Public health, the new ideology may be taken to mean the promotion of healthy lifestyles linked to behaviour and individual responsibility supported by government action; whereas traditionally the description tended to relate more to sanitary reform and ‘healthy conditions’. The chronological development of public health is mapped out, supported by the outlining and discussion of the emerging themes and influences pertaining to the study of public health. The approach to public health is positioned alongside the health of the population and the prevailing political/societal influence at the time. Public health is impacted on by poverty and environmental factors. Presently government policy to improve public health is delivered in a strategy that recognises the need for health improvement at times when the greatest impact on health is poverty and exclusion. The evidence reviewed demonstrates clearly that poor health without appropriate resources or intervention is cumulative and that the ‘right’ form of intervention can bring about long term health gains. Intervention from a national agenda needs to include individual’s health and the health of the community brought about through joint partnerships and multi-sectorial working.
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Historically, the environment was seen to be causative of ill health and disease, precipitated by inadequacy of the air. Humid, marshy areas or toxic, rotting debris were thought to cause ‘miasmic disorders’, and it was thought best to reside in airy, well-ventilated places. The supposition being, miasma could be seen or smelt and disease produced by miasma was transported through breathing contaminated air or absorbed through the skin. The presence of disease was acutely observed in the summer season, when the smell would be particularly offensive. Unfortunately the corresponding link between rotting debris, flesh and heat with an increase in pests and rodents, which would inform later health initiatives, was not made at this time (Cipolla 1992). Belief systems were influenced by naïve sensory perceptions linking odour and miasma with overcrowded spaces as places of disease. Those financially better placed began to deodorise their environment with aromatic oils, flowers and herbs (Wear 1992). The environment was also seen as significant in humoral theories, where the body was thought to need a healthy balance of four humours: blood, phlegm, yellow bile and black bile with four elements: earth, air, fire and water and four qualities: hot, cold, wet and dry (Nutton 1992). Being cold or wet was often seen as the cause of colds or fevers; perspectives still present in popular lay discourse today.
In earlier times levels of understanding relating to infectious diseases was demonstrated with the Romans building isolation hospitals known as Leprosaria, quarantining their plague victims. Quarantine was associated with a contagionist understanding of ill health. Disease and isolation in this approach was separating the ill and infectious, to control the spread of disease (Lupton 1995). Quarantine stemmed from the belief that disease resided in places and bodies were responsible for the transmission of disease from infected to non- infected place (Armstrong 1993).
Fear and suspicion co-existed with ignorance and lack of education and the plague was construed, as a case of divine retribution in the absence of popularly understood causative indicators. The contribution of the church in leading a crusade against disease or indeed identifying causative behaviours was said to be welcomed when so little was known about the causes of these diseases. This resulted in an association between spiritual uncleanness and pathological condition, with the church prescribing segregation and exclusion to control disease, further reinforced by a system of notification, where those who fell ill were reported to the local authorities and isolated in their homes with all who had been in contact with them or removed from their homes when dead, through the window, into a barrow to be buried outside the city.
The onus on notification of infectious disease is still seen today in the Control of Disease Act 1984 and the Regulation of the Infectious Diseases 1988. This may have positive benefits to public health, limiting illnesses such as food poisoning and rapid identification of outbreaks of bacterial meningitis, measles and other illnesses through prompt notification and medical or environmental intervention. The role of ‘social conscience’ however and its manifestation in social control may have been responsible for dividing communities through encouraging individuals to report their apparently ill neighbours.
Locating public health
The tradition of public health and inherent understanding of the term, dates back as early as pre-Christian times, classified in five periods or bodies of thought: The Graeco-Roman period with emphasis on water and sanitation, the Medieval emphasis on epidemics, the Enlightenment emphasis on disease prevalence, the Industrialisation emphasis on working conditions and Modern era emphasis on bacteriology and virology (Rosen 1993 cited in Costello and Haggart 2003). A prevalent feature throughout the earlier periods being religious control, utilising methods ranging from diabolism which was thought to wreak bodily evil, sickness and ill health to the use of moral metaphors and victim blaming which gave way to rationalist, ‘scientific thinking’ during the enlightenment.
The perspective of public health over the past two centuries has been broken down into four major regimes and linked to mechanisms for social control by Armstrong (1993):
1) Quarantine – inclusion or exclusion and dominant up until mid 19th century,
2) Sanitary science – regulating the movement between different spaces environmental,
3) Interpersonal hygiene psychosocial attitudes and behaviours,
4) New public health (social and environmental patterns from the 1970’s).
Armstrong states that ‘new public health’ differs from the earlier three in the way it increases the scope of surveillance, gears behaviour to health targets and generalises danger. Armstrong’s use of the word ‘regime’ when categorising this period is also revealing. Bennett and DiLorenzo (1999) accuse ‘new public health’ of ‘nannying’ and imposing moral regulation on the population. A position further supported by commentators stating that:
‘The new public health can be seen as but the most recent of a series of regimes of power and knowledge that are orientated to the regulation and surveillance of individual bodies and the social body as a whole’ (Peterson and Lupton 1996, p3).
Some commentators suggest that the ‘old’ public health lasted only until the 1870’s when it was replaced by a more individualistic approach with germ theory and discoveries such as immunisation and vaccination (Ashton and Seymour 1988). Others state that ‘new public health’ emerged during the 1914-1918 war but accept that it goes further than a biological stance and recognises health problems linked to social conditions and lifestyles (Watterson 2003).
The concept of a ‘new public health’ is distinct from the ‘old public health’ in its departure from the biomedical model of disease and the adoption of a social model of health which
‘advocated a multi-causal approach that saw infectious and chronic degenerative disorders as being the result of a complex interaction between biophysical, social or psychosocial factors’ (Brown and Duncan p363).
Whether there is a reliance on the medical model in new public health may be disputed but public health policies that recommend preventative strategies seen in earlier Conservative government documentation such as Promoting Better Health (DH 1987) and Health of the Nation (DH 1992) increased the remit and power of health professionals (Peterson and Lupton 1996). The act of authority inherent in surveillance, screening and measuring targets is usually ascribed to a powerful medical model.
The origin of sanitary science and interpersonal hygiene appears in developments from earlier periods. One example, the discovery of vaccination, actually emerged in the eighteenth century but did not gain validity until Edward Jenner publicised the vaccination against smallpox, which then became commonplace and compulsory in the mid nineteenth century (Fisher 1991 cited in Baggot 2000). The enlightenment (late 17th century to late 18th century), a subdivision of the quarantine period, was highly significant to public health and medicine, representing a period of change, with the rise of scientific method and the decline of unquestioning religious belief and superstition (La Berge 1992). The possibilities for medicine within this new paradigm were vast, with opportunity for learning through anatomical research and scientifically supported diagnosis. Medicine was identified as key in reducing ill health from the increasing urbanisation and industrialisation resulting from the capitalist labour market.
Public Health Acts and interventions began to emerge during this time. The Gin Act 1751, came about when high infant and adult mortality began to be linked with the intake of cheap gin. Some municipal corporations acquired Private Improvement Acts in an attempt to tackle problems in their immediate environment, but they invariably lacked local support if the proposed legislation was detrimental to the mode of capitalist production. The new, scientific approach magnified medical dominance when hospitals, which began to be built from 1720 by voluntary organisations, spread across the country to patronise the deserving poor, those whose misfortune was seen to be through no fault of their own (Porter 1996).
Poor health and disease was not confined to the unemployed or homeless. The concerns regarding the poor health of those recruited to the army and navy, the new immigrant workers to the industrial towns and the health of those in hospital and prisons was championed by reformers such as John Howard. Public health, at this time under the auspice of the social medicine movement, adopted enlightenment principles and a trend for paternalism (Turner 1990). Iron and steel, ship building, cotton and coal were all growing industries and many industrial philanthropists at this time were expressing concern about the health and welfare of their workers, going as far as building housing and hospitals, schools and villages for them to live and work in. It could be argued that the good health of the workers improved capitalist production and subsequently profit, for the industrialists, however the improved social conditions most definitely went some way in improving life expectancy and resistance to disease at this time.
This parallel, of personal health and environmental influences, illustrated the association of health as more than an individual issue. Through the concept of governmentality (Foucoult 1991) regulatory activity both for self and external influences was employed, shaping beliefs and behaviours. The movement for health reform at this time adopted a wider view, accepting social determinants of health as influential in the causation and containment of disease. The study of epidemics evolved, including both the search for cause and patterns of disease and the medical gaze began to focus on disease and the events surrounding its development (Foucoult 1975).
The concern regarding epidemic disease advanced with the unfolding of a new understanding relating to endemic disease. Smallpox and typhoid were rife and despite an understanding of the social determinants of health beginning to emerge, malnutrition was widespread. The modern public health movement began to evolve, with the move from sanitary to state medicine (Wear 1992). At the forefront of this change were individuals such as Edwin Chadwick, Sanitary Commissioner and Poor Law Reformer. The Poor Law commission was established in 1834 to reform the system of poor relief and reduce the burden on tax payers, with John Simon (the first medical officer for the government) being given a place on the General Board of Health, after Chadwick in 1854.
The need for sanitation and clean drinking water appeared to be only fleetingly understood, until the social changes brought about as a consequence of the agricultural and industrial revolutions, conveyed large proportions of the working population to a short life, of poverty and ill health. This urbanisation, produced overcrowded cities where families became wage dependent and reliant on factory systems (Iphofen and Poland 1998) and illness and disease became rife due to living conditions and limited resistance to ill health. The 1848 Public Health Act was implemented to improve water systems and sewerage. This act attempted to standardise the supply of water, to improve health and, resembling other initiatives in public health at this time attempted to provide the ‘greatest good for the greatest number’.
The preventative collectivist approach was favoured in policy formation, setting out to reduce environmental harm and secure health improvement. Environmental harm at this time included occupational features linked to industrialisation, such as respiratory disease from the weaving industry, hearing problems caused by noise in factories and accidents due to large and dangerous machinery. The need for sanitation was seen as elementary. Chadwick described as the ‘first leader of the sanitarians’ stated that sanitation was the foundation of good health and poor health was not caused by worker poverty and (Hamlin 2000). Poverty was not acknowledged as primarily responsible for illness and disease at this time of industrial capitalism. Public health at this time although favouring a preventative approach to improving health (McKeown 1976) was actually an ‘admixture of benevolent despotism, rate payers’ self-interest and social control, instigated for, rather than by, the mass of the people, who were treated as an homogenous group’ (O’Keefe, Ottewill and Wall 1992 p176). This was further manifested by the belief that the poor needed social order, education and training, not aid (Kelly and Symonds 2003).
When looking back at this period McKeown (1976) believes that the pre-industrial era had higher mortality, mainly due to malnutrition, semi-starvation and inability to resist disease. Industrial capitalism brought more wealth and increased food production it unarguably brought more exploitation and dependency, with the end of self-sufficiency and a reliance on a market economy. The latter part of the Industrialisation period did bring an increase in life expectancy but was consequently responsible for an increase in occupational ill health and life limiting disease.
The sanitation debate was minimised further when the experience of the Crimean war led Florence Nightingale to describe hygiene as critical in preventing ill health. Whilst accepting sanitation as fundamental she defined the four main causes of disease in a simple form as overcrowding of the sick, lack of bed space, lack of fresh and lack of light and air (Nightingale 1859 cited in Kelly and Symonds 2003). Nightingales influence has been described as politically powerful, securing improved environmental conditions, but it is argued that her popularity at the time may have been manipulated politically, with her being used as a screen to hide the horrors of war rather than national support for the evidence she presented. However, whatever the reasoning behind her rise to the public eye, she continued to exercise her considerable influence in the campaign for sanitary reform (Holiday and Parker 1996).
The notion of hygiene took on alternative significance and alluded to the individual person, their ‘cleanliness’; not only referring to their personal hygiene but also their behaviours and their interpretation as moral, clean and educated or blasphemous, uncontrolled and sexually depraved. The poor and working classes were depicted as uncivilised and in need of example through demonstration and education by the civilised middle classes (La Berge 1992). The high levels of infant mortality and low rate of adult life expectancy were becoming both a political and social issue. Morbidity not only affected quality of life, it interfered with industrialisation, capitalism and the functionalist requirement inherent with the individual’s role within society. Hygiene was now the driving force to bring about the civilisation and discipline, ultimately to secure an economically productive population (Jones 1986).
Women were identified as ‘reputable’ or ‘disreputable’ depending on how they cared for their family and their observable behaviours (Finch 1993). This principle was perpetuated during the early part of the next century in the drive for national efficiency, where women as mothers were seen as both the cause of and solution to physical degeneracy (Kelly and Symonds 2003). A lay perspective, some may suggest has influenced the gender debate to the present today.
The improvement in health during this period appeared to be attributable to sanitary reform and the increasing numbers of doctors. However critics commented that this amounted to environmental engineering and a soft approach towards the damaging effects of capitalism when radical social change was needed (Turshen 1989). The move towards personal hygiene was described as ‘relocating the responsibility for health improvement with individuals, as opposed to collective or community action or state intervention’ (Winslow 1952 cited in Adams L, Amos M and Munro J 2002 p7).
At the early part of the twentieth century more sinister eugenicist beliefs, combined with the emphasis on social class, disease and social Darwinist doctrines, suggested that ill health, disease and high infant mortality were paving the way for ‘race decay’ and that ‘poor housing was the natural environment for of an unfit class preparing the way for its own extinction’ (L. T. Hobhouse, 1922, quoted in Wohl 1983p 335). Whilst this opinion may have been of the minority, the underlying principles on a wider scale depicted a victim blaming approach where the onus is on the individual to live a ‘healthy lifestyle’.
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Educational reform supported the drive for improved public health with emphasis on exercise, diet and regulation. The major determinants for health from the nineteenth century were identified as nutrition, public hygiene and contraception (McKeown 1976). With the public health measures such as sanitation, drinking water and housing being implemented over several decades, culminating in the Great Public Health Act 1875 and the factors of nutrition and contraception, change began to be effectuated.
A decline in fertility rates starting from around 1870 and falling family size was outlined as responsible for reducing death rates for mothers and babies. This was due to many variables ranging from reducing risks through pregnancy and childbirth or by the possibility that smaller families start with a healthier better fed mother, and end with a more robust infant with a better birth weight; an infant more likely to get adequate food and nutrition, subsequently making the child and mother less vulnerable to disease and ill health (Hart 1985).
The improvement of general health for the population was paramount and the Fabian eugenicist, Sidney Webb (1901), stated ‘that the prevention of disease and premature death, and the building up of the nervous and muscular vitality of the race was essential’ (Donald 1992 p 28) and suggested that education would be the vehicle for such a vital strategy. The strategy of education supported the drive for national efficiency following the Boer war when the full extent of appalling public health was identified and acknowledged, when a large proportion of recruits for the war were found to be unfit for service.
The purpose was to educate the poor on self-care and the subsequent adoption of hygienic habits would improve both national efficiency and support eugenicist ideals by improving the calibre of the population (Wear 1992). Moral worth was directly linked to hygienic behaviours and the extremists believed that true social improvement of the race depended upon assiduous breeding out of undesirable racial or social characteristics, so that the fittest survived. The political position on Public Health was fortunately more far sighted and adopted the notion of improve, rather than remove, as their remit.
The Balfour Act (1902) outlined the responsibility of Local Education Authorities statutory duty to provide elementary education for children up to the age of fourteen. Webb believed that ‘collective provision for welfare through the state was an essential, and inevitable, development within British capitalist society’ (Alcock 2003 p5). This belief about the necessity for collective provision by the state for welfare to raise the standards of health, education and housing of the population was influential in the overhaul of welfare and social security and set out as a manifesto on National Efficiency (1901), a programme of social reform based on state control (Mackenzie 1979). The ultimate plan was to remove social ills and reform and reorganise British society to enable Britain to become a world leader.
The interest in the manifesto of national efficiency was cross-political (Searl 1971), not suprising in a time when the ‘discourses of imperialism, social efficiency and motherhood became inextricably linked with an eugenicist drive to improve the ‘quality’ of the population’ (Kelly and Symonds 2003 p19). The evidence from the Boer War, reports from social surveys such as Charles Booth’s study of London and Benjamin Seebohm Rowntrees study of York highlighted the extent of deprivation at the turn of the century. The breadth and depth of deprivation gave prominence to the need for national provision of welfare services.
National provision of services
A potent role for medicine materialised in this era of ‘governmentality’ (Foucoult 1991) in the diagnosis and treatment of individuals. This would ensure that individuals were fit to return to their place in society, which from a reductionism perspective views the capacity for work as their only substantive asset (Costello and Haggart 2003). National provision for health education, supplements and services such as baby clinics and school health clinics began to emerge and although offering sound advice and guidance, served also to represent the political interest in surveillance and standardisation to maintain the health and productivity of the population.
School medical inspection was followed by the Children’s Act (1908) to convene children’s health and welfare. The following period saw the introduction of a progressive tax system in an attempt to implement state financial systems through social policy. The purpose, allowing for the provision of economic assistance to improve material circumstances of those living in poverty through the Introduction of State Pensions for the elderly in 1908 and the National Insurance Scheme. This was followed up by the introduction of a National Health Insurance (NHI), funded by employer, employee and state to provide treatment for illness to the employee. This provision excluded dependants and did not give specialist treatment other than for tuberculosis.
The majority report of 1909 (cited in Baggott 2000 p39) called for a more acceptable system of care for the ill treated under the poor law, but retained the opposition view to free medical care and preferred that local authorities administered health service to the poor. The minority report (cited in Baggott 2000 p39) recommended the amalgamation of poor law health services and sanitary authorities, to combine their services. The poor law system continued however until the 1929 Local Government Act saw poor law boards replaced by local authority assistance committees and a more comprehensive service was developed for sufferers of tuberculosis, the blind, the mentally infirm and maternity and child welfare. The pre-existing Poor Law workhouses were identified for redevelopment as local hospitals, running alongside voluntary hospitals.
This time of expansive service provision brought about the era of the ‘golden age of public health’ (Holland and Stewart 1998). Although the altruistic concern for the well being of society predominated at this time, there unarguably remained the requirement for a physically fit population, not only for capitalist production, imperialism and armed forces, but also now for maintaining the welfare system through contribution. The Medical Officers for Health (MOsH) believed the 1929 Act would lead to the development of an integrated public health service but critics argued it was detrimental to public health and that the public health departments had gathered services up without fully considering the uniqueness of public health (Lewis 1986). The resulting reduced attention to the community watchdog function and increased attention to service delivery, antagonised the general practitioners (GP’s). Services for health or ill health, whether provided through public health clinics or general practitioner (GP), dominated and the overriding principle was that health was a moral duty and a prerequisite of a functional society.
The functionalist perspective of health was demonstrated by Parsons ‘Sick Role’ (1951), where with emphasis on a consensus model of health, the practice of medicine contributes to maintaining social order. However equality of access to the legitimate sick role was not population wide. Further criticism surrounding the authenticity and validity of the medicalisation of health suggests that medicine expanding into life experiences such as pregnancy (Oakley 1984) may offer up technical solutions but in doing so, circumscribe to moral decision-making (Zola 1972).
The 1944 Goodenough Committee on medical education saw social medicine as a crucial part of the medical training curriculum, drawing on perspectives gained from groups such as the Women’s Group on Public Welfare and the work of the Peckham Health Centre, which identified the concept of health as separate from the cure of disease (Wear 1992). Social medicine focused on either environmental relationship with the individual and their hereditary make up or social factors affecting their health status.
The drive for ‘social medicine’ was increasing, as was the need for a social conscience influencing the perception of health, but as it gained impetus, critics reflected on the reality of the term social medicine and the fact that the use of the word social and an understanding of social influences of health was not reflected in the training curricula of social and community medicine within medical schools. This remains so today although to a lesser extent as it could be conceded that at least in relation to Public Health medical officer training the study of epidemiology remains paramount and added value inherent in the control of communicable diseases (Evans 2003).
The inception of the National Health Service
The Beveridge Report in 1942 addressed the role of the state in meeting collective welfare need with subsequent post war reforms being introduced by the Atlee government. This welfare state attempted to tackle what Beveridge had described as the ‘five major ills’ afflicting society and was set out as:
The NHS to combat disease
Full employment to combat idleness
State education to age fifteen to combat ignorance (introduced in 1944)
Public housing to combat squalor
The National Insurance and Assistance schemes to combat want
Correspondingly, local authority Children’s and Mental Health Departments introduced a more comprehensive form of social service provision. This was said to be the creation of ‘social citizenship’ (T H Marshall, cited in Alcock 2003 p7) and embodied the role of state as provider for collective welfare. The advent of the National Health Service (NHS) in 1948, was in fact a compromise vision of the original, as a result of many battles with the medical profession and the medical profession managed to both retain their power and receive financial reward.
A Weberian approach to the study of professions suggests that ‘tradition; charisma and rational-legal authority maintain legitimate domination’ (Hart 1985 p111). In medicine, tradition: charisma and status have been acquired through time and opportunity, rational-legal power has been conferred as power of office and political organisation.
Critical analysis reveals that not simply an altruistic desire to contribute to the well being of society gave doctors such high status and reward but an occupational strategy of exclusion through restricted, lengthy training and the exercising of power demonstrated at the time when national investment was in the development of the NHS. The medical profession fought to retain the right to practice medicine privately outside of the NHS (Senior and Viveash 1998) and bio-medicine was again triumphant through the medicalisation of public health.
The type of health service which Britain adopted based itself on access to medical services (Klein 1989). This brought about change and reform in healthcare with the move from a community perspective to a focus on hospital treatment. The previously powerful departments with MOsH traditionally responsible for the clinics and services for vulnerable members of the population, were now deployed into administrating basic preventative services (Adams et al 2002). Some critics state this reorganisation led to a reduction of power for the MOsH evolving from the inter-war years, when what was seen as the ‘old public health’ declined. This came about when increasing emphasis on bio medical responses and curative approaches to ill health was not matched by growth and redefining theory in public health. MOsH were increasingly committed to establishing personal health care services and in doing so, overlooked the key functions of community watchdog and their role in supporting immunisation and researching health in relation to unemployment and morbidity/mortality statistics (Lewis 1986).
During this transitory time when the emphasis on public health changed from societal to the individual (RUiHBC 1989) there was no specific reason why the MOsH could not combine the benefits of a wider public health remit such as the determinants of health and environmental influences, with the emphasis on provision of services and individual responsibility, but it was suggested they lacked the strength of resources and political will (O’Keefe et al 1992). Where health is seen to be not directly related to environment, social conditions or factors such as epidemiology but located within the individual, then the influence of the MOsH is subjugated and as a result, a new dimension must be applied to regain medical control and prominence.
In the early part of the 2000 decade there were four major areas of responsibility for public health physicians which included: Advising on the purchasing for health services, based on a knowledge of community health need and population social structure, the control of communicable diseases, research in communicable disease and public health and the design, management and evaluation of health promotion activities. (Farmer, Miller and Lawrenson 1996). Recently, in 2009, this remains much the same but with increased emphasis on assessing evidence and impact of programmes for health intervention through statistical databases and national collaboration, through public health observatories.
The focus on health as a separate entity was further emphasised following the WHO (1946) definition of health. ‘Health is a state of comple
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