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St Ninian’s High School
Medicine and Health Through Time
Section two - Public Health
Electronic Textbook
Tim Dargan BA(Hons) Dip (Law) ACIS QTS (Manx) Feb 2012
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SECTION ONE:
WHAT IS PUBLIC HEALTH?
According to the Department of Health website www.dh.gov.uk/health/
category/policy-areas/public-health/ Public Health is: “ about helping people
to stay healthy and avoid getting ill......”
In our modern world this means our government takes an active role in
helping people follow a healthy diet and exercise regime.
In can also mean helping people stop smoking or give up drinking excessive
amounts of alcohol.
Our Government also ensures sewage and water systems are maintained by
using taxation to pay for this infrastructure.
The Government also has public health laws in place ensuring the population
has clean drinking water and live in sanitary conditions. Harsh penalties exist
for people who break these laws.
This is the reflection of a healthy wealthy sophisticated civilisation. What we
are going to look at in this study is how we got to the stage where we actually
have an entire government department dedicated to keeping the population
of the country healthy and productive.
As civilisation developed what steps were taken to keep the populations of
the villages that became towns and the towns that became and cities
healthy?
Who was responsible for these developments and how did they arrive at the
decisions they made?
What happened when they chose not to invest in Public Health?
In order to do this we have to right back to the beginning...........
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SECTION TWO:
DID THE ANCIENTS HAVE PUBLIC HEALTH?
As always when studying ancient civilisation we can only hypothesise as to
how they actually lived their lives.
In the excavated remains of Scara Brae in the Orkney Islands there is
evidence suggesting Neolithic people had toilets and sewers taking waste
away from their settlements.
Bed Chamber
Fire Pit
Ensuite
bathroom?
Archaeologists have suggested that this room is a
rudimentary “ Toilet” - there is evidence of sewage
pipes leading away and down hill from this dwelling.
We do not know this for sure but if we apply our modern
ideas and thinking to the evidence we arrive at the
conclusion that perhaps neolithic people had a basic
idea of public health..........
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SECTION THREE ROMAN PUBLIC HEALTH
Our first real evidence of a public system lies with the Roman Empire...
One
canʼt build an Empire if ones army is
dying of disease. One canʼt recruit an Army if
oneʼs citizens are dying of disease....... one has to
have a plan - Dontcha know! We Romans
donʼt do anything without a plan
The Romans realised the survival and expansion of
their Empire depended on the Health of their citizens
and soldiers.
(Originally before Rome had a professional Soldier all
male citizens had to serve in the Army)
Marcus Aurelius
They also knew Laws had to be passed and harshly
enforced to ensure all cities towns and villages
throughout the Empire had the same standards of public Health.....
When it came to people breaking their laws the Romans didnʼt mess about:
The Romans knew they had to have
the following:
1.A source of fresh clean water.
2.A means of storing this water
3.Public baths and toilets.
4.A means of taking sewage away
from the population centre.
This is what they did:
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The Roman Public Health Model:
Rivers are diverted to
supply water to
Aqueducts
Aqueducts bring
water to Resevoirs
in and around cities
Resevoirs supply
water to public
fountains, baths and
drinking fountains
Waste water is flushed
away via a sewage
system
Waste water is flushed
away via a sewage
system
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The Roman Public Health Model (Continued)
The Romans had found a way to provide their cities with clean drinking water
and to keep their citizens clean and healthy. Today we use a much more
developed version of this system.
The Romans have a problem: They can get their sewage away from their
cities - but where do they put it?
Answer:
The sewage is flushed into local rivers down
stream of their cities and towns.
This is fine if you live in this town - not so
good if you live down stream...
Eventually the old enemy of Empire builders:
Disease will make itʼs way to even the
cleanest Roman town. (The Roman road
system caused disease to spread quickly)
The Roman have
another problem:
The River Tiber
All Roads lead to Rome.
As the Roman Empire comes under threat from
Barbarian invaders once their armies on the
borders are defeated the invaders move quickly to
the gates of Rome.
As the Empire is destroyed so is the infrastructure
of water supply and waste disposal. As tax
monies disappear the people employed to
maintain these systems stop working - eventually the Roman Public health
system fails.
The Appian Way
The Civilisations that replace the Romans have to begin again............
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SECTION FOUR:
SAXON PUBLIC HEALTH:
After the Roman Empire collapsed the Infrastructure the Roman brought with
them Collapsed as well. Many roads fell into disrepair and were abandoned.
Buildings were destroyed with their stone being used to build saxon homes
and farm walls.
The supply fresh water brought by Aqueducts began to fall away as these
structures fell into disrepair. (There was no longer anyone who had the ability
or were willing to repair and maintain these structures).
As the country split into warring factions each vying for superiority people
began to move from the countryside towards the well built and well defended
old Roman cities.
Cities such as York and London quickly become overpopulated with their
rivers (that now supplied all the water these towns needed) became polluted.
Diseases such as Cholera and Dysentry become commonplace.
Cities did place regulations on where and how to dump Rubbish and treat
sewage however these laws were poorly enforced. The universal standards
the Romans maintained began to disappear.
In order to maintain these high standards and the complex infrastructure the
Romans charged heavy taxes and imposed heavy fines and punishments
usually enforced by the fearsome Roman Army.
In Saxon Britain there was no longer a large standing Army to enforce
discipline and people were unwilling to pay high taxes.
However there was one institution that still undertook large scale Engineering
projects collected high taxes and followed the Roman systems of Public
health :
Public Health This way.........
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SECTION FIVE:
THE CHRISTIAN CHURCH
As the Church grew in power and influence they were able to gain large
amounts of land from the kings and Queens their missionaries were
converting to Christianity.
With this land the Church were also given the power to raise money through
taxation or Tithe.
Usually priests and Bishops were amongst the few educated people of power
in any Kingdom they kept records. It is likely the Church had access to the
original Roman writings detailing their Public Health systems.
They used their taxation to build Churches and Monasteries. The Monasteries
became the centre of many new towns. The church also used systems of
public health similar to the Romans.
They always had access to a fresh water Supply.
They had large Cisterns to store the water
They had separate bath houses and toilets.
They had sewers to move waste away from the Monastery.
Although the church together with their engineers and masons had the ability
to extend their efficient public health systems to the towns that grew up
around their monasteries - they rarely did.
This in turn resulted in the spread of disease.
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SECTION SIX: NORMAN PUBLIC HEALTH
After 1066 the Normans began to colonise Britain. Saxon land owners and
Nobles were stripped of their lands.
Old wooden houses were destroyed to make way for Norman castles and
stone buildings.
By the 1060ʼs there were increasing numbers of Stone houses in towns.
Two hundred years later many houses had at least stone foundations.
The Normans passed laws to ensure Cess pits were built with a stone or
brick lining and were emptied instead of being sealed off and left .
As we have already seen Abbyʼs had stone sewage systems and plumbing to
ensure clean water supplies.
It took 600 years but slowly the Normans were beginning to return Britain to
Roman standards of public Health.
No matter how well the Norman cities were planned People at this time were
still susceptable to Plague, Cholera, Small Pox and other diseases.
It would not be until the discovery of Germ Theory that people understood
how what disease was and how it spread. They were then able to put in
place systems and measures to prevent disease.
At this time plagues were often put down to “Gods Will” Rigid unquestioning
belief in the guidance of the Christian church ensured people rarely looked for
the causes of disease.
This attitude also ensured Public health laws began to be ignored .....
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SECTION SEVEN:
14TH CENTURY PUBLIC HEALTH.
By the 14th century cities and towns had become over populated . Cities
were the places to trade and to make your fortune.
Cities such as London were given their own Royal Charter - which meant
they could govern themselves, pass their own laws and raise their own taxes.
The problems:
The City grew too fast. With the increasing
population came disease and pollution.
People uses the rivers as open sewers - people
also used the same rivers for drinking and bathing.
People were fined for dumping rubbish outside
their houses - wealthy people just paid the small
fine, and carried on littering,
Butchers slaughtered animals in the street and dumped the remains in the river.
Open sewers ran down the centre of streets. Disease spread quickly in this camped
environment.
The Solutions:
Sign of the guild of Butchers.
Laws were passed to ensure Butchers could only work in certain
parts of the city - known as “Shambles”
Trade Guilds ensured their members stuck by the Law. So
Butchers had to comply - from the selling of fresh meat to where
they could slaughter animals.
Gong Farmers were employed to rake up and clean the tonnes of animal manure and
human waste off the streets .
Laws were passed ensuring people could not build a cesspit two and a half feet from
a well.
Sewers were built to take waste to the river . Public toilets were built.
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SECTION EIGHT:
19TH CENTURY PUBLIC HEALTH
The Government in the 19th Century was Laissez Faire (This is french for
“leave it alone”) This meant the government did not believe in intervening in
the lives, and in this case health of itʼs subjects. For the Government to
engage in large public health projects would mean an unpopular raise in
taxation.
The people who wanted the government to say out of their affairs were known
as “The Dirty Party” They wanted public health to be left up to individual rate
payers and not a matter of national law.
At the start of the 19th Century public health was in a similar state to that in
the 14th Century - so what caused this to change?
The Answer?
Repeated Cholera epidemics
Cholera hit london on a regular basis throughout the 19th Century.
In 1832 after studying how the disease attacked /london people began to find
a link between Cholera and the water supply - however at this time people did
not understand that Germs were the real cause of this disease.
After the Cholera breakout of 1854 Doctor John Snow used statistics and
research to build up a detailed picture of the epidemic that seemed to effect
only one area of London
SECTION NINE:
CHOLERA AND THE WORK OF JOHN SNOW.
John Snow Observed the Victims from the area of
London around Broad Street.
He interviewed every household asking where
they drew their water from.
Even those who were not from the area but who
had the disease were interviewed.
He did notice that not everyone fro the area serviced by the Broad Street
water pump did not contract the disease.
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Snow discovered that the people not from the area who had contracted the
disease - did so because they drew their water from the broad street pump.
He also worked out that those who lived in the area but who had not
contracted the disease were drinking beer not water. They were brewery
employees. There was also a deep well within the brewery. (Beer was seen
as a health food in the nineteenth century).
Snow took the handle off the pump and observed the results...... the cases of
cholera dropped off.
Upon examination of the well it was found that a cess
pool had broken itʼs wall and was leaking into the well in
broad street.
Snow was able to prove the connection between
Cholera and water.
Although Snow was able to prove a link between water
and Cholera he was not able to show what Cholera
looked like. It would take Louis Pasteur and his Germ Theory to show the
existence of Germs.
This problem meant that even though snow had meticulous research there
would be doubters who would resist Government intervention.
Snow was not the only person dealing with issues of Public Health in Britain
at this time. ....
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SECTION TEN: THE WORK OF EDWIN CHADWICK.
Chadwick is one of the few medical Heroes who is not a scientist or a doctor he is a civil servant who was employed by The Poor Law Commission.
Chadwickʼs Job was to assess who need help and to work out how much
assistance they received from the taxes that were collected in his local area.
At this time the poor were given financial help on a local basis - so each area
had different rules. Today everyone in the country is entitled to the same
benefits and medical cover paid for by national insurance contributions.
Chadwick was tasked with producing a report on the Health of the poor in
both town and country.
Chadwick worked out :
Chadwick
suggested the rate
payers could save the
money they spent looking
after the poor if our living
conditions were
improved.
....and
the appointment of
district medical officers
with special
qualifications....
We
are only so poor
because of our horrible living
conditions which causes out
bad health - this makes us
unable to work.
He
also suggested that
rate payers fund public
drainage systems (Sewers) to
keep streets clean and
improve the health of
the public
At First the Government tried to ignore his report - However in 1848 a new
Cholera Epidemic was breaking out - so the Government passed The public
Health Act 1848. However the Government still wanted to remain Laissez
Faire (Remember this term from page 11?) So they made the Law voluntary not Compulsory - this meant local authorities did not have to build the sewers
if they chose not to - many chose not to.
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However subsequent epidemics increased international competition
especially from France the USA and Germany whose governments had
invested in extensive public health projects meant that the productivity of
Britainʼs workforce was falling behind its competition.
The final piece in the puzzle was the improvement of the microscope by
Joseph Lister and Louis Pasteurʼs Germ Theory and the Work of Robert Koch
which eventually showed the bacteria that caused diseases such as Cholera.
(See book one)
By 1875 in the face of international competition and indisputable scientific
evidence the British Government passed : The Public Health Act 1875. The
Act ensured local Authorities had to provide by law:
Proper Drainage
Sewers
Clean water
Medical Officers
Test Yourself:
What factors would you use to describe why the british government
passed the public Health Act 1875?
What factors would you use to describe the reasons behind the passing
of the Public Health Act 1848?
What does “Laissez Faire” mean? How does this term apply to the
British Government in the early 19th Century? How about the late 19th
Century?
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OTHER HEALTH REFORMS IN THE 19TH CENTURY
1802 - Factory Acts.
Improved working conditions.
1889 Isolation hospitals
for infectious diseases.
Ones
Husband Albert
died of Typhoid Fever This disease effected all
classes - it could have been
due to poor drains. One
was not amused
1852:
Compulsory
Vaccination.
1858 Regulation
of Doctors
Qualifications.
1876 Laws against the
pollution of Rivers
1870 Improved
Education. Every
local authority had
to set up schools
Queen Victoria - the
monarch for the
majority of the 19th
Century (1837 - 1901)
1876 Food Standards and
building regulations.
ANYTHING ELSE?...This fella:
Who is he? An outstanding engineer he was the
man who built the sewage system under London He set the template for all modern Sewage
systems - this system helped stop the Cholera
epidemics in London. This famous landmark was
built to accommodate the system:
Joseph Bazalgette
1819 -1891
The London Embankment.
underneath is Bazalgettes
sewage system.
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SECTION ELEVEN: 20th and 21st CENTURY PUBLIC HEALTH
From the 19th Century onwards successive British Governments began to
see the wisdom of spending money to ensure the health and well being of the
citizens. However most great changes tended to come because of a great
emergency.
In the 19th century it was the Small pox and Cholera epidemics which caused
the government to pass the Public Health Acts and introduce compulsory
Vaccinations.
In the 20th Century is was War!.
With Increased economic competition from countries such as Germany and
the prospect of invasion and defeat caused the government to increase
spending and investment in the Health of itʼs Public.
1911 The National insurance scheme was introduced - this provided payment
for healthcare.
1914-1918 World War One: Medical advances such as plastic surgery blood
transfusions, and mobile X-rays filter into civilian hospitals - Women doctors also
become more common place. Education levels increase people are able to read
and understand government health leaflets and posters.
1939 The Government start the “Emergency Hospital Scheme” Funded and
Run by the government - this is the fore runner to the “National Health Service”
1943 The Beveridge Report proposes a “National Health Service” which will be
free at the point of delivery to all British citizens.
1946 The National Health Service Act - provides a comprehensive healthcare
system.
5th July 1948 The first day of the National Health Service (NHS) Free
healthcare at the point of delivery.
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The National Health Service is paid for by the Government from peoples
National Insurance Contributions - this is an advanced version of the 1911
National Insurance Scheme.
If you want to know what the NHS does for us please refer to page 46 of the
SNHS Medicine and Health Through Time Book.
PUBLIC HEALTH IN THE 21ST CENTURY.
So where do we go from here?
We understand how disease spreads we know what bacteria look like and
how they cause disease.
We have vaccination and inoculation programmes paid for by the National
Health Service.
We have excellent Public Health Service services such as clean water and
sewage systems.
We have a free at the point of delivery health service.
What happens next.......?
As we progress as a civilisation we (and our public health systems) face new
challenges.
Challenges such as: Epidemics and Pandemics (A pandemic is an epidemic
that spreads from country to country )- remember the Bubonic and
Pneumonic plagues? As they spread across the known world they became a
pandemic!
At the end of WW1 a strain of the flu known as Spanish Flu (So called as it
was first reported in Spain) killed over 18 million people world wide (More
than the first world war) Since then governments have co-operated and spent
billions on combatting a variety of flu epidemics - such as Swine Flu and
Avian Flu
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Conditions such as the Human Immunodeficiency Virus (HIV) which can lead
to Aquired Immunodeficiency Syndrome (AIDS) still need to be addressed.
To combat these new challenges we need to have new levels of international
co-operation and communication, Education Scientific development,
Innovation, Individual Genius, Government investment, Corporate
investment........ to name but a few of the factors we need to survive and
prosper in the 21st Century.
NOW TRY THESE
1.
Medicine and Public Health from Roman Britain onwards.
(a) Describe the key features of the medical training of physicians in the thirteenth
and fourteenth centuries.
(9)
*(b) How much continuity was there from the Roman period to the end of the Middle
Ages in medical treatments and home remedies?
(16)
You may use the following in your answer and any other information of your own.
• In the Roman period the father was responsible for most
treatments within the family.
• The Christian Church taught that saints could heal sick people
through miracles.
• In 1348 bloodletting was used as a treatment for the Black Death.
(Total for Question 5 = 25 marks)
2.
Public Health c1350 to the present day.
(a) Explain why people living in towns had problems getting fresh water in the period
1350–1750.
(9)
*(b) How important was the work of Edwin Chadwick in improving public health in
towns in the nineteenth century?
(16)
You may use the following in your answer and any other information of your own.
• In 1842 Edwin Chadwick published a report on the living
conditions of the poor.
• Louis Pasteur published his germ theory in 1861.
• Public Health Acts were passed in 1848 and 1875.
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3.
Medicine and Public Health from Roman Britain onwards.
(a) What were the key features of public health in Roman Britain?
(9)
*(b) How far did ideas about the cause of disease change from the Roman period to
the end of the Middle Ages?
(16)
You may use the following in your answer and any other information of your own.
! !! Galen believed in the Theory of Four Humours.
! !! The Roman army was told not to camp in swampy areas.
! !! During the Black Death in 1348 some people whipped
themselves.
(Total for Question 5 = 25 marks)
4.
Public Health c1350 to the present day.
(a) Explain why diseases such as cholera spread so rapidly in industrial towns during
the nineteenth century.
(9)
*(b) ‘The government’s role in improving public health was more important during the
nineteenth century than during the twentieth century’. Do you agree?
Explain your answer.
(16)
You may use the following in your answer and any other information of your own.
! !! 1848: The first Public Health Act was passed.
! !! 1938: The government began a vaccination campaign to
prevent diphtheria.
! !! Since 1971 packets of cigarettes have carried a government
health warning.
(Total for Question 6 = 25 marks)
5.
Medicine and Public Health from Roman Britain onwards.
(a) What were the key problems of public health in the period after the Romans left
Britain in the fifth century until c1350?
(9)
*(b) How important was the influence of Hippocrates on Roman and medieval
medicine?
(16)
You may use the following in your answer and any other information of your own.
! !! Hippocrates developed the idea of Clinical Observation.
! !! Galen developed the Theory of Opposites.
! !! The Church controlled medical training during the Middle Ages.
(Total for Question 5 = 25 marks)
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6.
Public Health c1350 to the present day.
(a) What were the key features of John Snow’s investigation into cholera in 1854?
(9)
*(b) Why was the role of government so important in improving public health in the
period from 1900 to the present day?
(16)
You may use the following in your answer and any other information of your own.
! !! 1907: School Medical Service established.
! !! 1938: Free vaccinations offered against diphtheria.
! !! 1971: The government required a health warning to be placed on cigarette
packets.
(Total for Question 6 = 25 marks)
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