1.2 The history and development of public health in developed countries(cont’3)

Another feature of postwar public health concern was the shift from individual hygiene back to the environment (Hays 1987; Gottlieb 1993). To many, these heart diseases and cancers, along with other diseases and pathological conditions that seemed even more serious—for example, other forms of cancer, birth defects, lowered sperm counts—had broader structural causes and could be prevented only by comprehensive changes in the physical and social environment (Epstein 1979). Thus part of the liberal resistance to public health imposition was the argument that a focus on disciplining lifestyles came at the cost of attention to grander and more serious political issues (Tesh 1987; Turshen 1987).
While this new environmentalism had links with the nineteenth-century view of public health as environmental improvement, there were greater differences. The fear of insidious invisible radiation or the toxic chemicals that might lurk in numerous consumer products reflects the terror of germs or invisible odourless miasmas which germs replaced; however, the blame was quite differently directed. The new problems of environmental public health were those in which individuals were victimized by corporate oligopolies and by the governments they influence. While Chadwick and his associates had warned of vested interests, such as those that perpetuated slum housing, nineteenth-century environmental health problems had a communal character that was missing from the twentieth. Everyone in a nineteenth-century town produced excrement, smoke, ash, and rubbish; the great problem was to find within the community the will and means to act collectively (Wohl 1977; Kearns 1988). Few in a twentieth-century community produced radiation or toxic chemical waste, and the reasons why nothing was done about these seemed all too clear. Public health had failed in its police function; an institution that had evolved to stop the selling of spoiled food by the individual grocer or restauranteur could not cope with the conglomerate that sold goods whose harmful effects were less obvious and slower to appear but which might be much more widely distributed.
The result was an increasingly adversarial relationship between the people and the public health institutions that were supposedly safeguarding their health. To the degree that governments were seen as colluding with the proliferation of these dangerous materials, institutions of public health, as departments of government, were implicated too (Brown and Mikkelsen 1990, Edelstein 1988; Steneck 1984). Even the establishment of new departments of environmental protection, though it might be a means to apply new kinds of expertise to problems of environmental health, did not fundamentally alter the climate of distrust. Public health again became a matter for grassroots political agitation with the emergence of neopopulist Green parties, whose platforms gave prominent attention to health as part of environmental good, and who put their marginality to established governments at the centre of their appeal to the electorate.
Such a focus on bad environmental policy even informed the response to AIDS and to other new infectious diseases, like Ebola fever, that appeared in the 1980s and 1990s. While it became clear that these diseases could be largely controlled through the traditional means of changes in personal behaviour and isolation or restriction of the activities of victims, these recognitions were not fully reassuring. They did little to deflect demand for a vaccine, or the investment of hope in curative medicine. They too could be seen as environmental diseases, caused by environmental changes that had allowed animal viruses to acquire secondary human hosts for whom they were highly virulent. Chief amongst these changes was the unwise exploitation of tropical forests by an international oligopoly that put profit ahead of prudence (Garrett 1995).
Even those diseases most closely linked to lifestyle choice could be attributed to the broader social environment. People smoked, drank, used drugs, ate too much or vastly too little, practised unsafe sex, spent hours immobilized before televisions absorbing images of violence, hit their spouses and children, or shot their coworkers or themselves because they could no longer cope. To expect disciplined personal behaviour from alienated people living in a stressful world was unrealistic, and the institutions of public health should recognize this. But the critics were ambivalent as to what such an analysis implied. For some, the obvious response was to remake a society whose support structures were more consistent with the health behaviours it wished to promote. How absurd, for example, for a state to subsidize the production of tobacco and the addiction to it of people in other nations, whilst blaming its own citizens for smoking. For others such a response sounded like an even more invidiously intrusive state, bent on removing not only the means by which we satisfied unhealthful temptations, but also the temptations themselves. In this ‘critical public health’ view the lifestyle agenda was suspicious as the public health agenda of the untrustworthy state, not of its people. It was not clear that the personal benefits of delayed or denied gratification were worth it: perhaps one hould just enjoy life and rely on the miracles of modern medicine for redemption (Petersen and Lupton 1996).
This view, together with the emergence of widespread cancers and other chronic illnesses for which there was no clear preventive strategy, including the debilitating conditions of ageing, raised the question of why supportive and curative medical care did not form a part or priority of public health. It also raised the question of how far reaching the health obligations of the liberal state were to its citizens. This issue had vexed public health practitioners throughout the liberal era, though it had often been suppressed because it was seen as too politically volatile. In socialist or social democratic politics, or where the legacy of medical police remained strong (even when adopted, as in Sweden, by a democratic polity), there was often no clear boundary between public health and the public medical care most people demanded and received (Porter 1999). But elsewhere the recognition that public health was bound up in the larger issue of human welfare, which in turn included the rest of medical care, was problematic. Many of the newly prominent diseases were not infectious; they could be experienced privately without disturbing community or state, hence the reactive and police rationales for public health did not apply. But they did disrupt the fulfilment of human potential, and could justly take their place amongst the demands citizens could make of their governments.
In France, Germany, and Russia public health services had emerged from, and had remained closely linked to, medical services for the poor (Labisch 1992; Ramsey 1994; Solomon 1994). In mid-nineteenth century England, Edwin Chadwick, notwithstanding his own post as chief administrator of relief to the poor and the existence of a comprehensive national network of poor law medical officers, had deliberately severed public health (which he equated with sanitary engineering and saw as exclusively preventive) from the second-rate medical care that was offered to the poor, more on grounds of humanity than expectations of effectiveness. (It was hoped that they would thereby willingly pay for something better.) Chadwick’s English successors, while moderating the focus on sanitary engineering, retained a distinction between public health medicine and social welfare, which seemed to them only marginally medical and to have more to do with the moral chastisement of the feckless or the warehousing of the incompetent or neglected (Hamlin 1998). In Ireland, by contrast, an integrated system of public health, welfare, and medical care did emerge during the late nineteenth century, but more by accident than design (Cassell 1997). At the end of the nineteenth century, the Fabian socialists presented British parliament with a clear choice. The Fabians (mainly Beatrice Webb) proposed a much expanded scheme of prevention, though one which made even greater demands on personal and social behaviour as the price the citizen must pay for greater guarantees from the state. The liberals, whose view prevailed, would not discipline personal hygiene, but offered instead an insurance plan to pay for the medical care needed by stricken working men (Fox 1986; Eyler 1997). It was a policy acceptable to the rank and file of the medical profession and that retained and reinforced the split between public health and medicine.
Subsequent efforts to expand state responsibility for health into matters of care and cure have generally worked when medical professions have seen them as advantageous, yet the relationship between even this expanded public medicine and the broader questions of social welfare remain problematic (Starr 1982; Fox 1986). The kinds of objections that were made to Webb’s scheme still arise: however laudable prevention as a goal, ironically, as we have seen with the concerns about lifestyles and the environment, the strategies and priorities of the preventive public health of the last two centuries have not always been those most desired by the masses of people. To many, it has seemed that if the state was going to discipline behaviour for its own purposes, those who suffered that imposition deserved compensation for their trouble when things still went wrong. Such logic was clearest in compensating veterans of wars. It underwrote the postwar establishment of Britain’s National Health Service, which would provide ‘health for heroes’ and sustains the Veterans Administration medical system in the United States. Thus what some have complained of as an unrealistic demand for risk-free living, in which people demand a political right to complete freedom of action without accepting responsibility for the consequences (as if one could somehow live free of one’s biological self), may be better understood as a complaint about the fairness of the basic social contract of modern societies.
This problem of the relationship between the institutions of public health and the citizenry on whose behalf they claim to act is the greatest challenge currently facing public health in the developed world. That the problems that confront both public health and regular medical practice often stem from a wide range of social causes is plain. That it is so difficult to develop political will to respond to these problems is not chiefly a matter of epidemiological uncertainty. Such pathological phenomena are clearly the product of many causes on many levels and accordingly there are numerous points of access where defensible preventive measures might be taken. But almost all of them are likely to intrude on what are claimed as personal or cultural rights, and almost always attempts to act will be met with the response that it is fairer to act elsewhere. In such cases, epidemiology necessarily requires a large supplement, not from ethics so much as from a moral and political philosophy that must be acceptable to an increasingly diverse community. Without such a foundation, public health is forced to take refuge in science that is frequently challenged; but at the same time, it is not clear that the professional and educational institutions of public health, or the legal, political, and administrative structures that create and maintain it, will be able to initiate and implement a satisfactory enquiry about how these conflicting rights are to be adjudicated.
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