Public Health Services

I

Introduction

Public Health Services, services that provide collective action to protect the health of populations, often through state-funded agencies. Public health includes four major areas: (1) the promotion of positive health and vitality; (2) the prevention of infectious and non-infectious disease as well as injury; (3) the organization and provision of services for diagnosis and treatment of illness; and (4) the rehabilitation of sick and disabled people to their highest possible level of function. Inclusion of these four major areas among the concerns of public-health agencies was expressed on a worldwide scale in 1948, when health was defined by the World Health Organization (WHO) to include physical, mental, and social well-being and not merely the absence of disease or infirmity.

II

Promotion of Health

This broad area of health promotion represents, in a sense, a rediscovery of ancient concepts. As long ago as 3000 bc, cities on the Indian subcontinent had developed environmental sanitation programmes such as the provision of underground drains and public baths. Essential aspects of health were woven into daily activities, including personal hygiene, health education, exercise, codes of conduct and self-discipline, dietary practices, food and environmental sanitation, and treatment of minor ailments and injuries. By 1400 bc, this society’s so-called science of life, or ayurveda, mainly featured total health care through health promotion and education, although advances were also made in curative medicine and surgery.

This tradition was also highly developed in ancient Greece and Rome. The Hippocratic tradition concentrated on the patient rather than the disease and emphasized prevention (see Hippocrates). It used a system of dietetics to preserve and restore health through appropriate regimens for acquiring fitness and treating sickness. Its emphasis on health regimens was linked to a culture that revered an idealized body in a cult of athletics. Many Hippocratic authors linked their therapeutic regimens to the health of athletes. Under the influence of Greek physicians, Roman medicine equally emphasized the importance of personal regimens and dietetics to ward off disease. This was promoted above all by the most famous Greek physician of the Roman Empire, Galen, in his discussion of the natural (innate constitutional), non-natural (environmental), and preternatural (pathological) causes of health and disease that produced variations in the pulse and affected the balance of humours within the body. Galen adapted the philosophy of the humours into a system of physiology and pathology in which blood was regarded as the primary humour, claiming that all disease could be controlled or treated by its regulation. Galenic dietetics used dietary rules and protocols of personal hygiene, behaviour, and exercise to maintain healthy humoral balance. See also Medicine, Classical.

In 18th-century Europe, doctors of the Enlightenment revived the Hippocratic philosophy of prolonging life and preserving individual health through dietetics, regimen, and exercise. The massive increase in health advice books throughout Europe in the 18th century reflected the popularity of personal health cults. The same revival of classical values encouraged concern with environmental health regulation because the relationship between the health and wealth of nations was not lost on early modern political and economic thought. See also Medicine, Eighteenth-Century.

The early modern political philosophy of mercantilism stressed the need to measure the strength of the state by assessing levels of health. The growth of public health paralleled the rise of centralized government in this period. As the modern state began to emerge from the late 16th century onward, so incipient ideas of national health slowly gained ground. Methods for assessing the strength of the state by calculating population health were developed by political arithmeticians throughout the 18th century. The term statistik (statecraft) was invented by the professor of law and politics at the University of Göttingen, Gottfried Achenwall (1719-1772), to describe catalogues and surveys illustrating “the condition and prospects of society”. Early modern exploration of probability and population had a powerful influence on the development of public health. Statistics provided essential methods for enquiring into the health and disease profile of populations.

Political rhetoric about health and the political state was also significantly influenced by the Enlightenment philosophy of democratic citizenship. Democratic revolutions in America and France asserted new principles regarding the state and the health of its subjects. Thomas Paine did not include health among the property rights to which all free men are innately entitled but Thomas Jefferson declared that sick populations were the product of sick political systems. According to Jefferson, despotism produced disease, democracy liberated health. Jefferson believed that a life of political “liberty and the pursuit of happiness” would automatically be a healthful one. He told his co-signer of the Declaration of Independence, the physician and patriot Benjamin Rush, that the iniquity of European absolutism was reflected in its peoples’ wretchedly unhealthy and demoralized condition. French revolutionaries added health to the rights of man asserting that health should be a right of democratic citizenship in which the modern state was obliged to take measures to protect populations through the prevention of disease and the provision of medical services.

Eighteenth-century methods for calculating the health of populations and Enlightenment rhetoric of health citizenship provided the prerequisites for systematic disease prevention and the political legitimization for state intervention to procure public health in the 19th century. See also Medicine, Nineteenth-Century.

By the middle of the 20th century, dramatic reductions in infectious diseases and the creation of health care provision, together with a general rise in affluence, created new patterns of disease distribution and extended life expectancy in Western societies (see Medicine, Twentieth-Century). A longer life did not, however, necessarily mean a sweeter one and as a result a resurgence of interest in positive health occurred. Interest in the scientific basis of health led to new areas of research, such as the effect of malnutrition in pregnant women upon the physical and mental development of their children, and research into the effects of diet supplementation in improving the health and vitality of undernourished populations; the influence of optimal levels of temperature and other environmental conditions upon human comfort and ability to function; and the influence of diet and physical exercise in achieving positive health and well-being.

Beyond scientific research a variety of utopian philosophies developed in the 20th century that advocated their own ideals of health and alternative life styles. Furthermore, enterprising entrepreneurs in Europe and the United States took up the commercial potential of promoting methods for maintaining a healthy body. New intellectual discourses surrounding health have been expressed in the promotion of physical cultures that adopted their own moral tones imbued with cultural anxieties about social and biological degeneration and decline.

Concerns over the promotion of health have, from the early 19th century, been significantly overshadowed by the pressing need for and innovations in the prevention and treatment of disease.

III

Disease Prevention

The earliest direct involvement of civil government in the control and prevention of infectious disease was stimulated by the epidemic of bubonic plague that invaded Europe in the middle of the 14th century, commonly referred to as the Black Death. Records of plague exist from Biblical times, but the first well-documented epidemic occurred in ad 542, during the reign of the Byzantine emperor, Justinian I; by 547, when it was described by the Gallic bishop, St Gregory of Tours, it had reached Western Europe. Plague continued to appear in virulent bursts for the following 200 years. A second wave then appeared first in the Crimea in 1346 and shortly afterwards at Constantinople. It spread through the Middle East, the Mediterranean, and Western Europe by 1350, and moved on through Eastern Europe between 1350 and 1353. Extensive mortality wiped out whole communities and led to others being entirely abandoned. The rapid, high mortality made smaller settlements no longer viable and surviving populations relocated to towns and cities. Some have estimated that 20 million, ranging between 30 and 50 per cent of the population in different areas of Europe, perished during this epidemic. Cities such as Florence, Siena, Orvieto, and San Gimignano probably lost 50 to 60 per cent of their population.

The social disruption and threat to social order posed by the Black Death produced new interventions by political authorities into the social and economic relations of late medieval society. When plague first appeared in southern Italy in 1347, Italian port authorities began turning away vessels travelling from suspect areas. In 1348 this ad hoc measure was formally codified in Venice when it closed its port on March 20 to all suspect ships, and instituted systematic isolation of travellers and ships in the harbour, initially for a period of 30 days. In 1377 Venice’s Adriatic colony at the port of Ragusa (Dubrovnik) set up stations where travellers and merchandise from infected areas were isolated likewise. At Marseille (1383), Venice (1403), and Majorca (1471), the period was extended to 40, or quaranta, days, hence the term “quarantine”. The period of 40 days was believed to separate acute and chronic forms of disease. The subsequent development of Italian administrative measures including isolation of inland communities (cordon sanitaires), as well as port quarantines to prevent the spread of plague in the 15th and 16th centuries, provided a model that was gradually copied by political authorities throughout the rest of Europe. The emphasis on controlling the movements and lodging of healthy and sick individuals reflected a clear belief in the spread of plague through direct contact. The rulers of inland city-states had sufficient power to impose strict policing upon their citizens, enforce it through armed militia, and by using the religious authorities to provide surveillance and intelligence.

With the decline of plague by the early 18th century the disease profile of Western Europe changed focus. Geographical exploration, urban development, and imperial expansion created new patterns. Epidemic diseases of isolated communities became endemic in urban environments. By the 18th century shock invasions were replaced by rising levels of endemic infections and chronic sickness that occasionally became epidemic, such as malaria, smallpox, and gout. The absence of catastrophic disasters meant that emergency disease control was no longer a priority. Instead the Enlightenment became a period in which a new interest in the social scientific analysis of the health of populations developed. The 18th century also witnessed the development of innovations in sanitation and immunization such as night-soil collection, town improvement movements, and smallpox inoculation.

In Europe mercantilist concerns over healthy population levels promoted ever-stricter enforcement of port quarantines, border sanitary cordons, and the policing of public nuisances and civic disorders. Innovative systems of medical policing developed in the 18th century to monitor the spread of epidemics, influence the behaviour of individuals and communities, and regulate medical education and practice which provided templates for disease control in the 19th century.

The massive social dislocation brought about by the transformation of agrarian into industrial societies at the turn of the 19th century produced new patterns of epidemic invasions. Migration became a defining demographic characteristic of early industrial societies. Agricultural labourers migrated into towns to become industrial workers. Members of this industrial proletariat and its most wretched underclass (what Marxists have termed the “lumpenproletariat”) often moved more than once during a lifetime to follow the geographical flux of the business cycle. But the populations who migrated to look for work became the poorest and most deprived in the exponentially expanding urban environments of industrializing societies, and as a result became subject to the classic diseases that accompany refugee and other itinerant populations who are deprived of access to the basic amenities of domestic hygiene, such as regular clean water supplies.

High population densities and inadequate sanitation in the sprawling world of 19th-century industrial urban environments created new opportunities for infectious diseases. Infant death was responsible for the largest proportion of preventable mortality in the 19th-century industrial city—death from measles, whooping cough, smallpox, and above all diarrhoea. Children and young adults died of diphtheria and tuberculosis. Members of all age groups caught fevers, such as typhoid fever and typhus, and the great “grim reaper”, Asiatic cholera, brought periodic devastation.

A popular belief in disease as a form of atmospheric pollution, the miasmatic theory, encouraged environmental strategies to prevent it. From the middle of the 19th century, reform movements developed throughout Europe and the United States aimed at creating hygienic and sanitary urban environments with clean water supplies, waste disposal and effluence removal and drainage, slum clearance, and the regulation of industrial pollution. The sanitary revolution was implemented through a growth in bureaucratic government in industrial societies with the increasing employment of professional experts trained to specialize in environmental sanitary regulation, population and epidemiological analysis, and the operation of developing technologies of immunization such as smallpox and diphtheria vaccination.

Environmental sanitation—safe water supplies, improved sewage disposal systems, pasteurization of milk, and sanitary control of food supplies—resulted in the virtual disappearance of cholera and typhoid fever and the marked reduction in diarrhoea and infant mortality in industrial countries by the early 20th century. The discovery of effective vaccines, based on the growth of the science of immunology, led not only to the worldwide eradication of smallpox but also to the marked decline of such diseases as diphtheria, tetanus, whooping cough, poliomyelitis, and measles. Lack of adequate sanitation facilities, however, still impedes the developing countries in their efforts to reduce the toll of diarrhoea in infants and children—the main cause of death in the world today. Malaria, tuberculosis, influenza, and other infectious diseases also remain as major health problems in many countries.

Another area in which the modern state increasingly intervened was in the provision of care, or some would say, custody, of the mentally ill (see Mental Health) and disabled. The regulation of private “madhouses” through inspection and legislation began in Britain from the early 19th century. Publicly owned and charitable asylums for the insane expanded in number and size throughout the 19th century in Britain, Europe, and the United States. In the early 19th century new systems of medical and “moral” (psychological) management raised hopes that the asylum could function as a therapeutic hospital. As cures for “madness” proved illusive, 19th-century asylums increasingly functioned as custodial institutions for disruptive patients who were potentially a public danger. As a result, some historians have claimed that 19th-century asylums became museums housing the chronically ill who were unwanted by their relatives or indeed society at large. Mental hospitals continued to be viewed in this light in the 20th century by many critics of the psychiatric and psychological professions. Growing support for the “de-incarceration” of the insane encouraged many welfare states in the last quarter of the 20th century to try to replace institutional with community care for the mentally ill. Recent investigations into the working of 19th-century public asylums have revealed, however, that while they boasted very few therapeutic successes these institutions housed patients for short periods only. Asylum superintendents made extensive efforts to find justifications for releasing patients because the pressure for taking new admissions was relentless. In the 20th century the closure of large mental hospitals did not resolve the question of the most effective health care for the mentally ill. Care in the community has demonstrated a seriously limited capability of providing patients with sufficient support to manage their illness and some commentators attribute a large proportion of the rise in homeless populations in industrial and post-industrial cities to the lack of institutional care and adequate medical services for the mentally ill.

Industrial and post-industrial societies face new epidemiological challenges: the conquest and management of non-infectious diseases and chronic illness. These are not only the leading causes of mortality in the industrial nations but have become increasingly important in the developing nations as well. Conclusive proof of the germ theory in the last quarter of the 19th century by Louis Pasteur in France and Robert Koch in Germany focused new attention upon the importance of individual behaviour in the prevention of the spread of infectious disease. Epidemiology has subsequently concentrated on influencing individual behaviour as the solution to preventing chronic illnesses. Social and preventive medicine in the latter half of the 20th century used health education to try to reduce heart disease, certain kinds of cancer, stroke, accidents, chronic obstructive lung disease, and cirrhosis of the liver; and application of this preventive strategy resulted in dramatic reductions in death rates. In the United States from 1968 to 1978, for example, the age-adjusted death rate for coronary heart disease declined by 25 per cent, and the age-adjusted death rate for stroke showed an even more dramatic decline of 38 per cent. These achievements resulted largely from public-health education programmes for the control of high blood pressure and through health education of the public on the hazards of eating saturated fats and cigarette smoking.

The emergence of a new killer infection in the early 1980s reawakened public health concerns of an earlier era. AIDS and HIV were initially compared to dramatic historical invasions of the past such as plague and cholera. The initial impact of AIDS upon popular, political, and expert perceptions raised familiar issues regarding the right of the state to police and regulate the spread of infection through surveillance, notification, screening, and quarantine. In numerous national contexts, those who favoured authoritarian intervention called for the institution of compulsory testing, identity cards for people who were HIV-positive, and their isolation. Few national policy makers employed any of these strategies, however, and AIDS prevention has largely been developed through national and international education programmes along with economic aid programmes to provide additional welfare provision and medical services to cope with the exponential rise in AIDS victims. The social crisis precipitated by the epidemic levels of AIDS in many African states needed a dramatic expansion of international assistance to provide adequate services to respond to the disease. The international response, however, has yet to prove sufficient.

IV

Provision of Medical Care

Three basic systems of medical care exist in the world today: public assistance, private market-based health insurance, and national health-service systems funded by taxation. As of mid-2003, the first is dominant in 108 countries, constituting 49 per cent of the world’s population; these countries are located in Asia, Africa, and Latin America. For the great majority of the people in these countries, whatever medical care is available is provided through a means-tested public-assistance system for the poor. This includes government hospitals and health centres financed by general taxation. The system and its facilities are generally under-financed, overcrowded, and understaffed. In addition to such systems administered by health departments, programmes may exist that are operated by social security agencies for industrial and white-collar workers. Where they exist, these programmes usually cover only a small part of the population. In all these countries a small stratum of landowners, businesspeople, officials, and professionals use private doctors and hospitals for their care.

Private health insurance funds free-market delivery of medical care in 23 countries, constituting 18 per cent of the world’s population. In many of these countries private health insurance supplements a national system of health care delivery funded by taxation. In industrialized nations with capitalist economies in Western Europe, Australia, Japan, and Israel a mix of governmental and non-governmental insurance exists.

The system of national health services is dominant in 14 countries, constituting 33 per cent of the world’s population. They include countries in Europe, Australasia, and Cuba; all are either industrialized or undergoing rapid industrialization. Although most of the countries fund national health programmes through social security taxes on employees and employers, a considerable portion of the cost is borne by general taxation. National health services cover the entire population. Services are provided by a mix of private practitioners contracted to government service for primary care and salaried doctors and other health personnel who work in government hospitals and health centres. Practically all services are included and provided free of charge, and administration is unified by health departments. Regional integration of facilities, which is almost impossible to realize under private health insurance programmes, is one of the important achievements of national health services.

In countries without a national health service, such as the United States, health care is financed by private insurance and government health schemes such as Medicare and Medicaid (for the elderly and poor respectively). Most private health-insurance programmes in industrial nations are based on fee-for-service practice. Non-salaried private practitioners contract with patients or with authorized sick funds to provide primary and hospital care. In developing countries with private health insurance, government pays only for basic health care while more advanced facilities are purchased by the wealthy. Rich countries spend around 8 per cent of their gross national product (GNP) on health care—poor countries less than 1 per cent of a far lower GNP. In China traditional and modern medicine are integrated with a strong emphasis on preventive medicine (see Medicine, Chinese); in Chile a 40 per cent reduction in infant mortality was achieved through a special health programme. In the developed world, health finance problems are increasingly focused on the rising costs of high-technology medicine and the management of increasing levels of chronic illnesses in ageing populations.

The rapid expansion of East Asian economies such as Japan, Taiwan, and South Korea since World War II was achieved by a largely youthful population imbued with Confucian beliefs in the importance of self-reliance, individual success, and hard work for the benefit of the community. The rate of expansion together with age of the population meant that social welfare and protection were largely secured through full and increasingly affluent employment. Mainly low levels of unionization meant that organized labour was absent as a political force pressing for welfare reform.

In the 1960s Japan began to expand its social protection programmes through the introduction of welfare for the mentally disabled, national health insurance and a national pension scheme, public assistance for the aged, and maternal and child welfare. A campaign to improve the “quality of life” in the 1970s saw further expansion of these programmes and increasing public concern over issues such as pollution and traffic accidents. Feminist groups also began to emerge in the 1960s that highlighted the issue of discrimination by both employers and the state. The move towards welfare expansion was halted in 1974, however, following the economic crises experienced by most industrial societies resulting from the rise in crude oil prices. Between 1975 and 1985 unemployment in Japan expanded threefold resulting in an increase in public expenditure that provoked a backlash in the 1980s. A new political rhetoric in the 1980s concerned with the “reconsideration of welfare” stressed the cost of social welfare to the competitiveness of the economy. A political consensus between the ministry of health and welfare and the finance ministry agreed that social expenditure had to be curtailed. In 1981 fiscal reforms reduced the levels of state social expenditure shifting the burden of welfare costs back to the individual by placing surcharges on health care for the elderly, reducing the level of coverage of health insurance, increasing the age of eligibility for pensions from 60 to 70 for men and 55 to 60 for women, and imposing a 3 per cent indirect sales tax.

The prospect of increasingly ageing populations has raised the question of social welfare to a higher political priority. At the beginning of the 21st century Japan anticipated that the number of its retired people would more than double over the following two decades with 25 per cent of its population being over 65 by 2020; in the same period the number of people over 80 is expected to treble. Although savings levels in Japan, Taiwan, and South Korea are very high, such a major demographic transition poses serious questions for future social expenditure. Recently the Japanese government has attempted to address some of these questions by re-asserting the value of volunteer activity as a return to traditional, that is, Confucian, methods of welfare provision. The government encouraged the development of “residential participation organizations” such as quasi-state-funded, voluntary mutual-aid service banks run by the government and local communities to help increase both individual and local community participation in welfare organization and provision.

The worldwide trend is towards tax-funded health service systems. Among the industrial capitalist nations Britain in 1948 was the first to establish such a service (see National Health Service). The entire population is covered; hospital specialists are government employees, but general practitioners are still not salaried doctors working in community health centres. Instead they work as solo doctors or in small partnerships, usually in their own offices, and have a contractual relationship with the government. In developing countries, transition towards a national health service model is facilitated by the fact that both the public assistance and the social security health systems in these countries generally have developed on the basis of government hospitals and clinics employing salaried doctors. In Latin America two models of welfare states emerged towards the end of the 20th century offering a range of neo-liberal and social democratic options for social and health care policy. During the 1980s, international financial conditions encouraged the dominance of a neo-liberal financial hegemony among some Latin American governments, such as Chile and to a lesser extent Argentina, which led them to pursue market-determined, individualistic models of social policy. However, as the social costs of inequality upon social cohesion began to take effect, other Latin American governments, such as Brazil and Costa Rica, took up social democratic, market-correcting social policy and health care programmes. Costa Rica, for example, is now moving towards merging the two systems to form a complete national health service.