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Public lecture at Bayero University, Kano Senate Hall
on 7 February 2014 by Professor Omar Hasan Kasule Sr. MB ChB (MUK),
MPH (Harvard) DrPH (Harvard), Faculty of Medicine, King Fahad Medical City,
Riyadh Email: omarkasule@yahoo.com
WEB: www.omarkasule-tib.blogspot.com
PUBLIC HEALTH AS HEALTH
PROMOTION, HEALTH PROTECTION, AND DISEASE PREVENTION
·
Public health is the sum of
all official (government) efforts to promote, protect, and maintain health.
·
Public health has 3 main paradigms: health promotion, health
protection, and disease prevention.
·
Health promotion:
physical fitness and exercise, good nutrition, avoiding addictions (tobacco,
alcohol, and drugs), mental health, and health education.
·
Health protection:
avoiding unintentional injury, occupational health and safety, food and drug
safety.
·
Disease prevention:
vaccination, preventive clinical services, and specific preventive measures
targeted at disease risk factors.
PUBLIC HEALTH AS SOCIAL
INTERVENTION
·
The discipline alternates between holistic social interventions and
medical technological interventions depending on the challenges.
·
In ancient civilizations public health was a holistic approach to
social improvement with limited technological intervention.
·
In the 19th century public health was a social intervention involving
physicians, social workers, engineers, lawyers, and other social activists.
·
Health improvements in Europe and the US in the 19th century can be
attributed to social interventions. The medical technology alternative was not
yet developed.
PUBLIC HEALTH AS MEDICAL
TECHNOLOGICAL INTERVENTIONS
·
By the early 20th century the bio-medical model had become predominant
and thenceforward public health practitioners became physicians only relying on
curative medicine and the holistic social interventions were relatively
marginalized.
·
The biomedical model was very successful with infectious diseases but
failed to control chronic diseases like cancer and heart disease.
·
Chronic non communicable diseases that cannot be cured but are
preventable have forced us to return to the social intervention modality.
PUBLIC HEALTH IN ANCIENT
CIVILIZATION: HOLISTIC SOCIAL INTERVENTIONS
·
Mesopotamia: The
Hammurabi code instituted some public health measures.
·
Egypt: Drainage
systems were known in the middle Egyptian Kingdom (2000-2700 BC).
·
India: Archeological
findings in India show that in about 2000 BC bathrooms and drains in homes and
sewers at street level.
·
Greece: In 1600 BC
Myceans in Crete had toilets, flushing systems, and sewers. The Greeks engaged
in sports and exercise that are very modern forms of health promotion.
·
Roman period (500 BC to 500 CE): Romans improved Greek city water systems. The Romans built sewage
systems, regulated building construction, refuse collection, street cleaning,
and street repair.
·
The Muslim civilization made many contributions to public health: hygiene, social welfare, etc. This will
require a separate presentation.
PUBLIC HEALTH IN THE EUROPEAN
MIDDLE AGES
·
There was little development of public health services in Europe in the
Middle Ages (500 – 1500 CE) and the post reformation pre-industrial era (1500 –
1850 CE).
·
Middle ages: Failure to understand the environmental basis of disease
led to repeated epidemics.
·
Plague epidemics in 543, 1348, and 1664 CE. The 1348 plague, called the
Black Death, killed 25 million people.
·
Other epidemics were: smallpox, diphtheria, measles, influenza,
tuberculosis, anthrax, and trachoma.
·
Syphilis started in 1492 CE and assumed near epidemic proportions.
PUBLIC HEALTH IN THE EUROPEAN
RENAISSANCE and INDUSTRIAL REVOLUTION
·
The renaissance and age of exploration (1500-1700 CE): Rapid exchange
of ideas and spread of diseases.
·
It was realized that for some diseases like malaria (bad air) the
environment was an important factor. The epidemics of smallpox, malaria, plague
still occurred.
·
Industrial era (18th and 19th centuries): Rapid
urbanization led to crowded unsanitary living conditions. Epidemics still
occurred in the crowded cities.
·
The predominant theory for disease causation was the miasma theory
which assumed that vapors or miasmas were the cause of disease.
DEVELOPMENT OF PUBLIC HEALTH IN
THE UK: REAWAKENING
·
In the Victorian era (1837-1902) Britain became an industrial power
with unprecedented wealth.
·
There was marked decline in mortality from infectious disease that is
attributed to improved nutrition and standards of living.
·
The Victorian era had many public health problems arising out of rapid
industrialization and the rural-urban exodus.
·
Awakening: The cholera epidemics of 1831-2 and 1865-66 led to a more
serious interest in public health.
·
Sir Edwin Chadwick (1800-1890 CE) Secretary of the Poor Commission in
1842 published his ‘Report on the Sanitary Conditions of the Laboring
Population based on extensive field surveys. The Chadwick report emphasized the
link between dirt, crowding, and disease.
·
Following the passage of the Public Health Act of 1848. Edwin Chadwick
became a member of the General Health Board that was concerned with sanitation
and sewage disposal.
·
Due to his strong advocacy for public health that conflicted with
vested interests, Chadwick was forced to retire at the early age of 54.
DEVELOPMENT OF PUBLIC HEALTH IN
THE UK: Sanitation, Housing, School Health
·
The landmark legislation by the Public Health Acts of 1872 and 1875
established a sanitary authority in every district.
·
Housing laws of the 1870s included health codes.
·
In 1872 local authorities were required to appoint a medical officer of
health (MOH) whose work was mostly in sanitation and disease control.
·
School health programs started from 1890.
DEVELOPMENT OF PUBLIC HEALTH IN
THE UK: Home Visits, Sanitaria, Milk Hygiene, Clean Water
·
Measures were taken to decrease the high infant mortality rate by
visits to homes.
·
Sanitaria were established for tuberculosis patients with emphasis on
rest and open air as methods of treatment.
·
Pasteurization helped decrease TB transmission.
·
By the end of the 19th century clean water supplies were
available for all.
·
Sewage disposal systems.
DEVELOPMENT OF PUBLIC HEALTH IN
THE UK: Biomedical Interventions
·
The scope of public health in the 20th century changed.
·
The germ theory of disease that became popular in the closing years of
the 19th century narrowed the focus of public health to the
infectious disease model leaving out aspects that we know today to be important
for public health.
·
This model is still dominant and has found its challenge in heart
disease and cancer.
·
Biomedical interventions vs human will and human habits.
DEVELOPMENT OF PUBLIC HEALTH IN
THE US: The US Civil War
·
US civil war was an “eye opener” more soldiers from both sides died of
disease than of bullets.
·
State health boards were established in Massachusetts 1869, California
1870, District of Columbia 1871, Virginia 1872, Minnesota 1872, and Maryland
1974.
·
Congress created a National Board of Health in 1879 following a yellow
fever epidemic in the south of the US.
DEVELOPMENT OF PUBLIC HEALTH IN
THE US: The American-Spanish War
·
The American-Spanish of 1898 fought in both Cuba and the Philippines:
toll of death due to infectious disease was very high.
·
Program against yellow fever was started in Cuba and a Tropical
Diseases Bureau was set up in the Philippines.
·
An intensive campaign again mosquitoes led to control of yellow fever
and enabled the completion of the Panama Canal whose construction had been
abandoned because of disease.
·
Efforts on tropical diseases within the US also started. The
Rockefeller Foundation, starting in 1909, worked on control of hookworm
infestation in the south of the US.
DEVELOPMENT OF PUBLIC HEALTH IN
THE US: World War 1 and 2
·
The First World War: many young men called up for service had to be
rejected because of poor health. Renewed concern with public health started.
·
The Second World War: 40% of the young men called up were declared
unfit to serve in the armed forces for poor health.
·
Youth health problems persisted in the Korean and Vietnam wars.
DEVELOPMENT OF PUBLIC HEALTH IN
THE US: Social Organization
·
Industrial growth in the late 19th century, urban health
problems increased and cities were hardly coping. As a response to the urban
problems, public health was transformed into a social reform movement.
·
Organizations were formed to fight for improved housing, abolition of
child labor, provision of maternal and child health services, and promotion of
temperance.
·
By 1937 the average life expectancy was 59.7 years.
·
1882 - The American Red Cross formed
·
1902 - The National Committee for Mental Hygiene
·
1902 - The National Association for the Study and Prevention of
Tuberculosis
·
1904 - The National Tuberculosis Association was formed.
·
1905 - The American Social Hygiene Association
·
1912 - The American Public Health Association (APHA)
·
1913 - The American Cancer Society in 1913
·
1919 - The American Society for the Control of Cancer in 1919
DEVELOPMENT OF PUBLIC HEALTH IN
THE US: Public Health Legislation
·
1856 - New York passed a law on adulteration of milk
·
1878 - The Port Quarantine Act was passed
·
1890 - Pasteurization of milk started in 1890
·
1906 - The Pure Food and Drugs Act was passed in 1906
·
1910 - New York State passed the workmen compensation
·
1923 - The major achievement of this era was perhaps the prohibition of
alcohol which was accompanied by decline of alcoholism and alcohol—related
disease.
DEVELOPMENT OF PUBLIC HEALTH IN
THE US: Public Health Actions
·
1864 - First sanitary survey in New York
·
1891 - Milk inspection started
·
1895 - Septic tanks started
·
1895 - First nurse appointed
·
1910 - First occupational health clinic was set up in 1910
·
1912 - role of the United States Public Health Service was expanded to
include investigation of disease and sanitation
DEVELOPMENT OF PUBLIC HEALTH IN
THE US: Bacteriological Period of Public Health 1875-1900
·
The leading causes of death at the close of the 19th century
were communicable diseases: influenza, pneumonia, TB, GIT infections, typhoid,
malaria, diphtheria, pellagra, and rickets.
·
Death rates from infectious diseases started falling before vaccination
and antibiotics were available mainly due to environmental and social
improvements.
·
By the 1920s public health was dominated by medical persons. Sanitary
and other professions like municipal engineers, lawyers, and social reformers
who had been part of the public health reform movement took a lower profile.
·
Towards the end of the 19th century, bacteriology gave a new
impetus to public health by establishing the bacteriological approach which
emphasized the disease orientation.
·
In 1862 Louis Pasteur proposed the germ theory of disease.
·
1882 Robert Koch proposed criteria for diagnosis of bacterial disease.
·
There was a decline in public health in the post-war era due to various
reasons. The focus on bacteriology emphasized curative medicine using drugs to
eliminate disease without the necessity for public health measures.
DEVELOPMENT OF PUBLIC HEALTH IN
THE US: Early 20th Century
·
In 1900 Major Walter Reed announced his discovery that mosquitoes
transmitted yellow fever.
·
In the period 1946-1960s hospital construction increased under the 1946
Hill-Burton Act (National Hospital Survey and Construction Act).
·
The discovery of the polio vaccine gave a boost to infectious disease
control by immunization.
·
President Eisenhower’s heart attack stimulated the exercise movement.
DEVELOPMENT OF PUBLIC HEALTH IN
THE US: Period of Social Engineering (1960-1980)
·
In the 1960s the Great Society and War against Poverty programs
resulted into increased government funding for public health.
·
The federal government became involved payment for medical care and
environmental regulation. The Medicaid and Medicare bills were passed in 1965.
They increased access to health services but had the unwanted effect of increasing
the cost of health services.
·
Schools of public health responded by offering new training programs in
health policy and management, mental health, population control, environmental
health, and international health. Enrolment in public health schools increased
tremendously.
·
By the 1970s public health programs of various kinds were offered by
states.
DEVELOPMENT OF PUBLIC HEALTH IN
THE US: Period of Health Promotion (1980-1990)
·
By the mid 1970s health promotion and disease prevention were
recognized as priorities.
·
The Centers for Disease Control concluded in 1975 that about 48% of
premature deaths were due to lifestyle (lack of exercise, high fat diet,
smoking, and stress).
·
In the 1980 the US published 226 objectives for the nation in the field
of disease prevention and health promotion divided into three categories:
preventive services, health protection, and health promotion.
·
The objectives were based on the 1979 Surgeon-General’s Report titled
‘Healthy People: National Health Promotion and Disease Prevention Objectives’.
TUBERCULOSIS HISTORY: Mortality
and Treatment[1]
·
Tuberculosis has claimed its victims throughout much of known human
history. It reached epidemic proportions in Europe and North America during the
18th and 19th centuries, earning the sobriquet, "Captain Among these Men
of Death." Then it began to decline.
·
Identification of the tubercle bacillus as the etiologic agent by
Robert Koch in 1882.
·
BCG vaccination was widely employed following World War I.
·
The modern era of tuberculosis treatment and control was heralded by
the discovery of streptomycin in 1944 and isoniazid in 1952.
TUBERCULOSIS HISTORY:
Controversy about the Role of Social Reform vs Technology[2]
·
Tuberculosis (TB) began to decline in the Western world in the mid- to
late 1800s. In the United States, the disease receded until the mid-1980s.
·
TB epidemic sparked a controversy regarding the relative value of
targeted public health measures vs broad social reform.
·
Historical and demographic studies of Thomas McKeown - thesis that clinical
and primary prevention efforts had little effect on TB mortality.
·
The present author from analysis of historical information concludes
that public health measures, along with other factors, led to falling rates of
TB mortality beginning in the late 19th century.
TUBERCULOSIS HISTORY: 19th
Century Decline of Mortality
·
In 1815, one in four deaths in England was due to "consumption".
By 1918, one in six deaths in France was still caused by TB. (Wikipedia)
·
By the 1950s, mortality had decreased nearly 90%.
·
Improvements in public health began significantly reducing rates of
tuberculosis even before the arrival of streptomycin and other
antibiotics.
TUBERCULOSIS HISTORY: 19th Century
Decline of Mortality in New York (deaths per 1000 people)
·
1821 - Blacks 9.6 Whites 5.3
·
1830 - Blacks 12.0 Whites 4.4
·
1844 - Blacks 8.2 Whites 3.6
·
1855 - Blacks 12.0 Whites 3.1
·
1860 - Blacks 6.7 Whites 2.4
·
1865 - Blacks 6.7 Whites 2.8
TUBERCULOSIS HISTORY: 19th Century
Decline of Mortality in New Orleans (deaths per 1000 people)
·
1849 - Blacks 5.2 Whites 4.9
·
1880 - Blacks 6.0 Whites 3.3
·
1890 - Blacks 5.9 Whites 2.5
·
The BCG vaccine has been in use since 1921, but still arouses
controversy and uncertainties.
·
Study based on a systematic review of the literature in both English
and Spanish covering the period 1948 to 2006.
·
The protective effect of the first dose of the BCG vaccine against
tuberculosis in its military and meningeal forms is high.
·
The results vary in relation to the pulmonary form of the disease, with
some indicating zero effect and others levels of nearly 80%.
·
Research is being carried out to develop new vaccines that could
substitute the BCG or be used as a booster.
·
The protective effect against tuberculosis observed in various studies
ranged from -56% to 98%.
·
Case-control studies carried out at Nagpur reported moderate
effectiveness of BCG vaccination in prevention of tuberculosis. Its
effectiveness was higher against extra-pulmonary tuberculosis.
·
The summary protective effects obtained from meta-analysis of trials,
cohort studies and case-control studies of BCG vaccination and tuberculosis
were 51 (33-64), 76 (63-85), and 65 (57-72) percent respectively.
·
The results of the current study and systematic review thus supported
arguments favoring use of BCG vaccine for prevention of tuberculosis.
·
To study association between the geographic location (latitude) of
studies evaluating protective effect of BCG vaccine and it's efficacy /
effectiveness against tuberculosis. Study based on literature search.
·
The study recognized an association between geographic locations of
studies and reported protective effects of BCG vaccine against tuberculosis.
RELATION BETWEEN TB INCIDENCE AND HUMAN
DEVELOPMENT[6]
·
Objectives. Assess relationship between the Human Development Index
(HDI) and the incidence of tuberculosis (TB) in 165 countries in the World in
the period 2005-2011.
·
Inverse relation between TB and HDI.
·
High TB incidence was associated with low Human Development Index (P
<0.01).
·
The association varied with time variation of HDI.
MALARIA
·
Malaria has been successfully eliminated or greatly reduced in certain
areas.
·
Malaria was once common in southern Europe, but vector control
programs, in conjunction with the monitoring and treatment of infected humans,
eliminated it from those regions.
·
Malaria was eliminated from most parts of the USA in the early 20th
century by such methods, and the use of the pesticide DDT and
other means eliminated it from the remaining pockets in the South in the 1950s.
·
Several factors contributed, such as the draining of wetland breeding
grounds for agriculture and other changes in water management practices,
and advances in sanitation, including greater use of glass windows and screens
in dwellings.
INFANT
AND CHILD MORTALITY
NON
COMMUNICABLE DISEASES
RELATIVE
COST BENEFIT ANALYSIS OF INTERVENTIONS
MORE
PEOPLE HAVE MOBILE PHONES THAN TOILETS
THEORETICAL CONCLUSIONS
·
The multi causality of disease
·
The necessary cause + co factors = sufficient cause
·
It may be more effective to intervene against the cofactors by social
interventions
REFERENCES
[1] Daniel TM. The
history of tuberculosis. Respir Med. 2006 Nov;100(11):1862-70. Epub 2006 Sep
[2] Fairchild AL,
Oppenheimer GM. Public health nihilism vs pragmatism: history, politics, and
the control of tuberculosis. Am
J Public Health. 1998 Jul;88(7):1105-17.
[3] Pereira SM, Dantas OM, Ximenes R, Barreto ML. [BCG
vaccine against tuberculosis: its protective effect and vaccination policies].
Rev Saude Publica. 2007 Sep;41 Suppl 1:59-66.
[4] Zodpey SP. The BCG
controversy: a reappraisal of the protective effect against tuberculosis and
leprosy. Indian J Public Health. 2004 Apr-Jun;48(2):70-7.
[5] Zodpey SP, Shrikhande
SN.The geographic location (latitude) of studies evaluating protective effect
of BCG vaccine and it's efficacy/effectiveness against tuberculosis. Indian J
Public Health. 2007 Oct-Dec;51(4):205-10.
[6] Castañeda-Hernández DM, Tobón-García D,
Rodríguez-Morales AJ. [Association between tuberculosis incidence and
the Human Development Index in 165 countries of the world]. Rev Peru Med Exp
Salud Publica. 2013 Dec;30(4):560-8.