KNES 400 Public Health – Past and Present

Session 2 Instructor: Dr. Shannon Jette

Last day – quick review

•  United States: one of lowest life expectancy out of 30 OECD countries even though spend about 2x’s as much on healthcare – Only 3% goes to prevention

•  Major health disparities within the country with some portions of population living much longer than others – Metro map:

http://youarehere.cc/j/subway/WashingtonDC.html

Learning objectives •  Identify key periods/trends in the history of

public health practice •  Discuss how, although science of public health

has advanced, same debates remain about health disparities – Are they due to individual defects (biological or

moral) or related to wider social inequalities? •  Body ontology (what is the nature of the body)?

Not purely biological or ‘natural’ but rather site where power relations play out

Why is history important?

•  “Historical imagination is midwife to transformation: learning from those who have gone before and appreciating what we can now see that they could not encourages us to think critically in our own era” (Krieger & Birn, 1998, p. 1603). – Disrupt narrative of linear progression – A history of the present - use historical insights about

what did well and what did wrong to trouble/challenge present day assumptions

Changing face of public health …

•  Three dominant paradigms or ‘eras’ of organized public health – Sanitary science (early to late 19th century) –  Interpersonal hygiene movement (late 19th

century until early 20th century) –  Chronic disease epidemiology (1950s to …) (Lupton, 1996; Krieger, 2011)

1. Sanitary Science (early - late 19th cent.)

Industrial revolution: Rapid growth of cities in mid-late 18th century!

Population growth in London Urban tenements

Health implications of growing cities?

By 19th century, epidemics have more significant impact, esp. on poor (tuberculosis) although other disease (typhoid, cholera) had less respect for class boundaries •  Formation of Boards of Health (comprised of distinguished

citizens) = earliest organized response to epidemics – Edwin Chadwick (1800-1890): ‘official leader’ of sanitary movement in latter half of 19th century (1848 Public Health Act)

Two new classes created: Industrialists & Industrial

Working Class

Cause of epidemics? •  Disease visualized? As a poisonous vapor or mist that

emanated from decaying filth = Miasma theory •  ‘filth breeds sickness, sickness breeds unemployment

and unemployment breeds poverty’ – Filth-related disease imposed shocking costs (to gov’t and

business) by decreasing worker productivity

Solution to ill health? Sanitary Science •  ‘Environmental approach’ = clean up filth

–  City planning (grids); Sewage systems; Some housing improvements

–  Collection of data on the population (ability to track/describe disease distribution)

–  But implementation of anti-poverty measures largely ignored

•  In the USA: Lemuel Shattuck’s “Report of the Sanitary Commission of Massachusetts” (1850) = became blueprint for development of public health system!

Transition: Discovery of the microbe!

New science of bacteriology growing in dominance at turn of 20th century…

!

Health disparities •  Turn of 20th century, top 3 causes of death:

– Pneumonia, influenza and TB, and poor were affected at higher rates than wealthy

!•  Black US scholar, W.E.B Du Bois, analyzed

1900 census data –  Blacks die at 2-3x’s rate of whites of TB,

pneumonia –  Argued that disparity due to poverty (not due to

racial inferiority) !

2. Interpersonal hygiene movement •  Disease visualized? ‘Germ’ or microbe

– Served to support contagion theory by revealing the process by which contagion was passed from one person to the next (can trace cause of disease)

•  Disease also visualized? Genes (blood) –  Unequal distribution of resources (by class, race)

thought to reflect ‘survival of the fittest’ whereby the genetically strong were superior and therefore flourishing (Social Darwinism) = rich deserved to be rich and poor deserved to be poor

Solution(s)? Interpersonal Hygiene

Public health focus began to shift: from emphasis on environment to emphasis on individual; Filth/dirt still the issue but on ‘micro level’

GERMS: Vaccines; Educate about hygiene (of self/home)

Solution? Social Hygiene !GENES: Eugenics movement •  Encourage ‘better’ segments of society to reproduce •  Sterilization laws targeted groups by race, social

class: estimated 65,000 forced sterilizations in US (predominantly poor, of color, or with ‘disability’)

http://america.aljazeera.com/articles/2013/8/23/righting-a-wrongnctopayvictimsofforcedsterilization.html

Transition … into Chronic Disease Epidemiology

•  By mid 20th century: major improvement in public’s health (largely due to vaccines, improvements in diet, prenatal care; Social Security); Post WWII renewal

•  Infectious disease no longer major health threat – non-communicable diseases (NCD’s) on the rise

3. Chronic Disease Epidemiology: 1950 -… !

•  Lifestyle explanations for ill health, including lack of exercise – Individual body visualized at molecular level

(instead of ‘whole’ body, see individual parts, cells, DNA sequences)

!

Chronic illness - disparities

Source: The Commonwealth Fund, 2008

“… the field of public health … has many strands, repressive as well as progressive. Recognition of these conflicting legacies can illuminate contemporary debates about public health research and action and also help uncover ideologies and policies that contribute to or even expand social inequalities in health” (Krieger & Birn, 1998, p. 1605)

- includes a more nuanced examinations of role of exercise/physical activity

Knowledge about the body never neutral

!…!rather it serves a political function: – Sanitary Science: Is disease due to filth/immorality

(Chadwick) or poverty (Engels, Marx)? –  Interpersonal hygiene: Is disease due to germs and

genes (as per Social Darwinism) or racism and inequality (du Bois)?

– Today: Could it be that instead of focusing solely on lifestyle/biological factors and acute medical care, should also focus on poverty and other social determinants of health?

Questions of (Body) Ontology

Purely ‘natural’ or ‘physical’ and outside relations of power?

Shaped by (as it helps to shape) social context in which located?

Other ontological questions

!Nature Culture (Nurture) Individual Society Agency Structure Freedom Constraint

We will explore these aspects but try to avoid dualisms

!

Reminders

•  Weekly Discussion Questions and Key Concepts will be posted for week 1

•  Next week: Chronic disease epidemiology (and PA epidemiology) and Social epidemiology

•  No Discussion Section this week