more regularly about Socio-Behavioural and Communication Sciences, Biological
preventive management in diseases and to incorporate more Sciences and Managerial Sciences. The details of these core
of a preventive outlook in their daily practice. Similarly, areas are given in Table - 1.
public health physicians are being invited to move from
their preoccupation with primary prevention, to undertake Core Principles Underlying Public health Practice:
administrative involvement in health care systems. By doing Contemporary thinking indicates that the principles
so, they could relate to the total range of health care and underpinning the concepts of public health are as follows and
take part in the planning, operation and evaluation of any the public health specialist must develop the mental attitude to
or all of the health services. In fact, according to one of the adopt these core principles in her activities (17) :
contemporary views, “Medical Care Administration” has been ●● The emphasis on collective responsibility for health.
advocated as a legitimate concern of public health authorities. ●● An envisaged major role of the state in protecting and
While mostly public health activities are funded and regulated promoting the public’s health.
by the Govt. (National or State) the work of voluntary health ●● A focus on whole populations and not on individuals.
agencies is also very much part of public health activities since ●● An emphasis on prevention, especially primary prevention,
they represent an organized community effort and systematic while not losing track of the importance of curative
social action. medicine also.

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●● Readiness to undertake partnership with populations
Table - 1 : Core-Competency Areas in Public Health
being served.
Training & Practice
The “Dozen” Core Activities of Public Health : In 1995, the
(a) Quantitative and Analytical Sciences US Health and Human Services department identified ten core
●● General Epidemiology activities of public health (18). In our national context, we can
●● Field Epidemiology, including outbreak investigations think of the “One Dozen” core activities of public health, as
and public health surveillance systems follows :
●● Bio-statistics including statistical software 1) Protecting the environment, food and water.
●● Health Research Methodology 2) Promoting healthy behaviour through information,
●● Database Management and other core issues of education and communication.
Information Technology 3) Assessing needs, making community diagnosis and
(b) Environmental Sciences monitoring the health status of the population/ community
being served.
●● Water and Food Safety
4) Leading to the development of sound health policy and
●● Sanitation and Disposal of Wastes
planning.
●● Environmental heat, cold & altitude and related aspects
5) Health programme management and management of other
of shelter & clothing
medical & health care systems (health care system includes
●● Air, Soil and Noise Pollution
the triad of personal medical care, public health care and
●● Nuclear & Chemical Pollution
other inter-sectoral initiatives related to health).
(c) Socio-Behavioural & Communication Sciences 6) Preventing and investigating epidemics and maintaining
●● Sociology in Health surveillance on important diseases, to provide early
●● Life Style & diseases of the lifestyle warning.
●● Health Education, Information, Education & 7) Promoting the health and efficiency of the “workers” and
Communication (IEC) protecting the “work-environment”.
8) Effectively responding to disasters.
(d) Biological Sciences 9) Mobilizing community action.
●● Clinical Sciences (basic diagnostics and therapeutics 10) Research to develop new insights and innovative solutions
for common and important health problems in the for relevant community health problems.
Community) 11) Reaching out to link the health services with the high
●● Microbiology & Pathology risk, disadvantaged and hard to reach people (socio-
●● Infectious and Non-Communicable Diseases : economically weaker sections, hilly, tribal and inaccessible
Epidemiology, prevention and Control areas), or those requiring special attention (women,
●● Entomology children and old people).
(e) Managerial Sciences 12) Assuring the availability, accessibility, quality and
accountability of medical care.
●● General Principles of Management & application in
Health care
Bridging the Gap between Theory and Practice in
●● Health policies & programmes, including policy / Public Health and Community Medicine
programme management A very peculiar situation which all specialists in public health
●● Legal issues in Health care and community medicine realize after just a few years of
●● Health systems and Organization of health care delivery practice, is the wide gap between “theory” and actual “practice”
at various levels in this specialty. Such gaps occur in all other medical specialties
●● Personnel, Financial and Equipment Management too, but only to a limited extent - a patient of typhoid or one
●● Management of Hospitals & other Health Care Facilities with ante-partum haemorrhage will show variations as regards
●● Medical Care Administration at Primary, Secondary & clinical presentation and response to treatment when compared
Tertiary level to what is written in the standard textbooks, but only to a
●● Management of Health Care for Special Groups (Women, limited, understandable extent. In public health practice, the
Children, Workers, old people, the “challenged” and the practitioner is faced, everyday, with challenging situations, for
socio-economically disadvantaged) addressing which she has to work out innovative solutions,
●● Health Care Management during Disasters which may not be at all described in her standard textbooks (in
fact, that is why it is difficult to have a “standard textbook” in
●● A concern for underlying socio-economic determinants of public health; one could only have guidelines!). The reason is
health and disease as well as more proximal determinants, that in community medicine and public health, we do not deal
such as health care. with a patient; we rather deal with human groups, who are
●● A multi-disciplinary basis; the readiness to work, in a apparently healthy (at least that is the way they feel themselves
team, with different and diverging disciplines concerned to be). Human groups or communities have their own attitudes
with human health and development. and practices and their own diverse ways of assessing and
●● Attitude to incorporate qualitative and quantitative responding to situations.
methods, as appropriate, in the area of work. For the aforesaid reasons, the author would, based on own

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experience and the shared experience with colleagues, like to about their health problems and make assessment of their
narrate, certain “rules of the game’, which are otherwise not behaviours, beliefs, lifestyle and the environment they live in.
formally written down in any textbook. It is felt that putting 5. Develop “Multi - Disciplinary Team” approach : Always
these guiding principles into day to day practice may help remember that in public health, you have to build an effective
bridging the gap between theory and practice, thereby deriving team, comprising of people from various disciplines - Statisticians,
more satisfaction out of our specialty work. A dozen of such Clinicians, Social Scientists, Entomologists, Pathologists, Civil
guiding principles are as follows : Engineers, Management experts, Administrators, Politicians
1. Learn how to take insults, be tenacious : Remember that and so on. No public health specialist can be successful by
public health / community medicine with its focus on prevention, working in isolation. Learn how to form an effective team;
is more abstract than curative medicine and its achievements have respect for others, listen to their advice and take decisions
are therefore more difficult to recognize. The Doctor who cures in consultation with them after logical reasoning and not by
such a person has achieved a real, recognizable benefit and arguing or bulldozing. In fact, be proactive in seeking out allies
the patient is grateful; public health cannot point to the people from these various specialties / walks of life.
who have been spared illness by its efforts. Public health and 6. Always prepare very well before you meet people :
preventive medicine lead to silent, unrecognized victories. Whenever you go to attend a conference, be it of administrators
This “silence” accounts in large parts, for the relative lack of and specialists from allied specialties, or else a focus group
attention paid to public health by decision makers and the discussion with school - teachers, make sure to always read
general public (in comparison to the attention paid to medical the agenda and its details very well. Apply your thought to the
care). issues under discussion, think what do you want to achieve
So, remember, that while Public health may not be as glamorous and how you will be best placed to do so, with those present.
a specialty as Cardiac Surgery or Imaging, it has tremendous 7. Focus on “long term” but take action on “short term”
potential to improve the quality of life of innumerable human also : The objectives of public health (whether through an
beings - to give you a proof, the major improvements in health immunization program or purification of community water
and quality of human life during the last one century have supply, etc.) are achieved over the longer time period of decades
actually come from clean food and water, sanitary housing and or generations. However, Governments are generally reluctant to
immunization rather than all the other “glamorous” medical think further ahead of the 5 year term of parliament / assembly.
specialties put together. Despite this, preventive medicine and They would, naturally, like to demonstrate some results within
public health is often at the receiving end of insults as “Sewer the limited span of a couple of years. Hence, in public health
drain doctors” “insect catchers” or “people who could never practice, while gaining support for achieving the long term
make it to the clinical world”. You have to learn how to bear goals should be definitely an objective, it is equally essential to
with such humiliations, but do not lose heart - be tenacious, have some very readily identifiable strategies to demonstrate
keep moving forward - you have indeed selected the most progress towards these long term goals, in a shorter period of
humane specialty. time - the so called strategy of “Early Victories”.
2. Stick to the facts - preferably based on quantitative 8. Understand the “Politics” : Very often we find public health
evidence : Public health, with its very important tools of specialists talking about ways of influencing “Policy Makers”.
epidemiology and statistics, is an evidence based specialty This means getting to know your chief administrative boss
and is dependant on collecting, analyzing and interpreting the (and other influential people) and how he or she works. When
data in a valid manner and making use of good quantitative you are, as a public health management manager, affronted to
and qualitative evidence. Good public health practitioners a one of senior politicians or bureaucrat, the first things you
should collect good knowledge about topics they are dealing should do is to set to know what makes him or her “tick” and
with, whether it is the incidence of ARI among children in their do things in a way that merges with his / her line of thinking.
area of jurisdiction or it is concerning the amount of risk that
Public health specialists should also keep themselves well
tobacco carries for IHD. Good amount of reading into latest
aware of the “political climate” - not only international and
journals, reports or text books and discussion with experts is a
national but, also the “local” politics and even the political
must for public health practitioners.
climate in their own office. It is essential, in public health, to
3. Develop the art of communicating : Remember that unless have good political antennae. Moreover, in any organization or
“data” are turned into “stories” which are understood by all, office, it is essential to understand as to who wields the power
people would not show concern for your reasoning. Having - this may not only be the chief executive, but may be some
command on communication skills, both verbal and written, lower level staff officer also. It is also very paying to have good
is an art which is a compulsory requirement for public health relationships with colleagues.
practitioners and this art should be developed very diligently
9. Don’t take on too much : Failure to deliver is one of the
and methodically.
biggest potential risks for public health and you should
4. Walk well and talk well : A successful public health remember that one important reason for landing in this pitfall is
specialist is one who changes shoes every month or two, since when you take on too many jobs, well beyond your capabilities.
constant walking, seeing for herself and making assessments of You should learn how to say “No” to tasks which you feel are
environment and the community’s conditions, tears off the shoe getting on too much; or else, if it is something that has to be
- sole very fast. This is the typical shoe - leather epidemiology. done, then decide what is going to be dropped off your agenda.
So keep moving in your area, talk to the community members

•6•

Next, once you take on a job, then keep track of its progress. preventing illness, endeavours to keep individuals adjusted to
10. Develop Your Staff : A clinician may still do well without their environment as useful and contented members of society;
improving his staff and without delegating; conversely, in public or by restoring health and rehabilitating the former patient,
health practice you must constantly endeavour to develop your it endeavours to readjust individuals to their environment”.
staff and subordinates as regards their technical and managerial Preventive Medicine is that branch of medicine which deals
competence. Secondly, analyze their capabilities and learn how with promoting health and preventing disease. The cardinal
to delegate responsibilities / tasks to your subordinates. If you goal of preventive medicine is to avert the occurrence of
try to do everything yourself, in public health practice, you will disease. The field of Epidemiology has emerged as one of the
get bogged down and become inefficient pretty soon. most important tools in preventive medicine & public health.
CEA Winslow gave the most comprehensive & widely accepted
11. Always Know of Specialists who can do the Jobs : The
definition for public health which states as “The science and art
wide activity of public health inevitably means that you will
of preventing disease, prolonging life and promoting physical
not be able to retain all the necessary skills at any one time,
health and efficiency through organized community efforts for
though you may have been trained to some extent in all these
the sanitation of the environment, the control of community
disciplines (as entomology, epidemiology, statistics, database
infections, the education of the individual in principles of
management, etc.). Therefore, maintaining networks with
personal hygiene, the organization of medical and nursing
others who have the skills & expertise in that area, is vital.
services for the early diagnosis and preventive treatment of
12. Always Be There : Though stated in the last, this twelfth diseases and the development of social machinery which will
golden principle is one of the most important. Remember that ensure to every individual, in the community, a standard of
the world is run by people who are physically there at the place living adequate for maintenance of health”. The two unique
of action; the first rule of politics is to “be there”. It is surprising feature of public health are acknowledged as “Organized
how scant attention is paid to this very simple dictum. So, Community Effort” and “Systematic Social Action”. Preventive
for being a successful public health specialist, never miss a Medicine is a branch of medicine which deals with promoting
meeting, a workshop, any function, a sports meet or even any health and preventing disease. When preventive medicine
street play to which you have been invited. starts focusing on population groups rather than individuals
And, finally, keep the highest regards for your specialty - it is and utilises the approach of “organised community efforts” it
the biggest asset you have in the changing fortunes of time; takes the shape of public health. The integration of the social
Keep perseverance and faith alive, for, despite all it’s drudgery aspects of health and disease in theory, practice and teaching
and sham, it is still a beautiful world ---------. led to the birth of Preventive & Social Medicine (PSM) or
Social & Preventive Medicine (SPM). Community Medicine is a
Summary branch of medicine, which addresses certain selected aspects
The last two decades of the 20th century saw a renewal of of health promotion, disease prevention, health restoration (by
the world population’s interest in public health, in disease curative steps) and rehabilitation of the former patients, in the
prevention, communicable and chronic disease control, health community, usually, from an “Institutional Community Base”
protection and health promotion. The two reports in mid- which is usually either an Academic Department in a medical
nineteenth century by Edwin Chadwick in UK & Lemuel Shattuck college or through a curative centre.
in USA initiated the genesis of public health & preventive Public health plays a very important role in contributing to
medicine. During the 20th century, many lives have been saved the health of the public (community) through assessment of
and diseases prevented by simple public health measures as Health Status & Health Needs, development of Health Policies,
safe water supply, sanitary excreta disposal, vaccination and assurance of the availability and quality of Health Services.
insect-vector-control measures. Major sciences required for the practice of public health can be
Widely used definition of health by WHO states that “Health is grouped into five major core competency areas, viz. Quantitative
a state of complete physical, mental and social well being and Sciences, Environmental Sciences, Socio-Behavioural and
not merely the absence of disease or infirmity. This definition Communication Sciences, Biological Sciences and Managerial
is commonly seen as the statement of an “ideal” towards which Sciences.
nations should aspire. “Operational” definition of health, one Core Activities of Public Health include protecting the
drawn from the above “ideal” definition, has been forwarded, environment, food and water, promoting healthy behaviour
by a technical study group of WHO. This concept of health is through IEC, assessing needs, making community diagnosis and
viewed as being of two orders - first, in a broad sense, health monitoring the health status of the community being served,
can be seen as a condition or quality of the human organism development of sound health policy and planning, health
in given conditions : Genetic and environmental. Secondly, programme management and management of other medical &
in a narrow sense, more useful for working purposes which health care systems, preventing and investigating epidemics
includes no obvious evidence of diseases and that the person and maintaining surveillance on important diseases, to provide
is functioning “normally” & various organs of the body are early warning, promoting the health and efficiency of the
functioning adequately in themselves and in relation to one “workers” and protecting the “work-environment”, effectively
another. responding to disasters, mobilizing community action, research
A widely accepted definition of medicine by Henry Sigerist to develop new insights and innovative solutions for relevant
defines medicine as “Medicine, by providing health and community health problems, reaching out to link the health
services with the high risk, disadvantaged and hard to reach

•7•

people, or those requiring special attention, assuring the (3) Condition or quality of the human organism in given
availability, accessibility, quality and accountability of medical conditions : genetic and environmental; Within normal limits of
care. variations to the standards of health criteria; various organs of
the body in a state of equilibrium or homeostasis (4) Organized
Study Exercises Community Effort; Systematic Social Action (5) Organised
Short Notes : (1) Definition of health (2) Definition of public community efforts; Public health (6) Preventive Medicine.
health (3) Community Medicine - definition and scope (4) Core Match the Following : 1-d; 2-c; 3-e; 4-b; 5-a.
activities of public health
MCQs & Exercises References
1. Richardson, BW. The health of nations : a review of the works of Edwin
Fill in the Blanks Chadwick, vol 2, London 1887; Longmans, Green & Co.
1. Movement - now known as public health were initiated in 2. Shattuck, L. Report of the sanitary commission of Massachusetts - 1850.
(Dutton & Westworth, state Printers, Boston, 1850). Cambridge, 1948,
nineteen century by -------- &----------- in their reports on Harvard university Press.
sanitary conditions of the labouring population in Great 3. US Public health service. For a healthy nation : returns on investments in
Britain & sanitary commission of Massachusetts. public health.washington, DC : US Government Printing Office 1994 : p. 42.
2. Health is a state of complete ---------, ---------- and ------- 4. Bunker JP Improving Health : Measuring effects of medical care. Milbank
.
quarterly 1994; 72 : 225 - 58.
well being and not merely the absence of ------------ or -----. 5. Soanes C. Oxford Dictionary. Oxford University press, Oxford 9th ed, 2001.
This was the definition given by ----------------. 6. Engel GL. The need for a new medical model. A challenge for biomedicine.
3. “Operational” definition of health view’s health as being Science 1977; 196 : page129.
------------------ in broader sense & -----------, ----------- in 7. World Health Organization. The constitution of World Health Organization.
WHO Chron 1947; 1 : page29.
narrower sense. 8. World Health Organization. Measuring the levels of health : Report of a
4. Two unique features of public health are ---------------- and study Group. WHO TRS No 137, 1957.
----------------. 9. Sigerist HE. A history of medicine, Volume I : Preventive and Archaic
Medicine. New York; Oxford University Press, 1951.
5. When preventive medicine starts focusing on population
10. Milbank memorial Fund Commission Report, CG Sheps, Chairman. Human
groups rather than individuals and utilises the approach Education & Public Health, New York : Prodist, 1976.
of ------------- it takes the shape of----------. 11. Winslow C-E,A. The untilled fields of public health, Science 1920; 51 : page
6. ---------- is the branch of medicine which deals with 23.
12. Mustard HS, Stebbins EC. An introduction to public health. New York,
promoting health and preventing disease. Macmillan. 4th edition 1959.
Match the Following 13. Kark SL, Cobb S. From medicine in the community to community medicine.
JAMA 1974; 228 : page 228.
1. CEA Winslow a. Sanitary commission of
14. Horton R. the new public health of risk and radical engagement. Lancet
Massachusetts 1998; 352 : 251 - 2.
15. Hamlin C, Sheard S. Revolutions in Public Health : 1848 and 1998 ? BMJ
2. Henry Sigerist b Social medicine 1998; 317 : 587 - 91.
3. Rudolph Virchow c. Definition of Medicine 16. Institute of Medicine (USA). The Future of Public health. Report of
Committee for the study of the future of public health. Washington, DC.
4. Grotjahn d. Definition of Public health National Academy press, 1988 : 40 - 42. (Available at : http : //fermat.nap.
edu/catalog/1091html (accessed in 2006).
5. Lemuel Shattuck e. Virchows triad 17. Beoglehole R, Bonita R. Public Health at the cross-roads. Cambridge
Answers : University press, Cambridge U.K., 1997.
18. U.S. Health and Human Services, Public Health Service. For a healthy
Fill in the Blanks : (1) Edwin Chadwick; Lemuel Shattuck nation : returns on investment in public health. U.S. Govt. Printing office,
(2) Physical; Mental ; Social; Disease; Infirmity; WHO Washington DC, 1995.

healthy living and pursued regimens of exercise and hygiene
2 History of Public Health such as those prescribed by Hippocrates in his Regimen and
Regimen in Acute Diseases (4th century BC). Patients visiting
the temples of the god of healing, Aesculapius, were encouraged
Leo S. Vaz
to take part in exercise, but the temples were, again, not part
of a public health system. There was some development of
During the ancient Egyptian period developments such as
public health by the Minoans, a Mediterranean civilization
toilets and bathing were introduced, but this was on a private
that flourished on Crete about 3000-1050 BC. The Minoans
level. While Egyptian religious beliefs encouraged washing the
built baths and constructed channels to supply clean water
body, thereby improving the health of the population, this was
and remove waste. However, these facilities were lost when
not part of a public health programme. The Greeks encouraged
the Minoan civilization collapsed and their palaces and towns

•8•

were destroyed by natural disasters and invading Greek forces. During the Middle Ages (5th-15th centuries) in Europe, public
Aqueducts (bridges carrying water) were also constructed; one health systems collapsed and became virtually non-existent,
of the first great aqueducts was built in 691 BC to carry water particularly during the period known as the Dark Ages (around
for 80km to Ninevah, capital of the ancient Assyrian Empire. 500-1000 AD). The towns and cities of the Romans were often
However, the scale of the public health system introduced by abandoned and the aqueducts, sewers and baths were allowed
the Roman Empire from around 300 BC was without precedent to fall into disrepair. Medieval governments and wealthy
in the Western world. people in society no longer felt the responsibility or need to
Ancient India and Public Health provide public health. Money was not spent on providing
fresh, clean water or removing waste, but on more pressing
Ancient Indian thoughts, philosophy developed on concepts of concerns, such as the provision of armies and defences for
spirituality. Ayurveda is the ancient science of life. It lays down the almost continuous wars that raged throughout the period.
the principles of management in health and disease and the Various diseases (leprosy, consumption, typhoid fever and the
code of conduct for the physician. Charaka has described the black death) fatally affected approximately one-third of the
objective of medicine as two fold; preservation of good health population living in middle and southern Europe. In the Middle
and combating disease. Ayurveda emphasised the need for Ages, commerce and industry developed which were based on
healthy lifestyle, including cleanliness and purity, good diet, economic theory involving exchange of goods and services.
proper behaviour and mental and physical discipline. Purity Through the accumulation of wealth, individuals and nations
and cleanliness were to be observed in everything : jalasuddi became powerful. Because of such affluence, concern developed
(pure water), aharasuddi (clean food), dehasuddi (clean body), for labour as it related to productivity.
manasuddi (pure mind) and desasuddi (clean environment).
Streets were often used as dumping grounds for slaughterhouse
Ayurveda calls upon the physician to treat the patient as a whole: waste or the contents of chamber pots from people’s houses.
‘Dividho jayate vyadih, Sariro manasasthatha, Parasparanz Action was only taken during outbreaks of disease such as the
tavorjanma, Nirdvadvam nopalahhyate’. Diseases occur both Black Death, an epidemic of bubonic plague that swept across
physically and mentally and even though each part might Europe in the mid-14th century, killing between one-third and
be dominant, they cannot be compartmentalized. Ayurveda half of the population. When the plague arrived in England in
treats man as a whole body, mind and what is beyond mind. 1348, Edward III ordered the lord mayor of London to clean up
The earliest protagonists of Indian Medicine, such as Atreya, the streets of the capital and keep animals and slaughterhouses
Kashyapa, Bhela, Charaka and Susruta have based their out of the city. Public toilets were to be introduced and
writings on the foundations of spiritual philosophy and ethics. the dumping of waste in the streets was forbidden. The
Charaka Samhita prescribes an elaborate code of conduct. improvements continued until the end of the 14th century, but
The ruins of ancient civilizations like Mohenjadaro and the measures were often poorly enforced and had little effect
Harrappa show intricate water and sullage disposal systems. on the overcrowding and lack of cleanliness that was rife in
It can hence be assumed that sanitation played a major part in the larger towns and cities. Few hospitals existed and doctors
planning of these cities. were far too expensive for the poor to consult, so ill health and
Greeco-Roman Era disease were unchecked and spread rapidly.
This period focused on personal hygiene. Governmental public 18th-19th Centuries (Europe)
health practices were effected to augment the prevailing This was the period of the industrial revolution and cholera
religious attitude. Medical care hospitals, staffed with public epidemics. The industrial revolution brought about the need for
physicians and programs in environmental sanitation (water increased manpower and massive use of labouring classes. The
supply and sewage) were developed. These measures which life expectancy rate based on social class was : gentry, 35 years;
placed a high priority on a clean mind and body were developed tradesmen, 22 years; and labourers, 15 years. Approximately
for the upper classes. The Romans were able to implement one-half of the children of the working classes died before age
public health measures as they had an organized, centralized of five.
government and the money to pay for the work. Such a vast William Farr, the keeper of abstracts at the Registrar General
system of public health was unprecedented in history and Office in 1836 was convinced that mortality increased with
made the Romans a much healthier people. The Romans did density of population. From 1839 William Farr collected
not know about bacteria and the true causes of disease, but statistics from parish registers on births and deaths. He was
they observed that swamps caused illness and that a lack of able to show the impact of poor living conditions on life
fresh water was damaging to health. By the end of the Roman expectancy and the differences between different areas. The
Empire in AD 476, the Roman public health system was more Victorian middle class believed that the overcrowding resulted
advanced than any system of public health would be in Europe in immorality, drunkenness, crime, incest and destroyed the
for the next 1,400 years or so. sanctity of homes. This resulted in moralistic theories being
Middle Ages projected all over Britain & Europe as a cure of most evils
This is considered as a period identified as an era of paganism, including disease.
barbarism and anti-intellectualism. When Christianity became The poor engaged in agriculture went through a series of bad
the official religion of the Roman Empire, the poor and afflicted harvests at the end of the eighteenth century and by 1795 the
were given status and recognition. Society was given an farmers had fewer & fewer resources to pay their labourers.
obligatory responsibility for care and treatment of the sick. An allowance system was then started and administrated

•9•

through the Poor Law. A study of Poverty was carried out by vaccination was started by John Gibbs which ultimately
two assistants of Central Poor Law Commission an economist culminated in its modification in 1907.
and lawyer Nassau Senior and upwardly mobile lawyer Edwin Public Health in the United States
Chadwick. They concluded that the allowance system was a
threat to the free market economy. The Poor Law Amendment In the 17th - 18th Centuries in Colonial America, life
1834 which Chadwick wrote deprived the paupers of his liberty expectancy was less than in Central Europe. Towns and cities
and put them into workhouses. were generally unsanitary, contagious diseases were rampant
and most physicians were self-designated and itinerant. In
The cholera Epidemic of 1832 highlighted the problem of America the first colonist had found healthy land, clean water
disease. In 1837 Chadwick appointed doctors to investigate and fertile soil. However newer arrivals brought in scurvy,
the London districts with high typhus mortality. The report smallpox, cholera, measles, typhoid diphtheria and influenza.
highlighted the squalor of the inhabitants and the insanitary Small pox and measles contributed in large part to mortality.
conditions. Chadwick compiled a survey of “Sanitary condition In the eighteenth century quarantine laws were passed in all
of labouring classes of great Briton” in 1842 in which he major towns and pest-houses built for immigrants arriving on
recommended the “Sanitary Idea” with creation of a public infected ships.
health authority to provide drainage, potable water, sanitation,
regulation of buildings etc. He believed in the ‘miasmatic’ During the civil war a large number of soldiers died of Typhoid,
theory of disease origin where gaseous contamination of Malaria, camp Diarrhoea and camp Measles. However, wherever
atmosphere due to putrefaction of organic matter was the the sanitary commission improved sanitary conditions, disease
cause of disease. rates were found to be lower. Due to the industrial revolution
cities grew and there was increase in number of disease. Due to
The first British Public health Act was passed in 1848 creating a dedicated band of reformers, the Metropolitan Health Bill of
a General Body of health with Southwood Smith as its medical 1866 was passed. In 1879 a large yellow fever epidemic swept
advisor and Chadwick its only salaried member. The city of Mississippi and New Orleans, resulting in the creation of the
London also had its own private Sewers Act 1848. Internal National Board of Health.
conflicts in the Metropolitan Sewers Commission resulted in
removal of Chadwick in 1849. The Lemuel Shattuck Report encouraged social reform, including
documentation of disease conditions and collection of vital
A shift from “Sanitary idea” to medical managed took place when statistics. Some pertinent recommendations of the Shattuck
Chadwick was succeeded as Britain’s chief health administrator Report were establishment of sanitary inspection system,
by Dr John Simon. The new concept was of “State Medicine” He the collection and analysis of vital statistics, the promotion
had been credited to having laid the foundation of subsequent of health care, establishment of regulations to expose and
British health policy. He followed a comprehensive approach eliminate quackery. Port cities such as Boston, Baltimore,
to disease prevention and set up investigations into a wide New York and their respective states sought ordinances and
range of issues from regulation of food contamination & drug legislation to reduce mortality, establish medical services for
adulteration to hygiene standards of environmental planning. seamen and raise the professional status of physicians.
Simon’s most significant legislation was the Sanitary Act 1866.
In 1856 Dr Henry Rumsey published a series of “Essays on state Sanitary Theory
Medicine”. He claimed that medical prevention would cover a The theory of miasma, which said that disease is due to causes
broad range of causes of disease resulting in their elimination. contained in bad air including the cosmic radiations, found
In 1875 the Public Health Act was codified including all much support during the 18th and 19th century. It made sense to
existing sanitary legislation. The prevailing social conditions the English Sanitary reformers of the mid-nineteenth century.
in England resulted in an illustrative national survey, known Miasma explained why cholera and other diseases were
as the Edwin Chadwick Report, which focused on the health of epidemic in places where the water was un-drained and very
the labouring classes. The Chadwick Report affected sweeping foul-smelling. The theory led to improvements in the sanitation
reforms, such as the establishment of a National Board of systems, which led to decreased episodes of cholera, which
Health, advances in environmental sanitation and hygiene, helped to support the theory. Even though the miasmatic theory
new legislation regulating factory management; child labour has been dis-proven by the knowledge of viruses and bacteria,
and welfare and care for the aged and mentally ill. it made the connection between dirtiness and diseases. This
In 1864 the first contagious Disease Acts was passed which caused public health reforms and encouraged cleanliness, even
provided for compulsory examination of women believed to be though some doctors still did not wash their hands between
“Common prostitutes” who were to be locked up for up to one patients. They believed that the miasmata were only airborne
year without right to habeas corpus if they were diagnosed to and would not be stuck on the doctors’ hands.
have sexually transmitted disease. The Act was approved by Chadwick has generally been considered to be the person who
a large number of people including John Simon. The Act was defined prevention of disease in “ Sanitary” terms. However
repealed in 1886. Edmund Parkes, the first British Professor of hygiene who
Free vaccination were made available through the Poor Law was appointed to the Army Medical School at Netley believed
Medical Services in 1840. In 1853 vaccination was made that future of prevention lay in discovery of specific causes of
compulsory for all children with the first year of life. In individual diseases.
1867 the new Vaccination Act imposed penalties on parents A shift in public health took place during the Edwardian
not vaccinating their children. A drive against compulsory period when individuals began to be categorized into “Risk

• 10 •

populations”. These were on the basis of analysis of disease organisms, it was concluded that water sanitary hazards at
by Edmund Parkes. Soon thereafter came the germ theory industrial sites were generally remote with the exception of
which was based on the concept that specific microbes caused anthrax from tanneries and wool scouring facilities.
specific diseases. Developments in Bacteriology in 1880’s were Current Public Health
embraced by the preventive profession. A model was developed
in which one agent was related to one disease (Robert Koch). Classical infectious disease rates have declined while increased
This is discussed in subsequent chapters. rates of so-called modern diseases (heart disease, cancer
and immune deficiency diseases) are now being observed
Contemporary (19th and Early 20th Centuries) Public in epidemic proportions throughout the world. Classical
Health public health organizations and systems are now in a state
During the 19th Century and the first half of the 20th century, of flux because these structures were erected for classical
the perception of public health was limited to prevention of communicable disease control. New problem-solving systems
communicable diseases through environmental sanitation. are needed in areas such as health care financing, medical care
For example, a dramatic increase in industrialization in the for the aged, environmental health protection and health care
late 19th century, coupled with urbanization, had profound planning and administration.
effects on urban water supplies. There was pollution from
human wastes from homes and the workplace disposed in the
Founders of Modern Public Health, Community
waterways. Effluents containing organic and inorganic toxic Medicine & Preventive Medicine
and non-toxic material were dumped into the same waterways. Edward Jenner(1749-1823)
During this time medical theories were limited to bacteriological
Edward Jenner was born on May 17, 1749 in the small village
paradigms.
in Gloucestershire. He had always been
In 1898 when US sent troops into Cuba they lost 968 men fascinated by the rural old wives tale that
in battle and 5438 due to infectious diseases. When yellow milkmaids could not get smallpox. He
fever threatened troops in Cuba in 1900 an army commission believed that there was a connection between
under Walter Reed confirmed that the disease was transmitted the fact that milkmaids only got a weak
by mosquito and eliminated the disease from Havana. The version of smallpox - the non-life threatening
US Army in Philippines had to battle with malaria, dengue, cowpox - but did not get smallpox itself.
dysentery and beriberi to continue to remain in the region. Jenner decided to try out a theory he had
The French attempt to build a canal across Panama was developed. Jenner was given the opportunity
abandoned due to disease. The American attempt succeeded on the 14 May 1796, when a young milkmaid
due to an intensive campaign against mosquitoes and hence called Sarah Nelmes came to see him with sores on her hands
reduction of yellow fever and malaria so as to prevent malaria like blisters. He took some pus from cowpox blisters found on
in America troops. During World war II the Public Health service the hand of Sarah. She had milked a cow called Blossom and
established the control of Malaria in war areas. After the war had developed the tell-tale blisters. Jenner ‘injected’ some of
the organisation was converted into the Centres for Disease the pus into a young boy, James Phipps. This process he
Control and Prevention. repeated over a number of days gradually increasing the
In 1907 preventive medicine practitioners and town planners amount of pus he put into the boy. He then deliberately injected
got together to bring about housing reforms. Simultaneously Phipps with smallpox. James became ill but after a few days
legislations were passed for free school meals, medical inspection made a full recovery with no side effects. Jenner found a great
of school children and antenatal care. These concerns were deal of scepticism to his ideas and was subject to much ridicule.
clubbed by society into “Endowment of motherhood” movement However, what he had discovered could not be denied and
which included targeting of malnutrition and breaking habits eventually his discovery had to be accepted - a discovery that
of inefficient and unhygienic motherhood. A great emphasis was to eventually change the world. So successful was Jenner’s
was placed on health education. It was emphasised that infant discovery, that in 1840 the government of the day banned any
morality was not a “Weeding Out” process of eugenic value as other treatment for smallpox other than Jenner’s. Jenner died in
was earlier considered, but a preventable wastage of child life. Berkeley on January 26, 1823 aged 74.The word vaccination
Newsholm in 1910 introduced the concept of “Causal attack” comes from the Latin ‘vacca’ which means cow - in honour of
upon disease after redefining the environment from a “Social the part played by Blossom and Sarah in Jenner’s research.
Standpoint”. However, from the point of Jenner’s demonstrations, it took the
humanity almost two centuries to conquer small pox - In 1980,
In Germany, Pettenkofer first calculated the financial returns
the World Health Organisation declared that smallpox was
on public health investments to prove the value of sanitary
extinct throughout the world.
improvement in reducing death from typhoid.
John Snow (1813 - 1858)
Bacteriological analysis was used to determine the presence of
coliform bacteria in municipal water supplies. Since coliform Snow was a British physician and also one of the founder
bacteria are present in great numbers in humans and animals fathers of the discipline of anaesthesiology, is also considered
but are not typical water organisms, their presence served as an one of the founders of epidemiology for his work identifying
indicator of fecal pollution and possible pathogenic organisms. the source of a cholera outbreak in 1854. He was born into
Since industrial wastes did not contain these coliform a labourer’s family on 15 March 1813 in York and at 14 was

• 11 •

apprenticed to a surgeon. At the time, it was assumed that infections. Lind died in 1794 in Gosport.
cholera was airborne. However, Snow did not accept this Robert Koch (1843 - 1910)
‘miasma’ (bad air) theory, arguing that in fact entered the body
through the mouth. The French parasitologist Casimir-Joseph Davaine inspired by
the work of the French microbiologist
He published his ideas in an essay ‘On the Mode of Louis Pasteur had showed, in 1863,
Communication of Cholera’ in 1849. A that anthrax in sheep was due to the
few years later, Snow was able to prove presence of rod-like bodies in the
his theory in dramatic circumstances. In blood. Koch announced that he had
August 1854 a cholera outbreak occurred isolated and grown, the tubercle
in Soho. It was common at the time to bacillus to the Physiological Society of
have a cesspit under most homes. Most Berlin on 24 March 1882. He believed
families tried to have their raw sewage this to be the cause of all forms of
collected and dumped in the Thames to tuberculosis.
prevent their cesspit from filling faster
than the sewage could decompose into The outbreak of cholera in Egypt and the danger of it finding
the soil. After careful investigation, including plotting cases of its way to Europe, caused Koch, as a member of the German
cholera on a map of the area, Snow was able to identify a water government commission, to go to Egypt to investigate the
pump in Broad (now Broadwick) Street as the source of the disease. Although he was frustrated by the cessation of the
disease. He had the handle of the pump removed and cases of epidemic, he was able to study the disease long enough to
cholera immediately began to diminish. Snow later used a spot suspect a particular comma-shaped bacillus. Whilst there,
map to illustrate how cases of cholera were centred around the however he was able to discover the cause of amoebic dysentery
pump. He showed that companies taking water from sewage- and the bacilli of two varieties of Egyptian conjunctivitis. He
polluted sections of the Thames delivered water to homes with was able to complete his work on cholera by proceeding to
an increased incidence of cholera. Snow’s study was a major India. He discovered the cholera organism and its transmission
event in the history of public health and can be regarded as the via drinking water, food and clothing. When he returned to
founding event of the science of epidemiology. Berlin Koch advised regular checks on the water supplies and
recommendations regarding sewage disposal. He also organised
Snow was also a pioneer in the field of anaesthetics. In courses in the recognition of cholera. Koch investigated the
1853and 1857, he was responsible for giving chloroform to effect an injection of dead bacilli would have on a person who
Queen Victoria at the birth of her son Leopold and daughter subsequently received a dose of living ones. He concluded that
Beatrice. Snow died of a stroke on 16 June 1858. the local reaction produced might provide the means by which
James Lind (1716 - 1794) the disease could not only be diagnosed but, in the early stages,
Lind was a Scottish doctor, a pioneer of naval hygiene and perhaps even cured. He used as the active agent a sterile liquid
expert on the treatment of scurvy. James produced from cultures of the bacillus. As the liquid (tuberculin,
Lind was born in Edinburgh in 1716. In 1890) proved disappointing as a curative agent its importance
1747, while serving as surgeon on HMS as a means of detecting a present or past tubercular state was
Salisbury, he carried out experiments to not immediately recognised.
discover the cause of scurvy, the symptoms The result of Koch investigations into a bubonic plague epidemic
of which included loose teeth, bleeding in Calcutta in 1897 showed that rats were vectors of the disease.
gums and haemorrhages. He also demonstrated that sleeping sickness is transmitted by
Lind selected 12 men from the ship, all the tsetse fly. Other studies by Koch included leprosy, surra,
suffering from scurvy and divided them rinderpest, Texas fever and malaria. In 1905 Koch won the
into six pairs, giving each group different additions to their Nobel Prize for Physiology or Medicine for investigation and
basic diet. Some were given cider, others seawater, others a discoveries in relation to tuberculosis.
mixture of garlic, mustard and horseradish. Another group of Joseph Lister (1827-1912)
two were given spoonfuls of vinegar and the last two oranges By the middle of the nineteenth century, post-operative sepsis
and lemons. Those fed citrus fruits experienced a remarkable infection accounted for the death of almost
recovery. While there was nothing new about his discovery - half of the patients undergoing major
the benefits of lime juice had been known for centuries - Lind surgery. A common report by surgeons was
had definitively established the superiority of citrus fruits ‘operation successful but the patient died’.
above all other ‘remedies’. In 1753, he published ‘A Treatise of Sepsis was considered as a kind of
the Scurvy’ and in 1757 ‘An Essay on the Most Effectual Means combustion caused by exposing moist
of Preserving the Health of Seamen in the Royal Navy’, which body tissue to oxygen. It was therefore
threw much light on the appalling living conditions and diet of considered that the best prevention was to
seamen. In 1763, Lind published work on typhus fever in ships keep air away from wounds by means of
and in the 1768 publication ‘An Essay on Diseases Incidental plasters, collodion or resins.
to Europeans in Hot Climates’ he summarised the prevalent
diseases in each colony and gave advice on avoiding tropical Joseph Lister, a British surgeon, considered that infection was
not due to bad air alone and that ‘wound sepsis’ was a form

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Public Health Concepts Explained

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