History of Public Health (CMGB)

Ref: A History of Public Health, George Rosen, 1958; MD Publications. Library of Congress Cat Card No 58-8307

In 2000 BC, seen at areas excavated in the Indus Valley, many ancient Indian cities had covered sewers. In the ‘Middle Kingdom age’ of Egypt, also around 2000 BC the city of Kahun had sewers to drain water from the streets.

Excavations at Troy and elsewhere showed elaborate systems from bring water to homes. The Romans built aqueducts for the same purpose years later.

Inca history showed rotation of troops from highlands to lowlands to minimize diseases associated with swamplands.

Point- Public Health can be based on practical and historic observation rather than modern science identifying cause/effects.

Many diseases common in this century were common 5000 years ago. Anthropological examinations of burial centers have identified stigmata of tuberculosis and syphilis as well as common birth defects. Smallpox stigmata were identified in corpses from 1000 BC. Anthropology can contribute to epidemiologic understanding of changes in disease over the years.

Some of the first accounts of acute communicable diseases were described in Thucydides writings of the Peloponesian wars. Hippocrates in 'Epidemics-I' describes mumps, although it was not known by that name. Epidemics-II has descriptions consistent with diphtheria. In his book on 'Airs, Waters and Places" Hippocrates describes causal relations between disease and the environment and coined the term EPIDEMIC. This treatise was used by the Greeks to plan colonization.

In 500 BC the Greeks were clearly familiar with malaria and described the difference between quartian and tertian fevers. Greek medicine contained a lot of Hygiene or elements of health as opposed to treating diseases. The issue of medicalization of health by giving special names to syndromes is discussed in Ivan Illich’s book, Medical Nemesis. These regimens were available only to those able to afford it, the upper class. The Greeks had municipal services which we would associate with public health today (water supply and drainage.)

in 400 BC The Greek physician Hippocrates described a severe case of “colic” in a lead miner, and the Roman engineer Vitruvius noted that men who worked in lead smelters had disturbingly wan complexions.

Rome during its conquests introduced aqueducts, a significant historical advance. The aqueducts often had settling basins (You will hear about these in the session of water and sewer plants.) The Romans were the first to write about worker's health, mainly that of miners, but also sulfur workers and blacksmiths. Galen noted that miners worked naked because the vitriolic fumes destroyed their clothes (apparently people were more expendable than clothes!) While the owners did not supply slaves with protective equipment they allowed them to make their own from cloth, bags or bladders to reduce respiratory irritation.

Hospitals were first developed for troops and civilians between 100 BC to 100 AD period.

1000AD - 1500AD

For the next significant changes (or perhaps better, rediscovery of past public health practice) we have to jump to 1200 AD. Again the emphasis was on provision of drinking water. Egypt learned from the Romans and used aqueducts for their cities. Several religious orders started providing water for their own use and then allowed the surrounding community accesses to their water supplies. Tanners were forbidden from throwing animals remains into the public water supplies. In the 1400-1500s more European cities developed potable water supplies handing out severe penalties for pollution. In the 1600s Austrian cities forbade hog pens from facing the city streets. While there was concern for disposal if wastes with more citizens living in cities, most still clung to rural life styles, not being concerned about the accumulation of wastes (not that different in some rural areas today.).

In the Middle Ages

A concern for cleanliness started to appear, with markets being required to sweep up bones. Waste started to be associated with disease (effluvia- the time of the four humors in health and disease) In Florence no debris might accumulate within 1000 paces of the market. In the 1300s leftover meats or fish had to be sold at special stalls.

Many authors wrote about smallpox during the early 1000s(AD.). Measles was widespread. Outbreaks of St. Anthony's fire or 'Ergotism' were described between 800 and 1200 AD. Influenza epidemics were recorded between 1100 and 1450 AD. Leprosy had been relatively uncommon (or unrecognized) until the early Middle Ages. The Crusades may well have been responsible for its spread, both geographically and in numbers. Person to person communication of diseases started to be recognized and quarantines imposed. Lepers became identified as the 'living dead'

The Black Death (Bubonic Plague) was rampant from 1340AD being carried west from Eastern Europe by ship, sweeping through Europe over three years from 1348-1352, with smaller waves until 1388. The quarantine, initially applied to lepers was brought to bear on plague victims, who were isolated to their homes. All coming in contact were isolated. Quarantine started in Venice the chief port of entry from the Orient. (What famous book of short stories was written in this period?)


During this period, physicians, surgeons, hospitals and community responsibility for medical care started to become focused rather than catch as catch can. Scurvy and Rickets were described. Use of fresh vegetables and fruits to prevent scurvy was described by the Dutch in the 1500s and adopted by the British Navy (from whence comes ‘Limeys!")

In 1700 Ramazzini published the first treatise of Worker's diseases.

Among newly recognized diseases was the great pox - syphilis. Sexual behaviors were not morally restricted so major efforts were made to try and combat syphilis. Italy formalized some of the first efforts to control syphilis by registration of brothels and prostitutes. Quarantines, or community expulsion, started for those with syphilis using the models for leprosy and plague (think about some of the recent concern about AIDS).

In the 1600s smallpox became more prevalent, with epidemics in Europe, particularly England.

Leeuwenhoek reported the discovery of microscopic organisms in 1676.

Public Health administration was a responsibility of city councils, but not organized as seen today. It was a form of social policy based on epidemics and history.

Vital data started to be collected formally, first by William Perry then by John Graunt who wrote the classic "Natural & political observations upon the Bills of Mortality'' examining causes of death in London during the preceding 30 years. These statistics started governments looking at 'Health Policy.'

In the 1600s towns in Europe had standards for cleanliness and rules for responsibility.

Finally in the late 1600s hospitals in Europe became places not only to treat disease but to train doctors.

1750 -1830 AD

Revolutions in France and the US. A first Encyclopedia of Science was published in France. Jeremy Bentham of England provided an underpinning for British Social & Health Policy for the 19th century. Population increases started late in the 18th century to continue through the 19th.

In England, in 1751, a campaign against "GIN" was started and its implementation was associated with a decrease in infant mortality in England. In 1750 Infant mortality in some London parishes was about 90%! Also, during the last half of the eighteen-century programs for Obstetrics as well as to combat infant mortality were started. The maternal mortality rate over 1750-1798 dropped from 24 to 3.4, while for infants it dropped from 66 to 13!

Lemon Juice started being used to combat scurvy in seamen.

In Germany strides were made in occupational health.

Sand filters, which were used to filter water in troop bivouacs, started to be used in private homes but not by communities.

In 1777 in England a book on the 'State of Prisons' started inquiries into health of prisoners. Mental health reforms for 'madhouses' started, particularly with activities of the 'Society of Friends' in York. Increased numbers of hospitals for the poor were built. Social policy on housing and destruction of slums was seen to improve health. In 1808 iron pipes were used to replace wood pipes in transmission of water. Lead pipes were replaced by iron. In 1829 the Chelsea and Lambeth Water Company introduced slow sand filters, while in 1829 in Lynchburg, Virginia cast iron pipes were used for the first high-pressure water system in the world.

It was during this period that smallpox vaccination was introduced. In 1718 the wife of the British Ambassador in Constantinople had her son inoculated, then 3 years later her daughter. In 1772 the British royal children were inoculated. These inoculations used infectious material from mild cases, to prevent severe cases. In 1796 Edward Jenner tried inoculation using cowpox from an infected individual ( In 1986 the world was declared free of smallpox!). Then he tried to infect the inoculated individual with smallpox, which failed to take. A friend of Jenner's in London, a physician at St.Thomas's Hospital tried the vaccination. Then, finding it worked, he introduced it generally. By 1801 more than 100,000 English had been so vaccinated.

In 1798 the Marine Hospital Service (the forerunner of the USPHS) was enacted by the US Congress. The first federal quarantine program to forestall importation of Yellow Fever and Smallpox.

1799, Boston: First Board of Health in U.S., Paul Revere was a member of the first local Board of Health in the United States.

1830-1875- The Sanitary Movement.

This was coincidental with the industrial revolution. In 1832 Edwin Chadwick was named first assistant, then Commissioner of the Poor Laws in London. The Commission provided its first report in 1834. It emphasized support of those not able bodied. It emphasized availability of jobs, versus social support. Population expanded exceeding any ability to house and feed it. Chadwick suggested that development of a scientific method of population/health analysis could be a useful tool to manage poverty and productivity. He believed that prevention of disease was of paramount value (100 years ago!). He felt and stated that sanitary conditions had much to do with health status. A registry of births and deaths was set up in 1836. In 1842 he reported on ' the sanitary condition of Laboring populations in Great Britain.' This Resulted in changes in housing conditions and health services. It was so successful that in 1854 the combined efforts of engineers and physicians defeated adoption of a new public health act.

1848 John Snow reported on his findings of an outbreak of Cholera associated with the Broad Street Pump. This lead to the establishment of the General Board of Health for England. John Simon was appointed as the first Health Officer for London, and in 1855 he was appointed as the first National Health Officer.

In 1854-Dr John Griscom, City Inspector for the New York Board of Health wrote a Brief View of the Sanitary Condition of the City. His report had a similar effect as that of Chadwick in raising consciousness about prevention of disease by social interventions.

In 1850 the Massachusetts Sanitary Commission published the Shattuck Report. Shattuck was an organizer of the American Statistical Society. He had previously published a Census of Boston. That 1850 report revealed high mortality from many diseases as well as identifying horrible living conditions for the poor. He recommended a state board of health. Unfortunately his report fell on deaf ears. Despite an effective study of health status by the New York Senate in 1858 it was not until a publication by the Council on Public Health & Hygiene that actions started. After several attempts a law was passed in 1868 creating a Metropolitan Board of Health. In 1860 Shattuck's prescription for Massachusetts came to life with a state health department. By 1879 additional state health departments were organized (Virginia’s in 1872)

In the last half of the nineteenth century significant changes in sanitary services took place in Germany as well as development of a German health care system. In 1870 the first US Surgeon General was appointed and in 1872 the Marine Hospital Service was enhanced and federal responsibility for health started. History of Sewage Treatment since 1864, for Narragansett Bay.


1875-1950 The Bacteriological Era.

In 1876 Koch demonstrated that anthrax bacilli were responsible for a disease, that nothing else could produce it. In the next 20 years other major diseases were confirmed as due to bacteria. Bacteria were shown to be responsible for water borne diseases. In the 1890s the understanding of rats as vectors for plague developed. In 1890 Health Examinations of immigrants started. In 1901 yellow fever was demonstrated as caused by a bacterium. In 1890 public health laboratories were first developed. By 1900 diphtheria could be diagnosed with protection induced with use of antitoxin.

1870s- Major steps in development of potable water supplies. Development of central sewage disposal systems. Infant mortality was used as a sensitive barometer of community health status.

Between 1893-1903 in Villiers-du-lac in France, where every mother was required to nurse a child till 12 months of age (unless a wet nurse was found) plus use of clean milk and weighing each child each 2 weeks, infant mortality dropped to 0!

After the Civil War, in 1873 in New York, food kitchens were set up. Later, in 1878, they were converted to milk stations for babies. Other milk stations in Europe and US followed thereafter. 1908, the Child Hygiene Dept in NYCHD was the first of its kind. In 1910 Pasteurization of Milk resulted in elimination of summer diarrhea in children.

1910 Flexner Report of Medical Schools (Rockefeller Foundation)

1914 Flexner Commission of Public Health Education (Rockefeller Foundation)

1918 Johns Hopkins School of Public Health (first in the nation) opened (endowed by the Rockefeller Foundation)

1912 the federal Children's Bureau was created.

In 1935, the Social Security Act was passed with its Bureau of Maternal and Child Health, which has now become part of HHS. It also provided funds for public health training - the first federal funds for this purpose.

In 1946 the Centers for Disease control were created.

By 1954 the concept of social epidemiology and ecology was born.

In the late 1950s and the 1960s immunizations for viral disaes such as Polio and Measles were added to DTP immunizations. the Polio edpidemic of the 1950s was rapidly brought under control.

in 1973 the Smallpox eradication program started and was completed in 10 years.

In 1965 Medicare & Medicaid Legislation passed

In 1981 the last case of 'wild' polio was repiorted in the US

In 1981 the first cases of a disease apparently limited to homosexuals, and named AIDS, was reported. By 1984 the virus responsible was identified and named Human Immunodeficiency Virus.

IN the 1990s advances in disease detection had identified a number of diseasrs of Emerging Public Health Importance such as Legionaire's disease and Lyme disease. In 1999 a potential outbreak of Ebola Virus and a laboratory in Reston, VA was invesigated and found not to be a problem among humans. In 1999 West Nile Virus was detected in NewYork and zoonotic spread identified as far south as Virginia.  In 2003 SARS was identified.

1988 IOM - The Future of Public Health

2003 IOM - Who will Keep the Public Healthy - Educating Public Health Professionals inthe 21st Century

2010 The Affordable Care Act