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Medicine and the epidemiological transition to Public Health

Keywords:
History, social medicine, preventive medicine, Public Health.
ABSTRACT:


Historical perspectives are important in informing the current paradigm shift
from Medicine to Public Health. Five historical contexts are presented in this paper:
the Collegium Medicorum model of health care administration found in Sweden;
the sanitary idea in Britain; increased access to treatment through health insurance
in Europe; the shift to social medicine and community medicine; and the use of
epidemiological data. It is argued that social medicine and the epidemiological
transition reinforced the field of Public Health.
030-036 | JRPH | 2012 | Vol 1 | No 2
This article is governed by the Creative Commons Attribution License (http://creativecommons.org/
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www.jhealth.info
Journal of Research in
Public Health
An International
Scientific Research Journal
Author:
Kazhila C. Chinsembu.

Institution:
University of Namibia
Faculty of Science,
Department of Biological
Sciences P/Bag 13301,
Windhoek, Namibia.
Adjunct Associate Professor
of Health Sciences,
University of Lusaka,
Zambia.

Corresponding author:
Kazhila C. Chinsembu.



















Email:
kchinsembu@unam.na

Phone No:
+264-61-2063426.

Fax:
+264-61-2063791.


Web Address:
http://jhealth.info/
documents/PH0007.pdf.
Dates:
Received: 16 May 2012 Accepted: 26 May 2012 Published: 22 Sep 2012
Article Citation:
Kazhila C. Chinsembu.
Medicine and the epidemiological transition to Public Health.
Journal of Research in Public Health (2012) 1(2): 030-036
MINI REVIEW
Journal of Research in Public Health
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An International Scientific Research Journal
INTRODUCTION
In this paper, we provide a historical backcloth
to the current enthusiasm for the new paradigm of
Public Health. Five historical contexts of Public Health
are presented in this paper: a model administration of
health care in Sweden; the sanitary idea in Britain;
health equity and universalism through health insurance
schemes; social medicine and community medicine; and
epidemiology. It is believed that social medicine and the
epidemiological transition reinforced the field of Public
Health.
Health care administration: Sweden and the Collegium
Medicorum
In Sweden, several policies were used to
contribute to the good health of the population. These
policies included: medical police, health reporting, good
health administration and reforms, establishment of
professorial chairs in public health, and progressive use
of the public health law (Porter, 1999). The public policy
of medical police, introduced in the eighteenth century,
led to the reduction of mortality in the early nineteenth
century. After 1810, deaths no longer exceeded births
and the population almost doubled between 1750 and
1850, reaching 5.2 million by 1900 (Porter, 1999).
In 1663, a handful of Stockholm physicians
formed the Collegium Medicorum, the predecessor of
the present National Board of Health and Welfare
(Socialstyrelsen, 2012). The aim of the Collegium
Medicorum was to regulate the activities of the small
group of doctors who were practising in Stockholm.
Over the time, the Collegium Medicorum developed
into an administrative board with overall supervision of
the nations health and medical care.
The Collegium Medicorum represented state
medical interests by receiving reports from district
physicians, who described the disease profiles of local
areas, the level of medical treatment and drug therapy
available and the lifestyles of the population, including
nutrition, housing conditions, levels of alcoholism and
literacy, along with local climatic changes (Porter, 1999).
A prominent feature of these reports was the resistance
to medical intervention by the farming populations who
were reluctant to seek the services of a medical doctor
when they fell sick.
Also, in 1813 the Collegium Medicorum was
transformed into the National Board of Health
(Socialstyrelsen, 2012), and this provided the medical
profession with a new authority in public policy. But
the annual reports of the National Board of Health,
published from 1850, showed that the new political role
of the medical profession [doctor] failed to prevent the
spread of a persistently brutal regime of epidemic
diseases among children and adults, including malaria,
dysentery, cholera, typhoid and pulmonary
tuberculosis (Porter, 1999)
As economic growth increased in the last two
decades of the nineteenth century, Swedish agrarian
society was also becoming transformed into a modern
industrial nation. Urban expansion encouraged the state
to become increasingly involved in public health policy
from 1867 when Parliament created the first
professorship of public health. The first professorial
chair of public health was appointed at the Karolinska
Institute in 1876 (Porter, 1999). Public Hygiene became
part of the Swedish Medical Association in 1899 and a
National Laboratory for Bacteriology was established in
1907 (Porter, 1999).
The first Public Health Act was passed in Sweden
in 1874, establishing local boards of health responsible
for setting up local sanitary infrastructure by
establishing clean water supplies and efficient sewage
and refuse removal systems (Johannisson, 1994).
Medical doctors employed as local health officers were
charged with the duty to control local air pollution and


Chinsembu, 2012
031 Journal of Research in Public Health (2012) 1(2): 030-036
the sale of adulterated foods, inspect unfit housing and
monitor the personal health habits of the local
population, including domestic hygiene, alcohol abuse
and immorality (Johannisson, 1994).
Hygiene and sanitation: England and the sanitary idea
In England, during 1927 to 1950, health
practitioners such as William Frazer, Colin Fraser
Brockington, George Newman, and Arthur Newsholme
equated health to the sanitary idea (Porter, 1999).
It was believed that clean environments limited the
spread of germs. Thomas McKeown, for example,
argued that the provision of clean water supplies played
a major role in the rise of the population in England and
Wales (McKeown, 1976). Asa Briggs also posited that
because cholera was predominantly a disease of the
poor, its decline depicted a major historical change in
Victorian society (Briggs, 1961). Margaret Pelling even
used the economic, social, political and ideological
responses to disease and to explore the complex ways
in which change the both causes and was determined by
the impacts of epidemics (Porter, 1999).
Health equity and universalism: Health insurance in
Europe
The start of the health insurance industry
transformed the provision and quality of health care in
Europe. German health insurance, established in 1883,
was compulsory and financed by one-third contributions
from employers and two-thirds contributions from
employees (Milles, 1990). In France, group of workers
organized voluntary health funds through mutual aid
societies from the time of the late Napoleonic Empire.
The purpose of mutual aid societies was to provide
funds for medical diagnosis and income during illness
(Porter, 1999).
In Sweden, health insurance offered medical
care and cash benefits under a new law in 1931
(Porter, 1999). Compulsory state health insurance was
introduced in 1955, and Sweden was divided into seven
hospital administrative regions, each with a major
teaching and research hospital. Lloyd George, in Britain,
introduced health insurance under the 1911 National
Insurance Act (Honigsbaum, 1993). The National Health
Service (NHS) Act of 1946 came into effect on 5th July
1948. Later, Margaret Thatcher admitted that the NHS
was intended to serve great accidents and terrible
diseases, especially for the poor. Thus, creation of the
NHS was a result of new ideological shift towards
universalism in welfare provision (Clarke, 1990).
The sociological context of health: Community
Medicine or Social Medicine?
After the establishment of the NHS, the
managerial role of Medical Officers of Health (MOHs)
increased. MOHs found themselves trying to
co-ordinate an ever widening range of community
services from environmental regulation to social work
administration. Deep professional divisions
characterized clinical and preventive medicine
(Jefferys, 1986). By the end of the 1960s, a new concept
of human health as part of community service planning
was emerging. The expansion of this role ultimately led
to practitioners of a new discipline called community
medicine (Jefferys, 1986).
However, community medicine as a discipline
increasingly experienced difficulties in defining its
constituency and faced mounting problems of
implementation in practice (Warren, 1997). Still,
clinicians began to think that medicine should
re-orientate itself so that the medical doctor can take on
a new role, be trained in a different way, and practice a
new profession encompassing both prevention and cure
(Jefferys, 1986). The social hygiene movements of the
early twentieth century had begun to create a new
Chinsembu, 2012
Journal of Research in Public Health (2012) 1(2): 030-036 032


pathway for British medicine, and as Arthur Newsholme
would put it, from the social standpoint (Solomon and
Hutchinson, 1990).
Medicine from the social standpoint promoted a
new model of prevention which emphasized the
responsibility of the individual for their own health
behaviour. It utilized medical and social scientific
analysis of health and illness to maximize health chances
by encouraging individuals to change their lifestyles. The
social contract of health promoted by medicine from
the social standpoint is illustrated in modern day health
campaigns from anti-smoking to HIV/AIDS prevention.
In the Soviet Union, the social hygiene
movement prioritized the sociological context of health
and illness over and above its biological determinants
(Solomon, 1994). In Belgium, a chair in social medicine
was established with financial assistance from the
Rockefeller Foundation. In 1945, Ren Sand took up the
post at the Universit Libre de Bruxelles (ULB). Sand
wrote a number of treatises on the history of social
medicine in which he defined the modern discipline as
medical sociology (Sand, 1952).
Epidemiologic transition and the birth of Public
Health
After World War II, the biomedical model of
disease that became dominant in the first half of the
20th century began to give way to a multi-deterministic
paradigm where disease was now attributed to
environmental, behavioural, and socio-economic factors
(Brandt and Gardner, 2000). The biomedical model,
which focused on Kochs postulates, proved inadequate
in assessing the multiple causes of diseases.
Quantitative Epidemiology and Biostatistics now
provided new insights into empirical evaluations of
diseases that were prevalent in the population. This
epidemiologic transition (Brandt and Gardner, 2000)
would reinforce the field of study we now call
Public Health.
In retrospect, Public Health in the modern sense
emerged in the mid-19th century (circa 1850s) in several
countries (England, continental Europe, and the United
States of America [USA]) as part of the social reform
movements and the growth of biological and medical
knowledge (especially causation and management of
infectious diseases) (Kaplan et al., 2009).
William Farr (worked on cholera in Britain),
Edwin Chadwick (wrote a report on sanitary conditions
in Britain), Rudolf Virchow (German scientist famous for
Omnis cellula e cellula published in 1858), Robert Koch
(established causal relation between microbes and
disease), Louis Pasteur (French scientist who produced
the first vaccines for rabies and anthrax), and Lemuel
Shattuck (produced the sanitation report of
Massachusetts in 1850) helped to establish the field of
Public Health.
Public Health was established on the basis of
four pillars: decision making based on data and evidence
(vital statistics, surveillance and outbreak investigations,
laboratory science); a focus on populations rather than
individuals; a goal of social justice and equity; and an
emphasis on prevention rather than curative care
(Kaplan et al., 2009). Many workers contend that Public
Health is synonymous to prevention while Medicine is a
reductionist science committed to cure (Brandt and
Gardner, 2000). Also, the focus of Public Health is
upstream- on ameliorating the social and
environmental conditions producing disease while
Medicine is downstream- coming late after the
process of pathogenesis (Brandt and Gardner, 2000).
In 1920, Winslow in his paper, The untilled field
of public health defined Public Health as: Public
Health is the science and art of preventing disease,
prolonging life and promoting physical health and
efficacy through organized community efforts for the
Chinsembu, 2012
033 Journal of Research in Public Health (2012) 1(2): 030-036
sanitation of the environment, the control of
communicable infections, the education of the
individual in personal hygiene, the organization of
medical and nursing services for the early diagnosis and
preventive treatment of disease, and the development
of social machinery which will ensure every individual in
the community a standard of living adequate for the
maintenance of health; so organizing these benefits in
such a fashion as to enable every citizen to realize his
birthright and longevity (Winslow, 1920). This is the
definition of Public Health that has stood the test of
time (Kaplan et al., 2009).
Early Schools of Public Health
The earliest special education for Public Health
work may be traced to Munich, Germany, in 1882, when
an academy for postgraduate training of public health
physicians was established (Roemer, 1988).
In the USA, academic training for public health
started with the Harvard-Massachusetts Institute of
Technology School for Health Officers in 1913 and the
Johns Hopkins School of Public Health and Hygiene in
1916 (Roemer, 1986; Rosen, 1958). The scope of
instruction at the Harvard-Massachusetts Institute of
Technology School for Health Officers in the 1919-20
academic year included 16 subjects mostly concerning
environmental sanitation, microbiology, and vital
statistics (Roemer, 1988).
In 1945, the American Public Health Association
(APHA) issued an important report entitled "Local
Health Units for the Nation" authored by Professor
Haven Emerson (Emerson, 1945). The proper functions
of Local Health Departments were defined as the "basic
six": vital statistics, control of communicable diseases,
environmental sanitation, public health laboratory
services, maternal and child hygiene, and health
education of the general public. These six subjects
characterized the core pedagogy of University public
health training in the United States.
In 1988, Roemer proposed that the scope of
Public Health knowledge should consist of the following:
basic tools of social analysis, health and disease in
populations, promotion of health and prevention of
disease, and health care systems and their management
(Roemer, 1988). He further identified a number of
courses in each of these areas and suggested a four- or
five-year curriculum that mixed practice with
coursework. Many of the present-day degree programs
follow the four- or five-year model of study proposed by
Roemer.
Sadly, although Public Health education in the
USA is about 100 years old, there has been a century-
long debate about the sour relationship between
Medicine and Public Health (Brandt and Gardner, 2000).
These authors stated that the relationship between
Public Health and Medicine has been characterized by
critical tensions, covert hostilities, and, at times, open
warfare. Much of this warfare has been caused by what
sociologists call the boundary issue, an issue involving
the division of labour, the differences in theories and
skills, and the balance of authority and politics between
these two fields (Brandt and Gardner, 2000).

CONCLUSIONS
In this paper, five important themes of Public
Health are briefly discussed:
(i) Administration of health care: This is a very important
aspect of Public Health. And perhaps Sweden presents a
good model (Collegium Medicorum) for the
administration of the health care delivery system.
(ii) Hygiene and sanitation: The sanitary idea,
propounded in England during the early 20th century,
proved critical to the prevention of disease epidemics.
Chinsembu, 2012
Journal of Research in Public Health (2012) 1(2): 030-036 034


(iii) Equity: In 20th century Europe, health equity and
universalism was achieved through health insurance
schemes. This increased access to health care.
(iv) Prevention: By the mid-20th century, the focus of
health care shifted to social medicine, community
medicine, and preventive medicine.
(v) Epidemiology: Biostatistics provided new insights
about the environmental, behavioural, and
socio-economic causes of disease. The need for
prevention and the epidemiological transition
reinforced the field of Public Health.

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Chinsembu, 2012
Journal of Research in Public Health (2012) 1(2): 030-036 036
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