1.9: Public Health Early History

Both the discipline of public health and our understanding of disease have changed a lot over time. From the earliest civilizations, people have sought to prevent and treat disease in one way or another. Some of the practices that may have once been cultural practices -- for example, separating the sick from the well, or performing ablutions (ceremonial cleansings and hand washing) -- now have scientific explanations for how they may prevent the transmission of infectious diseases. Other approaches that once were common -- such as using leeches to bleed a sick person -- have been replaced, as we understand more about health and illness.

Note

Want to know more about the history of public health? This chapter in Public Health 101 offers a more detailed review of public health highlights, from early civilizations forward to the 21st century.

18th Century

The 18th century (the 1700's) saw the start of the industrial revolution, the growth of cities, and the expansion of trade and travel. Some of that "travel" was involuntary -- the trans-Atlantic slave trade brought thousands of West Africans to the Americas, from the 1600's to the early 1800's, with important consequences we still live with today. Other waves of migration were motivated by the search for a better life, with more economic opportunity or political freedom.

Important public health approaches in this time include

• The collection of population data -- the first census in the US -- was conducted in 1790. Population data is a key tool for public health.
• Quarantine -- including the quarantine of boats that carried infected crew or passengers -- was one common approach to containing disease in this period. (Quarantine began to be used centuries earlier as a way to separate people who might be infected with a disease for a time in order to see if they actually are sick, before allowing them contact with the broader population. Those who were sick were then put in isolation until they either got better or died.) The Marine Hospital Service established in 1798 was one of the first centralized public health institutions in the US. It was set up to deal with disease on ships.
• Variolation -- already used in several parts of Africa and Asia -- began to be used to increase immunity and stem the spread of disease in North America. See the box below.

While most histories of public health have a Eurocentric bias, we know there were important public health advances in other societies and continents. In New England, we have documentation of the enslaved African Onesimus teaching Cotton Mather (an influential colonist and slave owner) how to perform variolation around 1716 to prevent deaths from smallpox. Variolation was an important precursor to vaccination. Using variolation, pus from a small pox blister is used to infect a healthy person under supervision of a physician -- that is, the healthy person is deliberately infected (which does not happen in vaccination). The person often acquired a milder case of smallpox and with it, immunity to reinfection. Some people, however, died from smallpox acquired through variolation. Still, the population impact of increased immunity helped stem the epidemic. Cotton Mather went on to promote the practice and to document variolation use in several parts of Asia and Africa, long before it was known in Europe or North America. How or if Onesimus ever benefited from the increasing use of his variolation technique is unknown, and unlikely. He did, however, purchase his freedom from Mather later in life, at least in part. Sources: Philadelphia College of Physicians and History Channel. Variolation is no longer used today.

Development of Vaccines

Vaccines are different from variolation in that they do not cause a case of the disease they are designed to prevent. The first vaccine was developed as a protection against smallpox in 1796, by Dr. Edward Jenner in England. To develop the vaccine against smallpox, a very deadly disease, Jenner used cowpox, a far less dangerous disease. You can see in this short cartoon the basics of what Jenner discovered -- how he took what everyone could observe (that people who got cowpox tended to not get smallpox) and made it into something that could be used on a large scale. Vaccines continue to be fundamental tools for public health today.

19th Century

The 19th century (the 1800's) brought more movements of populations -- and again, not always voluntary. While in England, the "commons" where farmers grazed their animals were fenced off and privatized, many people were forced into factory work. Throughout the Americas, slavery (and the sharecropping and other mechanisms that followed) was the engine of both economic growth and cruel inequalities. The conquest of Native American nations by the US was brutal. We can see many health inequalities took root in this historical period -- Native Americans now have the shortest life expectancy of any racial/ethnic group in the U.S. Poverty, poor working conditions, crowded housing and other health hazards were something that many Americans of all races and ethnicities faced in this period. Gender inequality was beginning to be challenged by an emerging women's rights movement, and the abolitionist movement along with slave rebellions took on the work of dismantling slavery. The mid-1800's was a time of great ferment, both in public health and social movements, and the social justice roots of public health work took hold in this time period.

The miasma theory that was popular in the 19th century suggested that bad vapors, or bad smells common to the poor areas of town (due to crowded housing, no sewers, no refrigeration, etc.), were the cause of disease. People did not yet know about germs. The miasma theory was wrong -- and yet, there are some commonalities between the theory of miasma and analysis now, in the 21st century, of how poor living conditions affect health. The difference is that now we can focus scientifically on how social conditions affect people's health (e.g., a lack of grocery stores in some neighbhorhoods makes it hard to buy healthy food to eat). We don't blame it on bad smells or "bad vapors" in the air!

Even though people did not yet understand germ theory in the 19th century -- they did not know that viruses, bacteria and other microorganisms cause infectious diseases -- one of the most iconic public health actions to stop the spread of disease happened in 1854 in London. John Snow mapped cases of cholera, a deadly disease, and saw that they were common among people who drank water from the Broad Street Pump. When he broke the handle off the pump, he stopped or slowed the spread of the disease -- he took an upstream approach to stopping disease at its source. Please watch this 2-minute captioned video below that explains what John Snow did -- and ask yourself, how is this still relevant today? How can we use this same kind of logic to address new epidemics? (The video ends with a little teaser, encouraging the viewer to enroll in a longer video course to learn more -- that's not necessary.)

Around the same time in the US, Lemuel Shattuck prepared the first broad public health report for the Commonwealth of Massachusetts. This marks the start of the modern era of public health. Scientific advances in biology -- in particular, the discovery that a disease can be caused by a specific germ -- changed the way people looked at disease. No longer was disease seen as a consequence of poor morals or smelly neighborhoods -- public health began to focus on germs -- and so the bacteriological period of public health began. The discoveries by Louis Pasteur, Robert Koch and others helped us understand how infectious (communicable) diseases work.

W.E.B. DuBois, the African American scholar, intellectual, publisher and advocate whose work bridged the 19th and 20th centuries, also made significant contributions to the field of social epidemiology -- contributions that are only recently gaining recognition. His work to survey, map, document and visualize (through graphs, charts and other means) the health condition of the African American community in Philadelphia was among the first research in North America to explore racial health inequities. You could even say that he developed some of the first infographics, and he is still inspiring people to use visualization to discuss and advocate against racial inequities.

Let's see how you are doing so far. Answer the following questions:

In the 17th and 18th centuries, everyone understood that diseases were caused by germs.

True False Submit

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Why did Dr. Jenner inject the boy with cowpox?

a. To get even with the boy for stealing milk. b. To test whether exposure to the cowpox vaccine would give the boy some immunity to smallpox. c. So that he would get sick with smallpox and Jenner could test a cure for that disease. d. To stop the spread of cholera. Submit

References

Sources: Philadelphia College of Physicians and History Channel.

Seabert, Mckenzie, Pinger (2022).

add the videos and other links on this page?