Definitions: problems and solutions
In this Step we consider how the health problems experienced by the population, and the solutions offered to these by health services and other actors, are fundamental to our understanding of public health. It is often hard to separate ideas about public health from the challenges it faces. This was true in the past, just as it is today.
The historian Dorothy Porter begins her book on the history of public health from ancient to modern times by suggesting that:
For many students the idea of studying the history of public health provokes a very big yawn since it conjures up an image of investigating toilets, drains and political statutes through the ages.1
The problems & solutions of nineteenth century public health
We hope that the idea of studying public health history doesn’t make you yawn! But, when people think about the history of public health, what they often have in mind is sanitation and infection, the problems that toilets, drains and statutes helped to put right in Britain during the nineteenth century. This period was certainly crucial to the development of public health as an ideology and a collection of services and practices. Although communities had come together to combat health problems since the beginning of civilisation, in the nineteenth century there were two shifts that led to more organised forms of public health.
The first shift was the growth of the nation state and the development of better coordinated and further reaching forms of government. The second was industrialisation and urbanisation. The Industrial Revolution led to the rapid growth of towns and cities. Living conditions in these urban areas were extremely poor, perfect for the spread of infectious diseases like cholera and typhus. Life expectancy, which had been increasing since the 1720s, plateaued, as people became sick and died from infections. To combat this, government officials introduced legislation, like the 1848 Public Health Act, which made local authorities responsible for the provision of clean water and drainage. Gradual improvements in living conditions, together with other technical innovations such as vaccination, resulted in an improvement in life expectancy.
Towards the end of the nineteenth century, the discovery that micro-organisms (bacteria) were responsible for many infections led to a more specific understanding of the transmission of infectious disease, meaning that more effective preventive measures could be introduced. By the early twentieth century, deaths from infectious disease had declined. This is the so-called ‘epidemiological transition’, a development we will explore in greater depth in Steps 2.2 and 2.3.
Changing problems, changing public health solutions
For now, let’s focus on the impact of this shift on ideas about the meaning of public health. As infectious disease was less of a problem, public health officials became more concerned with other issues, such as child and maternal health, and the effects of poverty. New services were created to alleviate some of these problems. By the middle of the twentieth century, the ideas and practices of public health had changed quite radically from those of the nineteenth century. The challenges encountered by public health thus helped to shape its very nature.
The problem with problems…
Some historians have seen this as a problem. Jane Lewis argued that ‘After World War II, public health allowed itself to be defined by the activities it undertook. The idea of public health thus remained indistinct.’2 Without a clear philosophy, she suggests, public health services and practitioners were unable to carve out a role for themselves, or address public health problems effectively. We will return to this assessment later this week, when we look at the changing structure of public health services in more detail, but it is worth thinking about Lewis’s broader point – that public health is defined by what it does in response to the problems it encounters.
The problems & solutions of public health today
In 2006, the then British Prime Minister, Tony Blair, gave a speech about public health. He explored the nineteenth century history of public health in some detail, comparing the challenges encountered then, with those we experience now. He remarked that:
‘The problems of 19th Century public health were colossal. But they were, in a sense, easy to correct. The collective solutions were easy to identify - to improve slum dwellings; to construct a disposal system; to purify the water; to make the fruits of medical research available to the poor.’3
In contrast, he suggested, today
‘We are now in a new era, the time of conditions of affluence, of degenerative and man-made diseases…Our public health problems are not, strictly speaking, public health questions at all. They are questions of individual lifestyle - obesity, smoking, alcohol abuse, diabetes, sexually transmitted disease.’3
For Blair, ‘what we call “public health”’ was ‘really about “healthy living”.3 Public health, he suggested, had become synonymous with a set of problems linked to individual behaviour. We will investigate this shift more closely later this week, but it’s important to note here that definitions of public health are malleable, multi-dimensional and change over time. ‘Public health’ is not one thing, but many.
What does ‘public health’ mean in your society today? How is this different from the definitions we have presented here? How is this likely to change in the future?
© London School of Hygiene & Tropical Medicine