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Asclepion

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Medicine Through Time - Public Health Revision

Public Health is to do with the standard of people’s living conditions. This includes the quality of
housing, water and the disposal of waste. Public health is mostly the responsibility of governments.
Some governments in the past have done more than others to improve the health of their people.


(i) From Ancient Greece to the Renaissance


Ancient Greece


The Greeks believed in the importance of a balanced and healthy lifestyle. This fitted in with their
belief in balancing the four humours. As a result, the advice Greek doctors gave to their patients was:

  • Do not eat or drink too much
  • Keep clean by going to the baths regularly
  • Stay fit by exercising

These are all sensible points and there were a large number of bath houses in Greek towns and cities.


However, there were still epidemic diseases in Ancient Greece such as outbreaks of plague because
the towns were quite cramped and overcrowded with only basic systems for getting rid of waste.

Ancient Rome


The Romans prided themselves on being practical and using their common sense. They realised that
the dirtier parts of towns and cities always had the most diseases. As a result, the Roman government
invested a lot of money into public health facilities:

  • Bath houses were built in every town/city
  •  Reservoirs were created and aqueducts built to transport fresh, clean water to towns andcities. This water was carried through pipes to larger buildings and drinking fountains.
  • Sewers were constructed to take away human waste from toilets. Most towns had publiclavatories which were built over the sewers. The sewers were flushed with water which hadalready been used in the bath houses.
    Aqueduct

    Roman Aqueduct

The Romans, therefore, had reasonably good standards of public health (although they were nowhere
near as good as nowadays). Like the Greeks, however, ancient Rome also suffered from outbreaks of
plague and other epidemics. The larger towns and cities were overcrowded and the poorer areas
quite dirty. The quality of Roman roads and transport meant that these diseases actually travelled
faster across Europe in the Roman Empire than they had done before.




The Middle Ages

Public Health declined in the first half of the Middle Ages before recovering towards the end back to
around the same standard as the Romans.


The Dark Ages (500 ‐1000 AD)


When the Roman Empire collapsed around 500 AD, the tribes which took over control of Europe did
not have the same knowledge or expertise about public health. Most of the Roman facilities such as
bath houses, reservoirs and aqueducts fell into disrepair and were not used. Public health in the Dark
Ages was poor, for example in Saxon and Viking England:


  • Life expectancy was low
  • Infant mortality was high
  • Many women died young, particularly in childbirth
  • There were high levels of bone and joint diseases such as arthritis and rickets
  • Waste was left in the streets and trodden into the ground
  • Rivers were used for getting rid of waste but also for drinking water
  • Animals lived in the same houses as their owners
The main reason for this decline is that the rulers during the Dark Ages were not very strong or rich
and were constantly fighting for survival. This meant that they spent most of the money they had on
warfare rather than public health.
Middle ages

A Medieval Town


The Later Middle Ages (1000 – 1450 AD)


Public health began to slowly improve in the second half of the Middle Ages for various reasons:

  • Houses destroyed by war, e.g. the Norman Conquest in England (1066), were rebuilt tobetter standards – there were more stone houses; more houses had separateaccommodation for animals; more houses had two storeys.
  • People were starting to make the connection between the dirty conditions in towns and theoutbreak of diseases. Kings in the Middle Ages issued several orders to clean up the streets,e.g. Edward III during the Black Death (although these orders weren’t always carried out).
  • Butchers were ordered to carry out their trade in separate areas of towns.
  • Teams of ‘rakers’ were employed in many cities to clear up waste on the streets. There weralso fines for dropping waste on the streets.
  • Sewers were built to carry waste and dirty water into the rivers.
  • Cess pits were lined with brick or stone and emptied fairly regularly.
  • Wells were dug to get access to cleaner water.

There were clear improvements to public health in the second half of the Middle Ages, however,
there were some major limitations:


‐ The government was not strong or rich enough to enforce the new laws about keeping streets
clean strictly, so many people ignored the laws and carried on throwing waste into the streets.
‐ Life expectancy did not improve that much because people did not know the real cause of
disease and little could be done to prevent outbreaks such as the Black Death (1348).


The Black Death (1348) and the Great Plague of London (1665)

Plague6

The Spread of the Black Death


These two events were outbreaks of the same disease – plague –but were over 300 years apart. This
fact alone suggests that not a lot had improved between the Middle Ages and the Renaissance in
terms of public health. There were some differences in how people reacted to the two outbreaks,
although there were many similarities too:


Natural approaches

  • Some people believed that the plague was

caused by polluted air (miasma) so they
carried around sweet smelling herbs and
perfumes.

  • The government ordered the streets to be

cleaned as they realised there was some
connection between dirt and disease.

  •  Some people pressed chickens against the

plague sores in order to draw the poison out.

  • Other people burst the buboes to get rid of

the disease.


Supernatural approaches


  • Some people believed that the plague was

sent by God as a punishment and that praying
to God was the best way of getting rid of it.

  • Some people used magic spells and charms to

ward off the plague, e.g. wearing
‘Abracadabra’ necklaces.

  • Some people believed that the plague had

been caused by the position of the planets.
Natural Approaches

  • There was a more comprehensive system

of containing the plague in 1665, which is
why it did not spread outside of London.


‐ Examiners were appointed to find out
the cause of all deaths


‐ Houses where someone had died of the
plague were shut up and marked with a
red cross. The surviving relatives had to
live in quarantine for a month.


‐ Watchmen were appointed to make
sure no‐one left a quarantined house.


‐ The dead were buried before sunrise or
after sunset so that as few people as
possible came into contact with the
body. The dead were also buried at
least six feet underground.


‐ Public entertainment was banned, e.g.
sports, theatres, so that infected people
could not spread the disease to others.


(ii) Public Health in the Industrial Age (1750 – 1900 AD)


The Growth of Towns and the Problem of Poor Living Conditions

Industrial city

Industrial London


Between 1750 and 1900 the size of Britain’s towns and cities grew very rapidly due to the industrial
revolution when more and more factories were being built. This rapid urbanisation led to serious
public health problems. This was because:


  • The growth of towns and cities happened so quickly that the government had very little

control over it.

  • The new houses were built by private landlords who were only interested in profits. As a

result, they spent as little as possible on the houses and charged people as much rent as they
could get away with.

  • There were no laws concerning the quality of new housing being built. Most people at the time believed it was not the government’s job to get involved with private business and people’s living conditions (this was the ‘laissez‐faire’ attitude).


This situation created living conditions which were very bad, for example:

  1. There were no sewers for taking away human waste. Hundreds of people often shared a privy(toilet) which just emptied into a cess pit dug into the ground.
  2. There was no system of refuse disposal, so rubbish just built up on the streets.
  3. Water was often taken from rivers which were used for dumping waste.
  4. Houses were overcrowded. Whole families often lived in just one room. The poorest peoplelived in cellars which could flood with sewage water when it rained.
  5. Houses were so poorly built that they were often damp.
  6. Streets and courts were so narrow that there was very little ventilation. This led to serious airpollution which caused many lung diseases, e.g. tuberculosis.

Cholera


The most frightening killer disease of the 1800s was cholera. It spread when water became polluted
with the excrement of cholera victims (people did not know this till later in the 1800s). The first cases
of cholera in Britain were in 1831/32. The disease killed people through dehydration and was very
painful and agonising. At first, people in the 19th century came up with different ideas about the cause
of cholera:


  • The most common explanation was that cholera was caused by miasma (polluted air). This

made sense to a lot of people because the worst outbreaks of cholera were in the smelliest
parts of towns.

  • Some people still believed that cholera had been sent by God as a punishment for sinning.
  •  Others believed that cholera tended to affect those who lived an ‘intemperate’ lifestyle, i.e.they drank too much.

Many towns did take action to prevent cholera from spreading, although none of these measures
would have been effective in preventing the disease:


  • They ordered that the streets be cleaned.
  • They set up quarantine hospitals to isolate the victims.
  • They ordered that barrels of sulphuric acid be opened in the town to purify the air.
  •  They ordered local residents to ‘limewash’ (disinfect) their houses.
  • Most notoriously, in London, Edwin Chadwick ordered that all of London’s waste be flushedinto the River Thames. He thought that this would get rid of the smell (miasma) which wascausing the disease. Unfortunately, this act just made it worse because the Thames provided alot of London’s drinking water.
Cholera


In 1854, Dr John Snow discovered the true cause of cholera (i.e. polluted water). He proved this by:

  1. Removing the handle to the Broad Street water pump in central London. After he did this,

there were no more cases of cholera in that area. 

2. By pointing out the case of an old lady who now lived in Hampstead, but who had water from Broad Street sent to her every day because she liked the taste (yuk!). She got cholera but noone else in her neighbourhood did.


3.  Explaining why the brewery on Broad Street had no cases of cholera. Snow pointed out thatthis was because the brewery had its own water supply which was not polluted.

However, Dr Snow found it difficult to convince other doctors and public health officials that he was
correct. It was hard to overcome their commitment to the miasma theory. Snow was helped after 1861,
when Louis Pasteur proved that germs cause diseases and that germs could be found in water as well as
the air.


Improvements to Public Health in the 19th century


Edwin Chadwick and the 1848 Public Health Act:

1842 ‐ Chadwick wrote a bestselling report into the living conditions in towns. He pointed out that the
life expectancy of the richest people in cities was lower than that of the poorest people in the
countryside.


1847 ‐ A new Public Health Act, proposed by Chadwick and others, was defeated in Parliament. The MPs
who voted against were nicknamed the ‘Dirty Party’. They were against it because:


  • They did not want to pay higher taxes to fund cleaning up towns.
  • They believed in the laissez‐faire attitude that it was not the government’s job to interfere

in people’s everyday lives.

  • No‐one was sure of the real cause of disease. The ‘Dirty Party’ argued that they might bewasting their money on measures that wouldn’t work.

1848 ‐ Cholera returned to Britain. This scared a lot of people into supporting the campaign for cleaning
up. The Public Health Act was passed by Parliament. It said:

  • Local councils could set up a Board of Health if 10% of the richer taxpayers wanted one.
  • Local councils had to set up a Board of health if the death rate was above 33 per thousand
  • Local councils had the power to connect houses to sewers; supply clean water; provide public parks; raise local taxes to pay for the improvements.
  • A General Board of Health was set up in London with Chadwick as its chairman.


The 1848 Public Health Act had some positive impact but was also limited:

Positive impact of the 1848 Act

  • It was the first time that the government hadaccepted responsibility for the health of thenation. It challenged the laissez‐faire attitude.
  • 2500 miles of sewers were built in the next 8years.
  • Public Health was now considered an important national issue and was kept in the headlines.


Limitations of the 1848 Act.

  • The Act was permissive not compulsory. In other words councils could act if theywanted to, but didn’t have to. Many councils chose to do nothing because theywere worried about the cost of cleaning up.
  • Only 1/6 people in Britain were covered by aBoard of Health by 1853.
  • Chadwick was a difficult man to work with. He made enemies out of the doctors,engineers and civil servants who he shouldhave used to help him.
  • Mistakes were made, for example when Chadwick flushed London’s waste into theRiver Thames which only made cholera worse.


The 1875 Public Health Act


The 1875 Public Health Act was more effective because it was compulsory. All local councils now HAD to
provide clean water, proper drains and sewers and appoint a medical officer of health. There were
various reasons why this more effective act was possible in 1875 but not in 1848:


  • In the summer of 1858, Parliament had had to be evacuated because the River Thames smelt so bad.

This forced Parliament to give the go ahead to Joseph Bazalgette to build a new system of sewers for
London which was very successful. This proved public health measures worked.


  •  Prominent campaigners, such as Octavia Hill, put pressure on the government to make a firmer law. Octavia Hill herself bought run‐down apartment blocks and renovated them. She then rented them out at reasonable rates to poorer families. She also ran courses on how to run a healthy household.
  • Louis Pasteur had shown that germs cause disease, so the Dirty Party couldn’t argue anymore that their money might be wasted.
  • Cholera returned in 1866 which frightened more people into supporting a stronger Public Health Act.
Sewers

The London Sewers


(iii) Public Health since 1900


Poverty in 1900


Despite the improvements which happened in the second half of the 19th century, many people in
Britain still lived in poverty. This was revealed around the year 1900 in various ways:


- Charles Booth wrote a report into the lives of working class people in London in 1889. He
organised a team of researchers to investigate the circumstances of all streets in the city. He
concluded that about 30% of people lived in real poverty. He proposed that the government
should take more responsibility for the well‐being of the people, e.g. through introducing Old Age
Pensions. Some opponents argued, however, that London was unique and other towns weren’t
as bad.


- Seebohm Rowntree published a report into living condition in York in 1901. He found that 28% of
people in York were living below the poverty line, which meant that they did not have enough
money to ensure the health of their family. His study proved that it wasn’t just London that had
high levels of poverty. Rowntree was friends with David Lloyd George who was a prominent
politician in the Liberal Party. Lloyd George agreed something had to be done to help the poorest
people in society.

- During the Boer War (1899‐1902), 40% of men who volunteered to join up were rejected because
they were medically unfit for service. This revealed to the government how poor a lot of people’s
living conditions and diets were.


The Liberal Social Reforms (1906‐11)


The Liberal Party won the election in 1906 and decided to take action to improve the welfare of
poorer people in society. The leading figure in the Liberal Party arguing for these changes was David
Lloyd George. The reforms included:


1906 ‐ Local authorities were encouraged to provide free school meals for the poorest children.
1907 ‐ School medical checks were introduced to monitor the health of the nation’s children. The
first health visitors were appointed to advise new mothers.
1908 ‐ Old Age Pensions were introduced in order to help older people to survive.
1909 ‐ The building of back‐to‐back houses was banned
1911 ‐ The National Insurance Act was passed to provide a scheme for workers to pay into which
would give them some money to feed their families if they lost their job or were too ill to work.
The workers could also got to see a doctor paid for by the insurance scheme.


The reforms were successful, although there were a couple of limitations:


‐ The wives and children of workers in the National Insurance scheme were not covered, so
they still had to pay if they wanted to see a doctor.
‐ The Liberals did not do much to improve the existing slum housing which was still in a very
bad state.


The 1920s and 1930s


Between the two World Wars there were some small improvements in public health in Britain but
progress was limited. The main problem holding back progress was the economic depression which
followed the Wall Street Crash of 1929. This meant that the government had much less money to
invest in public health. The main improvements which did happen were:


  • 1919 Housing Act – this provided government money for the first time for the building ofcouncil houses. Lloyd George was now Prime Minister and he promised ‘Homes Fit forHeroes’ for the soldiers returning from the First World War. These council houses were ofgood quality, e.g. with indoor toilets, and were rented out at reasonable rates. By 1930, one million new council houses had been built.
  • 1930 Slum Clearance Act – the government realised that more had to be done for thepoorest people who still lived in terrible slums. A fiver‐year programme was started to knockdown the worst slums in each city and built better quality but affordable council housinginstead. This was a huge job and although progress was made, by 1939, there were still a lotof people living in slum housing.

The other main problem which remained was the uneven access to doctors and hospitals. Most
people had to pay to go to the doctor or to be treated in hospital. Many poorer people could not
afford this, so they still had to rely on basic remedies passed down through the family.

Ww1 houses

WW1 Homes for Heroes


The Impact of the Second World War (1939‐45)


The Second World War had a positive impact on the attitude of the government to improving
people’s health. The government wanted as many people as possible to be fit and healthy to help
the war effort. They did various things which made a difference:


  •  Rationing – this actually improved the health of many poorer people because it provided

them with a more balanced diet.

  • Poster campaigns – the government produced a number of posters advising people on how

to stay healthy. The most famous slogan was – ‘Coughs and Sneezes Spread Diseases.’

  •  Immunisation – the government organised a national diphtheria immunisation campaign which combated a disease which still affected thousands of people every year.
  •  Evacuation – children from the cities were evacuated to safer countryside areas. The poor health of a lot of these children shocked many people and the government realised that there was still a lot to be done to improve the health of everyone in the country.
  • The Beveridge Report – the most important thing the government did during the war was askWilliam Beveridge, a civil servant, to produce a report about how to make Britain a better placeafter the war. One of his recommendations was for a National Health Service to be set up. Healso said that the government should create a Welfare State to support people and keep themout of poverty ‘from the cradle to the grave.’


The National Health Service (NHS)


After the Second World War, the Labour Party formed the new government. They were committed
to introducing all of the changes proposed by William Beveridge. In 1946, they passed a law stating
that they would set up the NHS by 1948. The key thing about the new NHS was that it was to be free
for everyone. Surprisingly, they ran into quite a lot of opposition to this plan. Opponents of the NHS
included:


‐ Many doctors who were worried because they thought they would be paid less in the NHS
than they were earning as private doctors. Many doctors were also worried that they would
lose their independence and that the government would tell them what hours they had to
work and maybe even where they had to work.


‐ Some richer people who were worried that the new NHS would be very expensive and that
would mean they would have to pay higher taxes.


‐ Charities and local authorities who ran most of the hospitals were not very happy that they
would have to hand them over to the government.


In the end, Aneurin Bevan, the Minister of Health, persuaded most of the doctors to support the new
NHS by promising them that they could continue having private patients and work for the NHS at the
same time. By the time the NHS started in 1948, 90% of doctors had signed up to join it.

NHS Logo


The NHS had an immediate positive impact. It treated millions of people in its first year and
continues to do so. It is very popular with the majority of people in Britain. Through the NHS, the
government provides hospital care, GP services, maternity and child welfare, ambulances and
emergency health care, vaccination programmes (e.g. the BCG against tuberculosis), training of
doctors and nurses, and government funded medical research. The NHS is now supported by all
political parties, but it has not been without its problems:


‐ In 1950, the government was forced to introduce charges for false teeth and spectacles
because the cost of the NHS was so high. Aneurin Bevan was so angry about this that he
resigned from the government in protest. Since then, other charges have also been
introduced, e.g. for prescriptions.


‐ The NHS constantly faces new demands on its budget. New medical technology and new
drugs are introduced very frequently and are increasingly expensive. It is very difficult for
the NHS to afford all of these treatments.


‐ The problems that the NHS has faced has leant that many people have continued to pay for
private healthcare which has led to accusations that healthcare in Britain is still divided
between those that can afford private care and those that rely on the NHS.


Public Health in the late 20th century


Public health has improved hugely since the Second World War. There are many reasons for this.
One is the NHS (see above), others include:


  • 1956 Clean Air Act – the government took action to combat the smog which was polluting

the air in towns and cities. By 1971, smoke pollution had been reduced by 65%.

  •  The government has passed many laws to ensure – we have clean water; sewage is disposed

of safely; toxic waste is controlled; housing is of a good standard; health and safety at work is
much better; food is hygienic and carefully labelled.

  • Recently the ban on smoking in confined public places has led to a decrease in the impact of passive smoking.


There are still public health problems which concern the government nowadays. One major one is
the increasing level of obesity amongst the population in modern Britain. Another is the high level of
use of illegal drugs in this country.


The improving situation of public health in the second half of the 20th century has largely been
enjoyed by richer western countries. The majority of the world’s population, who live in developing
countries or the Third World, do not enjoy such high standards.

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