The modern era

With minor modifications, the public health pattern created by the medieval urba
n community continued in use from the sixteenth to the nineteenth century. With
the development of national states in Europe, central governments took action in
creasingly but sporadically; on the whole, public health problems were handled b
y the local community. During this period, however, basic scientific knowledge w
as being acquired on which the structure of modern public health would eventuall
y be erected. The great scientific outburst of this period began to make possibl
e the more precise recognition of diseases and a better understanding of their n
ature. At the same time, ideological form was given to the possibility and impor
tance of applying scientific knowledge to the health needs of the community. Con
currently, a quantitative approach to health problems developed out of the polit
ical and economic needs of the modern state. To increase national power and weal
th, a large population was considered necessary. It was in relation to this conc
ern that political arithmetic, that is, the collection and analysis of quantitat
ive data bearing on national life, developed. The founder of this approach was W
illiam Petty, a seventeenth-century physician and economist; but the first solid
contribution to vital statistics was made by his friend John Graunt, whose clas
sic book Natural and Political Observations Upon the Bills of Mortality appeared
in 1662. The application of statistical analysis to community health problems wa
s to prove extraordinarily fruitful for the development of public health.
The consideration of health problems in connection with the aim of maintaining a
nd augmenting a population that could be economically productive and provide fig
hting men logically implied a health policy for the entire dominion of a monarch
or of a nation. This implication was recognized and began to be developed in En
gland and on the Continent during the seventeenth and eighteenth centuries. Whil
e a number of thinkers and men of affairs endeavored to deal with public health
on a national scale, it was not until the nineteenth century, with the advent of
the new industrial and urban civilization, that the problem of organizing the l
arger community to protect its health became a matter of national concern and le
d to concrete results. The earlier efforts reached a high point in the work of J
ohann Peter Frank, whose career spanned the late eighteenth and early nineteenth
centuries, and who is best known as a pioneer in public health administration a
nd social medicine.
During the eighteenth century the cultural and economic movements known as the E
nlightenment and the industrial revolution provided the seedbeds in which the ne
w ideas, tendencies, and methods that revolutionized public health in the ninete
enth century germinated and developed. In Britain, France, the countries of cent
ral Europe, and the United States, similar problems were attacked in the name of
reason, order, human welfare, economy, and community concern. Among these were
alcoholism, infant mortality, epidemics, the care of the insane, the creation or
improvement of hospitals and dispensaries, improvement of the physical environm
ent in towns, and the health conditions of specific groups such as soldiers, sai
lors, scholars, prisoners, miners, metalworkers, and various kinds of artisans.
This interest is linked to the development of the health survey. The method was
applied to the investigation of regions, communities, institutions, or populatio
n groups. Thus, John Howard published his account of the State of the Prisons in
1777 and proposed means to ameliorate social and health conditions which he had
found. When applied to regions or communities, these investigations were known
as medical topographies. Comprising sanitary surveys, epidemiologic studies, and
social investigations, they prepared the way for the more specialized surveys a
nd analyses that were carried out during the nineteenth and twentieth centuries.
Today the survey as a tool for studying community health problems is an importa
nt component of the public health armamentarium.
Public health and sanitary reform

Modern public health developed out of the sanitary reform movement of the ninete
enth century, which began in England, where the impact of the industrial revolut
ion on health was first recognized as a matter of community concern requiring go
vernmental action on a continuing basis. Nevertheless, wherever industrialism de
veloped, whether in France, Germany, or the United States, the consequences were
similar and called for similar remedies. The human cost of industrialization an
d urbanization in terms of ill health and premature death was great, and the san
itary reformers endeavored to reduce it by organizing the community to protect t
he health of its members. This aim was coupled with a recognition that disease f
or which the individual could not be held responsible was an important factor in
the cost of public assistance and that it would be good economy to undertake co
mmunity-wide measures for the prevention of disease.
In England
The industrial revolution found England without any effective system of local go
vernment or any national agency to deal with the health problems which it create
d or intensified. At the same time urban communities grew and became more conges
ted, and more and more people became aware of the cities novel, powerful, and ala
rming qualities. It was apparent that endemic or epidemic diseases tended to see
k out the poorer districts, but they were not limited to them. This awareness an
d the consequent desire to reduce or eliminate disease and the destitution which
it produced are among the major roots from which the sanitary reform movement s
prang.
One of the first products of this reform movement was the Report on the Sanitary
Condition of the Labouring Population of Gt. Britain, a fundamental document de
aling with modern public health which appeared in 1842. Prepared by Edwin Chadwi
ck, lawyer, administrator, and one of the creators of sanitary reforms, the Repo
rt showed that communicable diseases were associated with filthy environmental c
onditions. In Chadwick s view, what was needed was an administrative organ to unde
rtake a preventive program by applying engineering knowledge and techniques in a
n efficient and consistent manner. He also recognized the need for a physician t
o see that action was taken when necessary and to keep watch on health condition
s in the community.
The Public Health Act of 1848, passed by Parliament after six years of agitation
, established the General Board of Health. This step was a major landmark in the
history of public health, because it created a basis for the further evolution
of public health administration in England and led eventually to the establishme
nt of the Ministry of Health in 1919. Moreover, it set an example whose influenc
e was felt far beyond England. The impact of British sanitary reform was nowhere
more pervasive than in the United States, where, as in England, one of the basi
c problems involved in the genesis and development of public health was the need
to create an effective administrative mechanism for the supervision and regulat
ion of community health.
In America
Between 1800 and 1830, only five major American cities had boards of health. Eve
n as late as 1875 many large urban communities had no health departments. Beginn
ing in the 1830s, however, increasing immigration and urban growth produced situ
ations that required urgent attention. Inadequate provision for housing, water s
upply, sewerage, and drainage brought into being a whole brood of evils that exp
ressed themselves in the urban slum. Recurrent epidemics of smallpox, typhoid an
d typhus, cholera, and yellow fever impressed upon the public the urgent need fo
r effective public health organization.
In 1866 the New York Metropolitan Board of Health was established, an event whic
h marked a turning point in the development of American public health. This exam
ple was soon followed by other states and municipalities in establishing effecti
ve health departments: Massachusetts, 1869; California, 1870; District of Columb

ia, 1871; Minnesota, 1872; Virginia, 1872; Michigan, 1873; Maryland, 1874; Alaba
ma, 1875; Wisconsin, 1876; and Illinois, 1877.
As state and local health departments were organized, the idea of a national hea
lth agency seemed the logical next step. However, it should be remembered that u
ntil practically the end of the nineteenth century the U.S. government had no co
ncern with public health matters. Organization and action for the protection of
community health were considered a local responsibility to be carried out by the
state or the locality. Thus, the doctrine of state sovereignty continued to hol
d sway in the health field and handicapped public health action on a national ba
sis for many years. Congress created the National Board of Health in 1879, but i
t was of little significance and disappeared after 1883. The establishment of a
national health agency was not achieved in the United States until 1953, when th
e Federal Security Administration became the cabinet Department of Health, Educa
tion and Welfare, which included the Public Health Service, the Children s Bureau,
and the Food and Drug Administration, as well as other health, welfare, and edu
cational services of the federal government.