Public health

Public health has been defined as "the science

and art of preventing disease, prolonging life
and promoting health through the organized
efforts and informed choices of society,
organizations, public and private, communities
and individuals".[1][2] Analyzing the
determinants of health of a population and the
threats it faces is the basis for public health.[3]
The public can be as small as a handful of
people or as large as a village or an entire city;
in the case of a pandemic it may encompass
several continents. The concept of health takes
into account physical, psychological, and Example of historical public health recommendations from
social well-being.[1][4] 1918 in New Haven, Connecticut, United States

Public health is an interdisciplinary field. For

example, epidemiology, biostatistics, social sciences and management of health services are all relevant.
Other important sub-fields include environmental health, community health, behavioral health, health
economics, public policy, mental health, health education, health politics, occupational safety, disability,
oral health, gender issues in health, and sexual and reproductive health.[5] Public health, together with
primary care, secondary care, and tertiary care, is part of a country's overall health care system. Public
health is implemented through the surveillance of cases and health indicators, and through the promotion of
healthy behaviors. Common public health initiatives include promotion of hand-washing and breastfeeding,
delivery of vaccinations, promoting ventilation and improved air quality both indoors and outdoors, suicide
prevention, smoking cessation, obesity education, increasing healthcare accessibility and distribution of
condoms to control the spread of sexually transmitted diseases.

There is a significant disparity in access to health care and public health initiatives between developed
countries and developing countries, as well as within developing countries. In developing countries, public
health infrastructures are still forming. There may not be enough trained healthcare workers, monetary
resources, or, in some cases, sufficient knowledge to provide even a basic level of medical care and disease
prevention.[6][7] A major public health concern in developing countries is poor maternal and child health,
exacerbated by malnutrition and poverty coupled with governments' reluctance in implementing public
health policies.

From the beginnings of human civilization, communities promoted health and fought disease at the
population level.[8][9] In complex, pre-industrialized societies, interventions designed to reduce health risks
could be the initiative of different stakeholders, such as army generals, the clergy or rulers. Great Britain
became a leader in the development of public health initiatives, beginning in the 19th century, due to the
fact that it was the first modern urban nation worldwide.[10] The public health initiatives that began to
emerge initially focused on sanitation (for example, the Liverpool and London sewerage systems), control
of infectious diseases (including vaccination and quarantine) and an evolving infrastructure of various
sciences, e.g. statistics, microbiology, epidemiology, sciences of engineering.[10]
Contents
Definitions and purposes
Definition
Related terms
Purposes
Characteristics and components
Methods
Ethics
Priority areas
Original focal areas
Changing and differing focal areas
Current practice
Organizations
Public health programs
Behavior change
Applications in health care
Conflicting aims
Global perspectives
Disparities in service and access
Health aid in developing countries
Sustainable development goals for 2030
History
Until the 18th century
After the 18th century
Society and culture
Education and training
Notable people
Country examples
Canada
Cuba
Colombia and Bolivia
Ghana
France
Mexico
United States
See also
References

Definitions and purposes

Definition
Public health has been defined as "the science and art of preventing
disease", prolonging life and improving quality of life through
organized efforts and informed choices of society, organizations
(public and private), communities and individuals.[2] The public
can be as small as a handful of people or as large as a village or an
entire city. The concept of health takes into account physical,
psychological, and social well-being. As such, according to the
World Health Organization, "health is a state of complete physical,
mental and social well-being and not merely the absence of disease Community health workers
or infirmity".[4]

Related terms

Public health is related to global health which is the health of

populations in the worldwide context.[11] It has been defined as
"the area of study, research and practice that places a priority on
improving health and achieving equity in "Health for all" people
worldwide".[12] International health is a field of health care, usually
with a public health emphasis, dealing with health across regional
or national boundaries. Public health is not the same as public
healthcare (publicly funded health care). The WHO is the predominant agency
associated with global health
The term preventive medicine is related to public health. The
American Board of Preventive Medicine separates three categories
of preventive medicine: aerospace health, occupational health, and public health and general preventative
medicine. Jung, Boris and Lushniak argue that preventive medicine should be considered the medical
specialty for public health but note that the American College of Preventive Medicine and American Board
of Preventive Medicine do not prominently use the term "public health".[13]: 1   Preventive medicine
specialists are trained as clinicians and address complex health needs of a population such as by assessing
the need for disease prevention programs, using the best methods to implement them, and assessing their
effectiveness.[13]: 1 , 3  

Since the 1990s many scholars in public health have been using the term population health.[14]: 3   There
are no medical specialties directly related to population health.[13]: 4   Valles argues that consideration of
health equity is a fundamental part of population health. Scholars such as Coggon and Pielke express
concerns about bringing general issues of wealth distribution into population health. Pielke worries about
"stealth issue advocacy" in population health.[14]: 1 63  Jung, Boris and Lushniak consider population health
to be a concept that is the goal of an activity called public health practiced through the specialty preventive
medicine.[13]: 4  

Lifestyle medicine uses individual lifestyle modification to prevent or revert disease and can be considered
a component of preventive medicine and public health. It is implemented as part of primary care rather than
a specialty in its own right.[13]: 3   Valles argues that the term social medicine has a narrower and more
biomedical focus than the term population health.[14]: 7  

Purposes

The purpose of a public health intervention is to prevent and mitigate diseases, injuries and other health
conditions. The overall goal is to improve the health of populations and increase life expectancy.
Characteristics and components

Public health is a complex term, composed of many elements and different practices. It is a multi-faceted,
interdisciplinary field.[10] For example, epidemiology, biostatistics, social sciences and management of
health services are all relevant. Other important sub-fields include environmental health, community health,
behavioral health, health economics, public policy, mental health, health education, health politics,
occupational safety, disability, gender issues in health, and sexual and reproductive health.[5]

Modern public health practice requires multidisciplinary teams of public health workers and professionals.
Teams might include epidemiologists, biostatisticians, physician assistants, public health nurses, midwives,
medical microbiologists, pharmacists, economists, sociologists, geneticists, data managers, environmental
health officers (public health inspectors), bioethicists, gender experts, sexual and reproductive health
specialists, physicians, and veterinarians.[15]

The elements and priorities of public health have evolved over time, and are continuing to evolve.[10]
Different regions in the world can have different public health concerns at a given time.

Common public health initiatives include promotion of hand-washing and breastfeeding, delivery of
vaccinations, suicide prevention, smoking cessation, obesity education, increasing healthcare accessibility
and distribution of condoms to control the spread of sexually transmitted diseases.

Methods
Public health aims are achieved through surveillance of cases and
the promotion of healthy behaviors, communities and
environments. Analyzing the determinants of health of a population
and the threats it faces is the basis for public health.[3]

Many diseases are preventable through simple, nonmedical

methods. For example, research has shown that the simple act of
handwashing with soap can prevent the spread of many contagious
diseases.[16] In other cases, treating a disease or controlling a
pathogen can be vital to preventing its spread to others, either
during an outbreak of infectious disease or through contamination
of food or water supplies. Public health communications programs,
vaccination programs and distribution of condoms are examples of
common preventive public health measures.

Public health, together with primary care, secondary care, and Newspaper headlines from around
tertiary care, is part of a country's overall health care system. Many the world about polio vaccine tests
interventions of public health interest are delivered outside of health (13 April 1955)
facilities, such as food safety surveillance, distribution of condoms
and needle-exchange programs for the prevention of transmissible
diseases.

Public health plays an important role in disease prevention efforts in both the developing world and in
developed countries through local health systems and non-governmental organizations.

Public health requires Geographic Information Systems (GIS) because risk, vulnerability and exposure
involve geographic aspects.[17]
Ethics
A dilemma in public health ethics is dealing with the conflict between individual rights and maximizing
right to health.[18]: 2 8  Public health is justified by consequentialist utilitarian ideas,[18]: 1 53  but is constrained
and critiqued by liberal,[18] deontological, principlist and libertarian philosophies[18]: 9 9, 9 5, 7 4, 1 23  Stephen
Holland argues that it can be easy to find a particular framework to justify any viewpoint on public health
issues, but that the correct approach is to find a framework that best describes a situation and see what it
implies about public health policy.[18]: 1 54 

The definition of health is vague and there are many conceptualizations. Public health practitioners
definition of health can different markedly from members of the public or clinicians. This can mean that
members of the public view the values behind public health interventions as alien which can cause
resentment amongst the public towards certain interventions.[18]: 2 30  Such vagueness can be a problem for
health promotion.[18]: 2 41  Critics have argued that public health tends to place more focus on individual
factors associated with health at the expense of factors operating at the population level.[14]: 9  

Historically, public health campaigns have been criticized as a form of "healthism", as moralistic in nature
rather than being focused on health. Medical doctors, Petr Shkrabanek and James McCormick wrote a
series of publications on this topic in the late 1980s and early 1990s criticizing the UK's the Health of The
Nation campaign. These publications exposed abuse of epidemiology and statistics by the public health
movement to support lifestyle interventions and screening programs.[19]: 8 5 [20]: 7   A combination of
inculcating a fear of ill-health and a strong notion of individual responsibility has been criticized as a form
of "health fascism" by a number of scholars, objectifying the individual with no considerations of emotional
or social factors.[21]: 8  [20]: 7  [22]: 8 1 

Priority areas

Original focal areas

When public health initiatives began to emerge in England in modern times (18th century onwards) there
were three core strands of public health which were all related to statecraft: Supply of clean water and
sanitation (for example London sewerage system); control of infectious diseases (including vaccination and
quarantine); an evolving infrastructure of various sciences, e.g. statistics, microbiology, epidemiology,
sciences of engineering.[10] Great Britain was a leader in the development of public health during that time
period out of necessity: Great Britain was the first modern urban nation (by 1851 more than half of the
population lived in settlements of more than 2000 people).[10] This led to a certain type of distress which
then led to public health initiatives.[10] Later that particular concern faded away.

Changing and differing focal areas

With the onset of the epidemiological transition and as the prevalence of infectious diseases decreased
through the 20th century, public health began to put more focus on chronic diseases such as cancer and
heart disease. Previous efforts in many developed countries had already led to dramatic reductions in the
infant mortality rate using preventive methods. In Britain, the infant mortality rate fell from over 15% in
1870 to 7% by 1930.[23]

A major public health concern in developing countries is poor maternal and child health, exacerbated by
malnutrition and poverty. The WHO reports that a lack of exclusive breastfeeding during the first six
months of life contributes to over a million avoidable child deaths each year.[24]
Public health surveillance has led to the identification and prioritization of many public health issues facing
the world today, including HIV/AIDS, diabetes, waterborne diseases, zoonotic diseases, and antibiotic
resistance leading to the reemergence of infectious diseases such as tuberculosis. Antibiotic resistance, also
known as drug resistance, was the theme of World Health Day 2011.

For example, the WHO reports that at least 220 million people worldwide have diabetes. Its incidence is
increasing rapidly, and it is projected that the number of diabetes deaths will double by 2030.[25] In a June
2010 editorial in the medical journal The Lancet, the authors opined that "The fact that type 2 diabetes, a
largely preventable disorder, has reached epidemic proportion is a public health humiliation."[26] The risk
of type 2 diabetes is closely linked with the growing problem of obesity. The WHO's latest estimates as of
June  2016 highlighted that globally approximately 1.9 billion adults were overweight in 2014, and 41
million children under the age of five were overweight in 2014.[27] Once considered a problem in high-
income countries, it is now on the rise in low-income countries, especially in urban settings.

Many public health programs are increasingly dedicating attention and resources to the issue of obesity,
with objectives to address the underlying causes including healthy diet and physical exercise. The National
Institute for Health and Care Research (NIHR) has published a review of research on what local authorities
can do to tackle obesity.[28] The review covers interventions in the food environment (what people buy and
eat), the built and natural environments, schools, and the community, as well as those focussing on active
travel, leisure services and public sports, weight management programmes, and system-wide approaches.

Current practice

Organizations

World Health Organization (WHO)

The World Health Organization (WHO) is a specialized agency of the United Nations responsible for
international public health.[29] The WHO Constitution, which establishes the agency's governing structure
and principles, states its main objective as "the attainment by all peoples of the highest possible level of
health".[30] The WHO's broad mandate includes advocating for universal healthcare, monitoring public
health risks, coordinating responses to health emergencies, and promoting human health and well-being.[31]
The WHO has played a leading role in several public health achievements, most notably the eradication of
smallpox, the near-eradication of polio, and the development of an Ebola vaccine. Its current priorities
include communicable diseases, particularly HIV/AIDS, Ebola, COVID-19, malaria and tuberculosis; non-
communicable diseases such as heart disease and cancer; healthy diet, nutrition, and food security;
occupational health; and substance abuse.

Others

Most countries have their own governmental public health agency, often called the ministry of health, with
responsibility for domestic health issues.

For example, in the United States, state and local health departments are on the front line of public health
initiatives. In addition to their national duties, the United States Public Health Service (PHS), led by the
Surgeon General of the United States Public Health Service, and the Centers for Disease Control and
Prevention, headquartered in Atlanta, are also involved with international health activities.[32]
Public health programs

Most governments recognize the importance of public health programs in reducing the incidence of disease,
disability, and the effects of aging and other physical and mental health conditions. However, public health
generally receives significantly less government funding compared with medicine.[33] Although the
collaboration of local health and government agencies is considered best practice to improve public health,
the pieces of evidence available to support this is limited.[34] Public health programs providing vaccinations
have made major progress in promoting health, including substantially reducing the occurrence of cholera
and polio and eradicating smallpox, diseases that have plagued humanity for thousands of years.[35]

The World Health Organization (WHO) identifies core functions of

public health programs including:[36]

providing leadership on matters critical to health and

engaging in partnerships where joint action is needed;
shaping a research agenda and stimulating the
generation, translation and dissemination of valuable
knowledge;
setting norms and standards and promoting and
monitoring their implementation;
Three former directors of the Global
articulating ethical and evidence-based policy options;
Smallpox Eradication Program
monitoring the health situation and assessing health reading the news that smallpox had
trends. been globally eradicated, 1980

In particular, public health surveillance programs can:[37]

serve as an early warning system for impending public health emergencies;

document the impact of an intervention, or track progress towards specified goals; and
monitor and clarify the epidemiology of health problems, allow priorities to be set, and inform
health policy and strategies.
diagnose, investigate, and monitor health problems and health hazards of the community

Behavior change

Many health problems are due to maladaptive personal behaviors. From an evolutionary psychology
perspective, over consumption of novel substances that are harmful is due to the activation of an evolved
reward system for substances such as drugs, tobacco, alcohol, refined salt, fat, and carbohydrates. New
technologies such as modern transportation also cause reduced physical activity. Research has found that
behavior is more effectively changed by taking evolutionary motivations into consideration instead of only
presenting information about health effects. The marketing industry has long known the importance of
associating products with high status and attractiveness to others. Films are increasingly being recognized
as a public health tool. In fact, film festivals and competitions have been established to specifically promote
films about health.[38] Conversely, it has been argued that emphasizing the harmful and undesirable effects
of tobacco smoking on other persons and imposing smoking bans in public places have been particularly
effective in reducing tobacco smoking.[39]

Applications in health care

As well as seeking to improve population health through the implementation of specific population-level
interventions, public health contributes to medical care by identifying and assessing population needs for
health care services, including:[40][41][42][43]

Assessing current services and evaluating whether they are meeting the objectives of the
health care system
Ascertaining requirements as expressed by health professionals, the public and other
stakeholders
Identifying the most appropriate interventions
Considering the effect on resources for proposed interventions and assessing their cost-
effectiveness
Supporting decision making in health care and planning health services including any
necessary changes.
Informing, educating, and empowering people about health issues

Conflicting aims

Some programs and policies associated with public health promotion and prevention can be controversial.
One such example is programs focusing on the prevention of HIV transmission through safe sex campaigns
and needle-exchange programs. Another is the control of tobacco smoking. Changing smoking behavior
requires long-term strategies, unlike the fight against communicable diseases, which usually takes a shorter
period for effects to be observed. Many nations have implemented major initiatives to cut smoking, such as
increased taxation and bans on smoking in some or all public places. Supporters argue by presenting
evidence that smoking is one of the major killers, and that therefore governments have a duty to reduce the
death rate, both through limiting passive (second-hand) smoking and by providing fewer opportunities for
people to smoke. Opponents say that this undermines individual freedom and personal responsibility, and
worry that the state may be encouraged to remove more and more choice in the name of better population
health overall.

Psychological research confirms this tension between concerns about public health and concerns about
personal liberty: (i) the best predictor of complying with public health recommendations such as hand-
washing, mask-wearing, and staying at home (except for essential activity) during the COVID-19
pandemic was people's perceived duties to prevent harm but (ii) the best predictor of flouting such public
health recommendations was valuing liberty more than equality.[44]

Simultaneously, while communicable diseases have historically ranged uppermost as a global health
priority, non-communicable diseases and the underlying behavior-related risk factors have been at the
bottom. This is changing, however, as illustrated by the United Nations hosting its first General Assembly
Special Summit on the issue of non-communicable diseases in September 2011.[45]

Global perspectives

Disparities in service and access

There is a significant disparity in access to health care and public health initiatives between developed
countries and developing countries, as well as within developing countries. In developing countries, public
health infrastructures are still forming. There may not be enough trained health workers, monetary
resources or, in some cases, sufficient knowledge to provide even a basic level of medical care and disease
prevention.[6][7] As a result, a large majority of disease and mortality in developing countries results from
and contributes to extreme poverty. For example, many African
governments spend less than US$10 per person per year on health
care, while, in the United States, the federal government spent
approximately US$4,500 per capita in 2000. However,
expenditures on health care should not be confused with spending
on public health. Public health measures may not generally be
considered "health care" in the strictest sense. For example,
mandating the use of seat belts in cars can save countless lives and
contribute to the health of a population, but typically money spent A village health worker in Zimbabwe
enforcing this rule would not count as money spent on health care. conducting a pediatric examination

Large parts of the world remained plagued by largely preventable

or treatable infectious diseases. In addition to this however, many
developing countries are also experiencing an epidemiological shift
and polarization in which populations are now experiencing more
of the effects of chronic diseases as life expectancy increases, the
poorer communities being heavily affected by both chronic and
infectious diseases.[7] Another major public health concern in the
developing world is poor maternal and child health, exacerbated by
malnutrition and poverty. The WHO reports that a lack of exclusive
breastfeeding during the first six months of life contributes to over a A community health worker in Korail
million avoidable child deaths each year.[24] Intermittent preventive Basti, a slum in Dhaka, Bangladesh
therapy aimed at treating and preventing malaria episodes among
pregnant women and young children is one public health measure
in endemic countries.

Since the 1980s, the growing field of population health has

broadened the focus of public health from individual behaviors and
risk factors to population-level issues such as inequality, poverty,
and education. Modern public health is often concerned with
addressing determinants of health across a population. There is a
recognition that health is affected by many factors including class,
race, income, educational status, region of residence, and social A malaria test in Kenya. Despite
relationships; these are known as "social determinants of health". being preventable and curable,
The upstream drivers such as environment, education, employment, malaria is a leading cause of death in
income, food security, housing, social inclusion and many others many developing nations.[46][47]
effect the distribution of health between and within populations and
are often shaped by policy.[48] A social gradient in health runs
through society. The poorest generally have the worst health, but even the middle classes will generally
have worse health outcomes than those of a higher social level.[49] The new public health advocates for
population-based policies that improve health in an equitable manner.

Health aid in developing countries

Health aid to developing countries is an important source of public health funding for many developing
countries.[51] Health aid to developing countries has shown a significant increase after World War II as
concerns over the spread of disease as a result of globalization increased and the HIV/AIDS epidemic in
sub-Saharan Africa surfaced.[52][53] From 1990 to 2010, total health aid from developed countries
increased from 5.5 billion to 26.87 billion with wealthy countries continuously donating billions of dollars
every year with the goal of improving population health.[53] Some efforts, however, receive a significantly
larger proportion of funds such as HIV which received an increase in funds of over $6 billion between
2000 and 2010 which was more than twice the increase seen in any
other sector during those years.[51] Health aid has seen an
expansion through multiple channels including private
philanthropy, non-governmental organizations, private foundations
such as the Bill & Melinda Gates Foundation, bilateral donors, and
multilateral donors such as the World Bank or UNICEF.[53] The
result has been a sharp rise in uncoordinated and fragmented
funding of an ever-increasing number of initiatives and projects. To
promote better strategic cooperation and coordination between A Cuban doctor performs an open air
partners, particularly among bilateral development agencies and operation in Guinea-Bissau. Cuba
funding organizations, the Swedish International Development sends more medical personnel to the
Cooperation Agency (Sida) spearheaded the establishment of developing world than all G8
ESSENCE,[54] an initiative to facilitate dialogue between countries combined.[50]
donors/funders, allowing them to identify synergies. ESSENCE
brings together a wide range of funding agencies to coordinate
funding efforts.

In 2009 health aid from the OECD amounted to $12.47 billion which amounted to 11.4% of its total
bilateral aid.[55] In 2009, Multilateral donors were found to spend 15.3% of their total aid on bettering
public healthcare.[55]

International health aid debates

Debates exist questioning the efficacy of international health aid. Supporters of aid claim that health aid
from wealthy countries is necessary in order for developing countries to escape the poverty trap. Opponents
of health aid claim that international health aid actually disrupts developing countries' course of
development, causes dependence on aid, and in many cases the aid fails to reach its recipients.[51] For
example, recently, health aid was funneled towards initiatives such as financing new technologies like
antiretroviral medication, insecticide-treated mosquito nets, and new vaccines. The positive impacts of these
initiatives can be seen in the eradication of smallpox and polio; however, critics claim that misuse or
misplacement of funds may cause many of these efforts to never come into achievement.[51]

Economic modeling based on the Institute for Health Metrics and Evaluation and the World Health
Organization has shown a link between international health aid in developing countries and a reduction in
adult mortality rates.[53] However, a 2014–2016 study suggests that a potential confounding variable for
this outcome is the possibility that aid was directed at countries once they were already on track for
improvement.[51] That same study, however, also suggests that 1 billion dollars in health aid was associated
with 364,000 fewer deaths occurring between ages 0 and 5 in 2011.[51]

Sustainable development goals for 2030

To address current and future challenges in addressing health issues in the world, the United Nations have
developed the Sustainable Development Goals to be completed by 2030.[56] These goals in their entirety
encompass the entire spectrum of development across nations, however Goals 1–6 directly address health
disparities, primarily in developing countries.[57] These six goals address key issues in global public health,
poverty, hunger and food security, health, education, gender equality and women's empowerment, and
water and sanitation.[57] Public health officials can use these goals to set their own agenda and plan for
smaller scale initiatives for their organizations. These goals are designed to lessen the burden of disease and
inequality faced by developing countries and lead to a healthier future. The links between the various
sustainable development goals and public health are numerous and well established.[58][59]
History

Until the 18th century

From the beginnings of human civilization,

communities promoted health and fought disease at the
population level.[8][9] Definitions of health as well as
methods to pursue it differed according to the medical,
religious and natural-philosophical ideas groups held,
the resources they had, and the changing
circumstances in which they lived. Yet few early
societies displayed the hygienic stagnation or even
apathy often attributed to them.[60][61][62] The latter
reputation is mainly based on the absence of present- Mass burials during the second plague pandemic
day bioindicators, especially immunological and (a.k.a. the Black Death; 1346–1353) intensified
statistical tools developed in light of the germ theory of urban responses to disaster on the basis of earlier
disease transmission. practices. Miniature from "The Chronicles of Gilles
Li Muisis" (1272–1352). Bibliothèque royale de
Public health was born neither in Europe nor as a Belgique, MS 13076–77, f. 24v.
response to the Industrial Revolution. Preventive
health interventions are attested almost anywhere
historical communities have left their mark. In Southeast Asia, for instance, Ayurvedic medicine and
subsequently Buddhism fostered occupational, dietary and sexual regimens that promised balanced bodies,
lives and communities, a notion strongly present in Traditional Chinese Medicine as well.[63][64] Among
the Mayans, Aztecs and other early civilizations in the Americas, population centers pursued hygienic
programs, including by holding medicinal herbal markets.[65] And among Aboriginal Australians,
techniques for preserving and protecting water and food sources, micro-zoning to reduce pollution and fire
risks, and screens to protect people against flies were common, even in temporary camps.[66][67]

Western European, Byzantine and Islamicate civilizations, which

generally adopted a Hippocratic, Galenic or humoral medical
system, fostered preventive programs as well.[68][69][70][71] These
were developed on the basis of evaluating the quality of local
climates, including topography, wind conditions and exposure to
the sun, and the properties and availability of water and food, for
both humans and nonhuman animals. Diverse authors of medical,
architectural, engineering and military manuals explained how to
apply such theories to groups of different origins and under
different circumstances.[72][73][74] This was crucial, since under A depiction of Aztec smallpox
Galenism bodily constitutions were thought to be heavily shaped victims
by their material environments, so their balance required specific
regimens as they traveled during different seasons and between
climate zones.[75][76][77]

In complex, pre-industrialized societies, interventions designed to reduce health risks could be the initiative
of different stakeholders. For instance, in Greek and Roman antiquity, army generals learned to provide for
soldiers' wellbeing, including off the battlefield, where most combatants died prior to the twentieth
century.[78][79] In Christian monasteries across the Eastern Mediterranean and western Europe since at least
the fifth century CE, monks and nuns pursued strict but balanced regimens, including nutritious diets,
developed explicitly to extend their lives.[80] And royal, princely and papal courts, which were often
mobile as well, likewise adapted their behavior to suit environmental conditions in the sites they occupied.
They could also choose sites they considered salubrious for their members and sometimes had them
modified.[81]

In cities, residents and rulers developed measures to benefit the general population, which faced a broad
array of recognized health risks. These provide some of the most sustained evidence for preventive
measures in earlier civilizations. In numerous sites the upkeep of infrastructures, including roads, canals and
marketplaces, as well as zoning policies, were introduced explicitly to preserve residents' health.[82]
Officials such as the muhtasib in the Middle East and the Road master in Italy, fought the combined threats
of pollution through sin, ocular intromission and miasma.[83][84][85][86] Craft guilds were important agents
of waste disposal and promoted harm reduction through honesty and labor safety among their members.
Medical practitioners, including public physicians,[87] collaborated with urban governments in predicting
and preparing for calamities and identifying and isolating people perceived as lepers, a disease with strong
moral connotations.[88][89] Neighborhoods were also active in safeguarding local people's health, by
monitoring at-risk sites near them and taking appropriate social and legal action against artisanal polluters
and neglectful owners of animals. Religious institutions, individuals and charitable organizations in both
Islam and Christianity likewise promoted moral and physical wellbeing by endowing urban amenities such
as wells, fountains, schools and bridges, also in the service of pilgrims.[90][91] In western Europe and
Byzantium, religious processions commonly took place, which purported to act as both preventive and
curative measures for the entire community.[92]

Urban residents and other groups also developed preventive measures in response to calamities such as
war, famine, floods and widespread disease.[93][94][95][96] During and after the Black Death (1346–53), for
instance, inhabitants of the Eastern Mediterranean and Western Europe reacted to massive population
decline in part on the basis of existing medical theories and protocols, for instance concerning meat
consumption and burial, and in part by developing new ones.[97][98][99] The latter included the
establishment of quarantine facilities and health boards, some of which eventually became regular urban
(and later national) offices.[100][101] Subsequent measures for protecting cities and their regions included
issuing health passports for travelers, deploying guards to create sanitary cordons for protecting local
inhabitants, and gathering morbidity and mortality statistics.[102][103][104] Such measures relied in turn on
better transportation and communication networks, through which news on human and animal disease was
efficiently spread.

After the 18th century

With the onset of the Industrial Revolution, living standards amongst the working population began to
worsen, with cramped and unsanitary urban conditions. In the first four decades of the 19th century alone,
London's population doubled and even greater growth rates were recorded in the new industrial towns,
such as Leeds and Manchester. This rapid urbanization exacerbated the spread of disease in the large
conurbations that built up around the workhouses and factories. These settlements were cramped and
primitive with no organized sanitation. Disease was inevitable and its incubation in these areas was
encouraged by the poor lifestyle of the inhabitants. Unavailable housing led to the rapid growth of slums
and the per capita death rate began to rise alarmingly, almost doubling in Birmingham and Liverpool.
Thomas Malthus warned of the dangers of overpopulation in 1798. His ideas, as well as those of Jeremy
Bentham, became very influential in government circles in the early years of the 19th century.[105] The
latter part of the century brought the establishment of the basic pattern of improvements in public health
over the next two centuries: a social evil was identified, private philanthropists brought attention to it, and
changing public opinion led to government action.[105] The 18th century saw rapid growth in voluntary
hospitals in England.[106]
The practice of vaccination began in the 1800s, following the pioneering work of Edward Jenner in treating
smallpox. James Lind's discovery of the causes of scurvy amongst sailors and its mitigation via the
introduction of fruit on lengthy voyages was published in 1754 and led to the adoption of this idea by the
Royal Navy.[107] Efforts were also made to promulgate health matters to the broader public; in 1752 the
British physician Sir John Pringle published Observations on the Diseases of the Army in Camp and
Garrison, in which he advocated for the importance of adequate ventilation in the military barracks and the
provision of latrines for the soldiers.[108]

Public health legislation in England

The first attempts at sanitary reform and the establishment of public

health institutions were made in the 1840s. Thomas Southwood Smith,
physician at the London Fever Hospital, began to write papers on the
importance of public health, and was one of the first physicians
brought in to give evidence before the Poor Law Commission in the
1830s, along with Neil Arnott and James Phillips Kay.[109] Smith
advised the government on the importance of quarantine and sanitary
improvement for limiting the spread of infectious diseases such as
cholera and yellow fever.[110][111]

The Poor Law Commission reported in 1838 that "the expenditures

necessary to the adoption and maintenance of measures of prevention
would ultimately amount to less than the cost of the disease now
constantly engendered". It recommended the implementation of large
scale government engineering projects to alleviate the conditions that Sir Edwin Chadwick was a pivotal
[105] influence on the early public
allowed for the propagation of disease. The Health of Towns
health campaign.
Association was formed at Exeter Hall London on 11 December 1844,
and vigorously campaigned for the development of public health in the
United Kingdom.[112] Its formation followed the 1843 establishment
of the Health of Towns Commission, chaired by Sir Edwin Chadwick, which produced a series of reports
on poor and insanitary conditions in British cities.[112]

These national and local movements led to the Public Health Act, finally passed in 1848. It aimed to
improve the sanitary condition of towns and populous places in England and Wales by placing the supply
of water, sewerage, drainage, cleansing and paving under a single local body with the General Board of
Health as a central authority. The Act was passed by the Liberal government of Lord John Russell, in
response to the urging of Edwin Chadwick. Chadwick's seminal report on The Sanitary Condition of the
Labouring Population was published in 1842[113] and was followed up with a supplementary report a year
later.[114] During this time, James Newlands (appointed following the passing of the 1846 Liverpool
Sanatory Act championed by the Borough of Liverpool Health of Towns Committee) designed the world's
first integrated sewerage system, in Liverpool (1848-1869), with Joseph Bazalgette later creating London's
sewerage system (1858-1875).

The Vaccination Act 1853 introduced compulsory smallpox vaccination in England and Wales.[115] By
1871 legislation required a comprehensive system of registration run by appointed vaccination officers.[116]

Further interventions were made by a series of subsequent Public Health Acts, notably the 1875 Act.
Reforms included the building of sewers, the regular collection of garbage followed by incineration or
disposal in a landfill, the provision of clean water and the draining of standing water to prevent the breeding
of mosquitoes.
The Infectious Disease (Notification) Act 1889 mandated the reporting of infectious diseases to the local
sanitary authority, which could then pursue measures such as the removal of the patient to hospital and the
disinfection of homes and properties.[117]

Public health legislation in other countries

In the United States, the first public health organization based on a state health department and local boards
of health was founded in New York City in 1866.[118]

In Germany during The Weimar Republic the country faced many public health catastrophes. The Nazi
Party formed with a goal of modernizing health care with The Volksgesundheit, German for public health
folk; this modernization was based on the growing field of eugenics and measures prioritizing group health
over any care for the health of individuals. The end of World War 2 led to the Nuremberg Code, a set of
research ethics concerning human experimentation.[119]

Epidemiology

The science of epidemiology was founded by John Snow's

identification of a polluted public water well as the source of an
1854 cholera outbreak in London. Snow believed in the germ
theory of disease as opposed to the prevailing miasma theory. By
talking to local residents (with the help of Reverend Henry
Whitehead), he identified the source of the outbreak as the public
water pump on Broad Street (now Broadwick Street). Although
Snow's chemical and microscope examination of a water sample
from the Broad Street pump did not conclusively prove its danger,
his studies of the pattern of the disease were convincing enough to
persuade the local council to close the well pump by removing its
Early epidemiologist John Snow
handle.[120]
mapped clusters of cholera cases in
London
Snow later used a dot map to illustrate the cluster of cholera cases
around the pump. He also used statistics to illustrate the connection
between the quality of the water source and cholera cases. He
showed that the Southwark and Vauxhall Waterworks Company was taking water from sewage-polluted
sections of the Thames and delivering the water to homes, leading to an increased incidence of cholera.
Snow's study was a major event in the history of public health and geography. It is regarded as the
founding event of the science of epidemiology.[121][122]

Control of infectious diseases

With the pioneering work in bacteriology of French chemist Louis Pasteur and German scientist Robert
Koch, methods for isolating the bacteria responsible for a given disease and vaccines for remedy were
developed at the turn of the 20th century. British physician Ronald Ross identified the mosquito as the
carrier of malaria and laid the foundations for combating the disease.[123] Joseph Lister revolutionized
surgery by the introduction of antiseptic surgery to eliminate infection. French epidemiologist Paul-Louis
Simond proved that plague was carried by fleas on the back of rats,[124] and Cuban scientist Carlos J.
Finlay and U.S. Americans Walter Reed and James Carroll demonstrated that mosquitoes carry the virus
responsible for yellow fever.[125][126] Brazilian scientist Carlos Chagas identified a tropical disease and its
vector.[127]
Society and culture

Education and training

Education and training of public health professionals is available

throughout the world in Schools of Public Health, Medical Schools,
Veterinary Schools, Schools of Nursing, and Schools of Public
Affairs. The training typically requires a university degree with a focus Paul-Louis Simond injecting a
on core disciplines of biostatistics, epidemiology, health services plague vaccine in Karachi, 1898
administration, health policy, health education, behavioral science,
gender issues, sexual and reproductive health, public health nutrition,
and occupational and environmental health.[128][129]

In the global context, the field of public health education has evolved enormously in recent decades,
supported by institutions such as the World Health Organization and the World Bank, among others.
Operational structures are formulated by strategic principles, with educational and career pathways guided
by competency frameworks, all requiring modulation according to local, national and global realities. It is
critically important for the health of populations that nations assess their public health human resource
needs and develop their ability to deliver this capacity, and not depend on other countries to supply it.[130]

Schools of public health: a US perspective

In the United States, the Welch-Rose Report of 1915[131] has been viewed as the basis for the critical
movement in the history of the institutional schism between public health and medicine because it led to the
establishment of schools of public health supported by the Rockefeller Foundation.[132] The report was
authored by William Welch, founding dean of the Johns Hopkins Bloomberg School of Public Health, and
Wickliffe Rose of the Rockefeller Foundation. The report focused more on research than practical
education.[132][133] Some have blamed the Rockefeller Foundation's 1916 decision to support the
establishment of schools of public health for creating the schism between public health and medicine and
legitimizing the rift between medicine's laboratory investigation of the mechanisms of disease and public
health's nonclinical concern with environmental and social influences on health and wellness.[132][134]

Even though schools of public health had already been established in Canada, Europe and North Africa,
the United States had still maintained the traditional system of housing faculties of public health within their
medical institutions. A $25,000 donation from businessman Samuel Zemurray instituted the School of
Public Health and Tropical Medicine at Tulane University in 1912 conferring its first doctor of public health
degree in 1914.[135][136] The Yale School of Public Health was founded by Charles-Edward Amory
Winslow in 1915.[137] The Johns Hopkins School of Hygiene and Public Health was founded in 1916 and
became an independent, degree-granting institution for research and training in public health, and the
largest public health training facility in the United States.[138][139][140] By 1922, schools of public health
were established at Columbia and Harvard on the Hopkins model. By 1999 there were twenty nine schools
of public health in the US, enrolling around fifteen thousand students.[128][132]

Over the years, the types of students and training provided have also changed. In the beginning, students
who enrolled in public health schools typically had already obtained a medical degree; public health school
training was largely a second degree for medical professionals. However, in 1978, 69% of American
students enrolled in public health schools had only a bachelor's degree.[128]

Degrees in public health

Schools of public health offer a variety of degrees generally fall
into two categories: professional or academic.[142] The two major
postgraduate degrees are the Master of Public Health (MPH) or the
Master of Science in Public Health (MSPH). Doctoral studies in
this field include Doctor of Public Health (DrPH) and Doctor of
Philosophy (PhD) in a subspecialty of greater Public Health
disciplines. DrPH is regarded as a professional degree and PhD as
more of an academic degree.
The London School of Hygiene &
Professional degrees are oriented towards practice in public health Tropical Medicine is the oldest
settings. The Master of Public Health, Doctor of Public Health, school of public health in the
Doctor of Health Science (DHSc/DHS) and the Master of Health Anglosphere[141]
Care Administration are examples of degrees which are geared
towards people who want careers as practitioners of public health
in health departments, managed care and community-based organizations, hospitals and consulting firms,
among others. Master of Public Health degrees broadly fall into two categories, those that put more
emphasis on an understanding of epidemiology and statistics as the scientific basis of public health practice
and those that include a more wide range of methodologies. A Master of Science of Public Health is similar
to an MPH but is considered an academic degree (as opposed to a professional degree) and places more
emphasis on scientific methods and research. The same distinction can be made between the DrPH and the
DHSc. The DrPH is considered a professional degree and the DHSc is an academic degree.

Academic degrees are more oriented towards those with interests in the scientific basis of public health and
preventive medicine who wish to pursue careers in research, university teaching in graduate programs,
policy analysis and development, and other high-level public health positions. Examples of academic
degrees are the Master of Science, Doctor of Philosophy, Doctor of Science (ScD), and Doctor of Health
Science (DHSc). The doctoral programs are distinct from the MPH and other professional programs by the
addition of advanced coursework and the nature and scope of a dissertation research project.

Notable people
John Graunt (1620–1674) was a British citizen scientist who laid the foundations for
epidemiology.[143]
Edward Jenner (1749–1823) created the smallpox vaccine, the first vaccine in the world. He
is often known as "the father of immunology."
Benjamin Waterhouse (1753–1846) introduced the smallpox vaccine in the United States.
Lemuel Shattuck (1793–1859) has been described as an "architect" and "prophet" of
American public health[144]
Sir Joseph William Bazalgette (1819–1891) created a sewer network for central London in
response to the Great Stink of 1858. This proved instrumental in relieving the city from
cholera epidemics.[145]
Louis Pasteur (1822–1895) conducted research that laid the foundation for our
understanding of the causes and preventions of diseases.
Charles V. Chapin (1856–1941) public health advocate and researcher credited with
planting "the roots of quality in public health" in the United States[146]
Sara Josephine Baker (1873–1945) was an "instrumental force in child and maternal
health"[147]
Nora Wattie (1900–1994) led the development of public health services and sanitation, and
education in improving women and child health in the poorest slums of Glasgow, for which
she received the OBE.[148]
 Jonas Salk (1914–1995) developed one of the first polio vaccines and campaigned
vigorously for mandatory vaccinations.

Country examples

Canada

In Canada, the Public Health Agency of Canada is the national agency responsible for public health,
emergency preparedness and response, and infectious and chronic disease control and prevention.[149]

Cuba

Since the 1959 Cuban Revolution the Cuban government has devoted extensive resources to the
improvement of health conditions for its entire population via universal access to health care. Infant
mortality has plummeted.[150] Cuban medical internationalism as a policy has seen the Cuban government
sent doctors as a form of aid and export to countries in need in Latin America, especially Venezuela, as well
as Oceania and Africa countries.

Colombia and Bolivia

Public health was important elsewhere in Latin America in consolidating state power and integrating
marginalized populations into the nation-state. In Colombia, public health was a means for creating and
implementing ideas of citizenship.[151] In Bolivia, a similar push came after their 1952 revolution.[152]

Ghana

Though curable and preventive, malaria remains a major public health issue and is the third leading cause
of death in Ghana.[153] In the absence of a vaccine, mosquito control, or access to anti-malaria medication,
public health methods become the main strategy for reducing the prevalence and severity of malaria.[154]
These methods include reducing breeding sites, screening doors and windows, insecticide sprays, prompt
treatment following infection, and usage of insecticide treated mosquito nets.[154] Distribution and sale of
insecticide-treated mosquito nets is a common, cost-effective anti-malaria public health intervention;
however, barriers to use exist including cost, household and family organization, access to resources, and
social and behavioral determinants which have not only been shown to affect malaria prevalence rates but
also mosquito net use.[155][154]

France
The French Third Republic followed well behind Bismarckian Germany, as well as Great Britain, in
developing the welfare state including public health. Tuberculosis was the most dreaded disease of the day,
especially striking young people in their 20s. Germany set up vigorous measures of public hygiene and
public sanatoria, but France let private physicians handle the problem, which left it with a much higher
death rate.[156] The French medical profession jealously guarded its prerogatives, and public health activists
were not as well organized or as influential as in Germany, Britain or the United States.[157][158] For
example, there was a long battle over a public health law which began in the 1880s as a campaign to
reorganize the nation's health services, to require the registration of infectious diseases, to mandate
quarantines, and to improve the deficient health and housing legislation of 1850. However the reformers
met opposition from bureaucrats, politicians, and physicians. Because it was so threatening to so many
interests, the proposal was debated and postponed for 20 years
before becoming law in 1902. Success finally came when the
government realized that contagious diseases had a national
security impact in weakening military recruits, and keeping the
population growth rate well below Germany's.[159]

Mexico

Public health issues were important for the Spanish Empire during
the colonial era. Epidemic disease was the main factor in the
decline of indigenous populations in the era immediately following
the sixteenth-century conquest era and was a problem during the
colonial era. The Spanish crown took steps in eighteenth-century
Mexico to bring in regulations to make populations healthier.[160]
In the late nineteenth century, Mexico was in the process of
modernization, and public health issues were again tackled from a
scientific point of view.[161][162][163] As in the U.S., food safety
became a public health issue, particularly focusing on meat Ghanaian children receive
slaughterhouses and meatpacking.[164] insecticide-treated bed nets to
prevent exposure to malaria
Even during the Mexican Revolution (1910–20), public health was transmitting mosquitos
an important concern, with a text on hygiene published in
1916.[165] During the Mexican Revolution, feminist and trained
nurse Elena Arizmendi Mejia founded the Neutral White Cross, treating wounded soldiers no matter for
what faction they fought. In the post-revolutionary period after 1920, improved public health was a
revolutionary goal of the Mexican government.[166][167] The Mexican state promoted the health of the
Mexican population, with most resources going to cities.[168][169]

United States

The United States Public Health Service (USPHS or PHS) is a

collection of agencies of the Department of Health and Human
Services concerned with public health, containing nine out of the
department's twelve operating divisions. The Assistant Secretary
for Health oversees the PHS. The Public Health Service
Commissioned Corps (PHSCC) is the federal uniformed service of
the PHS, and is one of the eight uniformed services of the United
States.

PHS had its origins in the system of marine hospitals that originated
in 1798. In 1871 these were consolidated into the Marine Hospital
Service, and shortly afterwards the position of Surgeon General
and the PHSCC were established. As the system's scope grew to Logo of the United States
include quarantine authority and research, it was renamed the Public Health Service
Public Health Service in 1912.

The United States lacks a coherent system for the governmental funding of public health, relying on a
variety of agencies and programs at the federal, state and local levels.[170]
Between 1960 and 2001, public
health spending in the United States tended to grow,
based on increasing expenditures by state and local
government, which made up 80-90% of
total public health spending. Spending in support of public health
in the United States peaked in 2002 and declined in the following decade.[171] State cuts to public health
funding during the Great Recession of 2007-2008 were not restored in subsequent years.[172]
As of 2012, a
panel for the U.S. Institute of Medicine panel warned that the United States spends disproportionately far
more on clinical care than it does on public health, neglecting "population-based activities that offer
efficient and effective approaches to improving the nation's health."[173][171] As of 2018, about 3% of
government health spending was directed to public health and prevention.[35][174][175] This situation has
been described as an "uneven patchwork"[176] and "chronic underfunding".[177][178][179][180]
The
COVID-19 pandemic has been seen as drawing attention to problems in the public health system in the
United States and to a lack of understanding of public health and its important role as a common good.[35]

See also
Effects of climate change on human health
European Public Health Association (EUPHA) is an umbrella organization for public health
associations and institutes in Europe
List of national public health agencies

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