The Role of Public Health in Protecting and Improving Health

Economic inequality is measured by looking at the distribution of wealth and income in a society, not the general wealth of a country. A growing body of research suggest that inequality – more so than absolute wealth alone – has a profound influence on a population’s health, in every socioeconomic group from rich to middle class to poor. Sir Michael Marmot, professor of epidemiology at University College London, found there is a stepwise relationship between your socioeconomic position and your health. In the 21st century public health stresses the importance of an approach that addresses the social determinants of health. Social determinants of health include policies that offer a living wage, higher assistance levels for those unable to work, a more progressive tax structure that redistributes income more fairly, increased unionization, better funding of affordable, high-quality childcare and early education, increased spending on a housing strategy.

A prevailing view of the origin of modern human disease is that most arose after the advent of animal domestication and urbanization during the Neolithic period some 12,000 years ago. The first public health measures were based upon the idea that miasmas – bad smells – caused disease. Although the idea was wrong, the measures against miasmas involved a greater focus on cleanliness, and the improved public health. In mid-19th century the miasmas theory was replaced by the Germ Theory of disease. In 1861, Pasteur published his germ theory which proved bacteria caused disease. The idea was taken by Robert Koch in Germany who began to isolate specific bacteria that caused specific diseases such as TB and cholera. Of the top 10 most common causes of death in the US, influenza and associated pneumonia is the only one of acute infectious etiology. Influenza and associated pneumonia caused 14.3 deaths in the US per 100,000 population in 2017.

A viral infection, small pox spread along trade routes, emerging first in Africa, Asia and Europe and reaching the Americas in the sixteenth century. Because smallpox requires a human host to survive it tended to smolder in densely populated areas, erupting in a full-blown epidemic every ten years or so. Small pox was a leading cause of death in the 18th century. Most people became infected during their lifetime, and about 30% of people infected with small pox died from the disease, presenting a severe selection pressure on resistant survivors. Quarantine was the only measure available to reduce the spread. In the 19th century, cow pox or calf lymph was used as a vaccine. They were able to control outbreaks with vaccination. In 1853 vaccination against smallpox was made compulsory in Britain. Vaccination of Americans against small pox stopped in 1972 after the disease was eradicated in the world.

Edwin Chadwick (1800-1890), a leader in sanitary reform, noted that it was necessary to address issues of sewage and good water supplies before actually being able to determine the contribution of crowded housing to health problems. He was appalled at the number of people admitted to the workhouses and became convinced that if the health of the working population could be improved then there would be a drop in the numbers of people on relief. Chadwick used an economic argument to drive change – loss of revenue to the government because of early death of so many people. He believed that a healthier population would be able to work harder and would cost less to support, and if all of his recommendations were carried out the average life expectancy for the laboring classes would increase by at least 13 years. In 1848, a cholera epidemic that killed over 50,000 people, terrified the government into doing something about prevention of disease – through both public and individual health measures.

Cholera spread across the world in multi-pandemics during the 19th century. The 3d pandemic occurred from 1846 to 1860. The 1854 Broad Street Cholera outbreak in London ended after physician John Snow identified a neighborhood Broad Street pump as contaminated and convinced officials to remove the handle. This action proved contaminated water was the main agent spreading cholera, although he did not identify the contaminant. It would take many years for this message to be believed and fully acted upon. In 1849, cholera claimed 5,308 lives in the major port city of Liverpool, England, an immigration departure point for immigrants to North America. Cholera, believed spread from Irish immigrant ships from England, spread throughout Mississippi River system, killing 4,500 in St Louis, and over 3,000 in New Orleans. Thousands died in New York, a major destination for Irish immigrants. During this pandemic some US scientists began to believe that cholera was somehow associated with African Americans as the disease was prevalent in the south in areas of black population.

The diphtheria threat grew significantly during the late 19th century to become one of the major causes of death, fueled by the industrial revolution and increasingly crowded urban centers. Though mostly a disease associated with the poor and a particular threat to children, diphtheria did not discriminate by class and age, and its cause, route of spread and cure remained a mystery until the last part of the 19th century. The US recorded 206,000 cases of diphtheria in 1921, resulting in 15,520 deaths. Diphtheria death rates range from about 20% for those under age five and over 40, and 5-10% for those age 5-40 years. Since the introduction of effective immunization, starting in 1920s diphtheria rates have dropped dramatically in US and other countries that vaccinate widely. Diphtheria is transmitted from persons usually via respiratory droplets. Between 2004 to 2008, no cases of diphtheria were recorded in the US.  

It also became clear that providing immunizations and treating infectious diseases did not solve all health problems. Despite remarkable success in lowering death rates from typhoid, diphtheria, and other contagious diseases, considerable disability continued to exist in the population. There were still numerous diseases, such as tuberculosis, for which infectious agents were not clearly identified. Draft registration during World War I revealed that a substantial portion of the male population was either physically or mentally unfit for combat. It also became clear that diseases, even those for which treatment was available, still predominantly affected the urban poor. Registration and analysis of disease showed that the highest rates of morbidity still occurred among children and the poor. On the premise that a healthier society could be built through health care for individuals, health departments expanded into clinical care and health education. In the early 20th century, the New York and Baltimore health departments began offering home visits by public health nurses.1

The primary goal of influenza vaccine in high risk groups – those >65 years of age, those with chronic medical conditions including pulmonary, cardiovascular, or renal disease as well as immunosuppression –  is to prevent unnecessary hospitalization and premature death related to influenza, since episodes of influenza tend to exacerbate chronic medical conditions and lead to occurrence of secondary bacterial pneumonia. In the US about 67% of over age 65 get annual influenza vaccination. When the vaccine is well-matched with the circulating strain there is a 40-60% reduction in in hospitalization and mortality. The ability of adults >65 years of age to receive seasonal influenza vaccine is influenced by structured, intermediate, and healthcare-related social determinants which have an impact at the health system, provider, and individual levels. CDC identifies that the average number of Americans who die from influenza and associated pneumonia annually is 56,000. The first death from COVID-19 in US was in California on February 6, 2020; the number of deaths from COVID-19 reported by April 27, 2020 in US exceeded 56,000.

Although science provided a foundation for public health, social values have shaped the system. Despite the huge successes brought about by scientific discovery and social reforms, and despite a phenomenal growth of government activities in health, the solving of public health problems has not taken place without controversy. Repeatedly, the role of the government in regulating individual behavior has been challenged. Chadwick’s influential sanitary report of 1842 divided people into ‘clean’ and ‘dirty’ parties and some people believed Chadwick wanted the poor to be made clean against their will – government attitudes also played a role.  In 1853, Britain’s Board of Health was disbanded because Chadwick, its director, “claimed a wide scope for state intervention in an age when laissez-faire was the doctrine of the day.” The unprecedented natural effort to shut down much of life to slow the spread of COVID-19 is promoting a growing number of protests. Right-wing media supports the protest by spreading misinformation about coronavirus.

The coronavirus spreads inequality: Better-off Americans are still getting paid and are free to work from home, while the poor are either forced to risk going out or lose their jobs. Americans with less education and lower incomes are far more likely either to have been showing up at their workplaces – putting themselves at greater risk for infection – or more likely to see their work dry up. Dylan Scott reports, “Black New Yorkers are dying [from coronavirus] at twice the rate of their white peers; Latinos in the city are also succumbing to the virus at a much higher rate than white or Asian New Yorkers. The same trends can be seen in infection and hospitalization rates, too.” On the other hand, in 2017, the age adjusted death rate of influenza and associated pneumonia was 26% higher among blacks compared to whites. Socioeconomic status is the most powerful predictor of disease, disorder, injury and mortality we have.

The determinants of health are understood to interact with each other in a variety of ways, to compound vulnerabilities for certain sections of the population, and to be modifiable through public health policy and changing social norms. As public health leaders look for ways to put a cap on coronavirus spread – primarily through social distancing practices and in some cases shelter in place protocol – the nation is seeing just how deep health disparities run. There are clear delineations between different social groups and how they are faring in the new normal as tens of millions of additional citizens are falling into poverty – clearly COVID-19 vaccine will not solve all health problems. If public health cannot directly affect broader societal conditions, interventions should be focused around advocacy and education about the societal determinants of health. As such, the health sector needs to take a more political approach in finding solutions for health inequities.

1 A History of the Public Health System https://www.ncbi.nlm.nih.gov/books/NBK218224/

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