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June 14, 2012

The Heroes And Villains Of Public Health

While preparing for my first lecture for the first year medical students, I have decided to feature some of the "heroes" and maybe even "villains" throughout the history of Public Health. Being a history buff myself, I feel that learning the history of how Public Health developed is important in the understanding of the current status of our modern-day public health.


Hippocrates - also considered as the Father of Medicine, can also be considered as the Father of Public Health. According to historians, Hippocrates was born in the island of Kos in Greece sometime in 460 BC. Hippocrates taught and practiced medicine throughout his life, traveling at least as far as Thessaly, Thrace, and the Sea of Marmara.[12] Several different accounts of his death exist. He probably died in Larissa at the age of 83, 85 or 90, though some say he lived to be well over 100. Hippocrates is credited with being the first person to believe that diseases were caused naturally, not because of superstition and gods, thus separating the discipline of medicine from religion.

In his book "On Airs, Waters, Places", the relations of disease to physical, social, and behavioral settings are presented for the first time. This book served as a guide for decisions regarding the location of urban sites in the Greco-Roman world, and may be considered the first rational guide to the establishment of a science-based public health.

It can also be said that Hippocrates is also the Father of Medical Ethics, or at least that is what I would want to believe. He wrote the book, "On The Physician" which detailed how a physician must behave from how a physician must operate to how long his nails should be. Hippocrates extended clinical observations into family history and environment.

It was Hippocrates who introduced terms such as "acute" and "chronic" and "endemic" and "epidemic". Of course, who can forget the Hippocratic Oath which is being recited by all physicians worldwide even until now.


Shamans - before the time of Hippocrates, it was the shaman who acted as society's "doctor". Primitive societies interpret illness or diseases as an act of God, a divine action, usually a curse for a wrong deed done. To diagnose, treat, and, in some cases, prevent the spread of these malevolent forces, the sick person must seek the attention of the shaman who is a person trained to intervene on the spiritual and physical level. Thus, the most primitive societies provide an "organized" approach to the recognition and management of disease.

Even today, there are still cultures around the world that believe and rely in the powers of the shaman. In the Filipino culture, still deeply embedded is the albolaryo who drives away evil spirits that cause the illness through the use of herbs and rituals, thus the term albolaryo from the word herbolario which is Spanish for herbalist.


The Faculty of Salerno Medical School - The Salerno Medical School was the first secular medical school. During the Dark Ages, Christianity became the unifying force and also the provider of hospice and medical care especially to traveling pilgrims. Thus, the Christian Church was tasked not only to provide theological and spiritual teaching to the people but also to administer more mundane activities such as health care. Later, this administrative role transferred to the feudal lords who oversaw the running of feudal systems including health-related activities such as opening up of markets, cleaning of sewage systems and even regulating prostitution.

When the Salerno Medical School was put up, this marked a huge development in the history of Public Health. Its faculty was a roster of renowned doctors and experts. It was a lay organization, independent of the church, and it welcomed students of any race or creed. Its faculty included women, who apparently dealt with obstetric issues, and the renowned peripatetic scholar, Constantine the African, who translated many important Arabic works into Latin. Its most prominent literary product was the Regimen Sanitatis Salernitanum, a lengthy poem, prescribing healthy habits from birth to old age. Drawing on the whole corpus of Greco-Roman and Arabian medical writings the Regimen emphasized personal hygiene, diet, exercise, and temperance. It was the first "health guide" for the masses.

Black Death In Europe - also known as the Bubonic Plague, it swept over Europe during the Renaissance Period. Thought to have started in China or central Asia, it travelled along the Silk Road and reached the Crimea by 1346. The Bubonic Plaque was caused by Yersinia pestis bacterium carried by rat fleas. The aftermath of the plague created a series of religious, social and economic upheavals, which had profound effects on the course of European history. It took 150 years for Europe's population to recover. The plague occasionally reoccurred in Europe until the 19th century.

With the recurrence of plague epidemics, it finally became apparent in the cities of northern Italy that the ad hoc arrangements of the city councils were inadequate to deal with these episodes. By the middle of the fifteenth century, the major cities of the region had established permanent boards of health, perhaps the prototype of our modern-day local health boards, who were responsible for determining the existence of plague, establishing quarantine, issuing health passes, arranging for the burial of plague victims and the fumigation of their residences, and the management of lazarettos (houses and institutions of quarantine).

The boards maintained close relations with the local physicians who provided medical care and prophylactic advice. As time passed, the boards expanded their purview to the control of markets, sewage systems, water supplies, cemeteries, and the cleanliness of streets; and they took jurisdiction over the professional activities of physicians and surgeons, the preparation and sale of drugs, and the activities of beggars and prostitutes. With the disappearance of plague at the end of the seventeenth century, the boards of health of northern Italy withered away. Nevertheless, they provided a model for nineteenth-century organization of public health activities.


Girolamo Fracastoro - was an Italian doctor who wrote and published the book, "On Contagions and the Cure of Contagious Diseases." Fracastoro proposed that many diseases are caused by transmissible, self-propagating, disease-specific agents called "spores", which propagate themselves in tissues of the infected host and cause disease by setting up chemical processes. Most importantly, Fracastoro proposed that spores are spread by direct contact (person to person), by contact with fomites (inanimate objects), and by distant transmission. His theory remained influential for nearly three centuries, before being displaced by germ theory.

It was actually Fracastoro who also coined the term "syphillis", based on his poem, "Syphilis sive morbus gallicus (Syphilis or The French Disease)"

John Snow - was a British doctor and considered to be the Father of Modern Epidemiology. Snow was a skeptic of the then dominant miasma theory that stated that diseases such as cholera or the Black Death were caused by pollution or a noxious form of "bad air". The germ theory of disease had not yet been developed, so Snow did not understand the mechanism by which the disease was transmitted. His observation of the evidence led him to discount the theory of foul air. He first publicized his theory in an essay On the Mode of Communication of Cholera in 1849

In 1855 he published a second edition of his article, documenting his more elaborate investigation of the effect of the water supply in the Soho, London epidemic of 1854.
By talking to local residents (with the help of Reverend Henry Whitehead), he identified the source of the outbreak as the public water pump on Broad Street (now Broadwick Street). Although Snow's chemical and microscope examination of a water sample from the Broad Street pump did not conclusively prove its danger, his studies of the pattern of the disease were convincing enough to persuade the local council to disable the well pump by removing its handle.

Snow later used a dot map (perhaps the prototype to what we now call "spot map") to illustrate the cluster of cholera cases around the pump. He also used statistics to illustrate the connection between the quality of the water source and cholera cases. He showed that the Southwark and Vauxhall Waterworks Company was taking water from sewage-polluted sections of the Thames and delivering the water to homes, leading to an increased incidence of cholera. Snow's study was a major event in the history of public health and geography. It is regarded as the founding event of the science of epidemiology.


Edward Jenner - was a British doctor who basically came up with the vaccine against smallpox. He is often called "the father of immunology", and his work is said to have "saved more lives than the work of any other man". Noting the common observation that milkmaids were generally immune to smallpox, Jenner postulated that the pus in the blisters that milkmaids received from cowpox (a disease similar to smallpox, but much less virulent) protected them from smallpox.

On 14 May 1796, Jenner tested his hypothesis by inoculating James Phipps, an 8-year old son of Jenner's gardener, with pus scraped from the cowpox blisters on the hands of Sarah Nelmes, a milkmaid who had caught cowpox from a cow whose hide now hangs on the wall of the St George's medical school library. Phipps was the 17th case described in Jenner's first paper on vaccination.

Jenner inoculated Phipps in both arms that day, subsequently producing in Phipps a fever and some uneasiness but no full-blown infection. Later, he injected Phipps with variolous material, the routine method of immunization at that time. No disease followed. The boy was later challenged with variolous material and again showed no sign of infection.


Jeremy Bentham - was an English author, jurist, philosopher, and legal and social reformer. He was enunciating a similar humanitarian social philosophy and consequent political reform. In Introduction to the Principles of Morals and Legislation (1789), Bentham argued, among other ideas, that society should be organized for the greatest benefit for the greatest number (Utilitarianism). In his Constitutional Code (1830), Bentham proposed radical new legislation dealing with such issues as prison reform, the establishment of a ministry of health, birth control, and a variety of sanitary measures.

But it was his "disciple" Edwin Chadwick who basically implemented Bentham's principles. Chadwick had been secretary of England's Poor Law Commission, established in 1834 to effectuate the New Poor Law, and was aware of the pervading interaction of disease and poverty. Thus, when the Commission undertook a special study in 1839 of the prevalence and causation of preventable diseases, particularly of the working poor, Chadwick took the lead. The resulting publication, General Report on the Sanitary Condition of the Labouring Population of Great Britain (1842), is considered one of the most important documents of modern public health. Unwilling to administer an act of which he was largely the author in any way other than the way he thought best, he found it hard to get along with his superiors. This disagreement, among others, contributed to the dissolution of the Poor Law Commission in 1847. Chadwick's chief contribution to political controversy was his belief in entrusting certain departments of local affairs to trained and selected experts, instead of two representatives elected on the principle of local self-government.



Charles-Edward Winslow - was an American bacteriologist and public health expert. During a time dominated by discoveries in bacteriology, he emphasized a broader perspective on causation, adopting a more holistic perspective. The department under his direction was a catalyst for health reform in Connecticut. It was Winslow who defined public health as "the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health."







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