Overview of the History of Public Healthand

Perception of Health and Disease in High and Middle Income Countries

Prof. Dr. med. Frank P. SchelpProfessor Emeritus

Charité-University Medicine Berlin GermanyVisiting Professor Faculty of Public Health

Khon Kaen University, Thailand

Definition of Public Health

• The approach to medicine that is concerned with the health of the community as a whole– Source: MedicineNet.com Webster’s New

World Medical Dictionary

Main Public Health Activities• Prevention, promotion and protection

– Communicable disease control– Selected health promotion– Organized immunization– Environmental health– Food standards and food safety– Screening programs– Health economy– Manpower improvements and supervision– Research

Dichotomy:Curative Medicine and Public Health

Curative medicine Patient oriented; Individual is only interested to

seek help from health delivery service in case of sickness;

Patient and medical personnel focus on the disease of patient;

Medical personnel will gain patient’s gratitude and credit if she or he succeeds in curing the patient.

Public Health Population oriented medicine; Prevents the occurrence of

disease; Measures implemented are

often not very popular; Interfere with lifestyle patterns:

Smoking, alcohol drinking, eating, sexual behavior etc.;

Statistical reasoning is not understood neither by curative sector nor by general public.

Historical Chapters of Public Health• Prehistoric times

– Sanitation, Housing• Greco-Roman World• Middle Ages

500 – 1500 • Mercantilism, Absolutism

1500 – 1750• Enlightenment and Revolution

1750 – 1830• Industrialism and the Sanitary Movements

1830-1875• Bacteriological Era

1875 -

Western medicine trace it’s origin back to…..

the ancient Greek healer Hippocrates (460 to 377 B.C.)

he wrote a paper on air, water and places.

Air, water, places …..whoever wishes

to investigate medicine properly should proceed thus:

Conflicting developments from ancient times to preventive medicine and public

health • Hippocrates reaching was more or less forgotten• For centuries academic teaching was based on books written by

the roman healer GALEN

Christian believes disregarded the body and did not emphasize personal hygiene, sometimes even declaring cleaning of the body as sinful behavior

Believe of medical establishment that occurrence of disease was due to sinful behavior

• For many centuries academic medicine was not able to contribute to the prevention of infectious diseases

• Local authorities applied measures to prevent the spread of diseases sometimes with very drastic measures

• Beginning of the 17th century the MIASMA theory was developed

Examples of Major Plaque EpidemicsCentury No. of

major epidemics

Local examplesYear

Area Deaths

16. 16 156215-1577

NürnbergVenice

+9.000 from 40.000+70.000

17. 16 1601-160316301665-16661679

MoscowMilanLondonVienna

+127.000+140.000 from 200.000+ 69.000+ 77.000

18. 11 1720-1722

1770-1772

Toulon Rural areaMoscow

+ 87.000 from 247.000

+ 52.00 from a total of 230.000 inhabitants 170.000 fled, and 57.000 remained in the city

• Concept of transmissible diseases was already established especially in the context of the severe epidemics.

• Urban authorities developed methods against the spread of diseases such as quarantine which was introduced by Venice during the 14th century.

• At that time important medical centre such as in Padua (Italy) contributed to the fight against epidemics.

• First description of some infectious diseases recognized as being transmissible.

Concept of transmissible diseases

Girolamo Cardano (1501 – 1576)

• Distinguished epidemic louse-born typhus from measles.

• Wrote a book about his knowledge about typhus “De Mado Recentiorum Medicorum Usu Libellus”)

Girolamo Fracastoro (1483 to 1553) Described Typhus even more accurately; Wrote a poem about Syphilis in naming the disease

after a figure in the Greek mythology; Wrote the book “De contagione et contagiosis morbis

eorumque curatione (1546) (“that the seeds of diseases are minute animals able to reproduce their kind”);

The book can be considered to be the foundation of modern epidemiology

Public health in the second half of 17th century

• In the middle of Europe at that time wars, epidemics, famines and impoverishment related to the pre-industrial production methods.

• Institution of public (city) medics inaugurated who supervised drug sellers, midwives, surgeons and other medical professions.

• Start of taking records about birth, deaths, illnesses and epidemics as well as climatic conditions. – Beginning of a scientific epidemiology.

• One of the after-effects of the French revolution (1789 – 1799) was the increasing interest in public health and preventive medicine.

• It was now possible for energetic and ambitious individuals belonging to the lower classes to influence matters of public health.

• One of such individuals was Pierre Charles Alexander Louis, a Frenchman born in 1787 - stressed the necessity to recognize and acknowledge laws of life sciences also in medicine.

• He recognized that blood letting, which was very common at that time, was in most cases of no advantage to the patients, instead, very often brought about a further deterioration in the health status of the patients and sometimes death.

• He supported statistical method as the method of choice also for epidemiology.

The theory of a contagion vivum was widely rejected because people became more concerned with finding scientific proof of a cause-effect relationship;

Although even after the microscope was invented it was not possible to detect, for instance, the agent for cholera;

The controversy between miasma and the contagious vivum theory remained up to the time ofPasteur, who may be recognised as the founder of

modern bacteriology, Henle, who saw bacteria and suggested that they

are causing diseases as well as Koch who discovered the agents for tuberculosis

in 1882 and for cholera in 1883.

Development of Modern Public Health

Johann Peter Frank – wrote a “System of Medical Police (1779-1827).

He formulated and presented a coherent and detailed health policy which had considerable impact both within Germany, Hungary, Italy, Denmark and Russia

Sanitary movements in the first half of the 19th century in England

Edwin Chadwick (1800-1890) – fight for social justice for the poor of the lower classes (Sanitary conditions of the Labouring Classes of Great Britain

John Simon (1816- 1904) demanded improvement of hygienic measures

William Farr (1807 – 1883) – developed modern statistical methods and the epidemiological way of thinking

John Snow (1813 – 1858)He investigated the cholera epidemic of 1853

to 1854He also was an anesthesiologist and

administered chloroform to Queen Victoria for the delivery of her youngest son (Leopold) and for youngest daughter (Beatrice).

Examples of Discoveries in the Bacteriological Area

1880 Leprosy Hansen

1880 Malaria Laveran

1882 Tuberculosis Koch

1883 Cholera Koch

1884 Tetanus Nicolaier

1894 Plague Yersin, Kitasato

1898 Dysentery bacillus

Shiga

‘Primary Care’ and ‘Primary Health Care’

• Primary care – Health services by providers who act as the principal point

of consultation for patients within a health care system• Primary care physician• General practitioner • Family physician• Pharmacist• Nurse practitioner• Nurse• Clinical officer

– Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care

• Primary health care– Alma-Ata Declaration

Welfare system• 31% of GDP spend for entitlement

programs of the government sector• 41% of the voting age adult population

lives primarily on government transfers:

– State pensions– Full scale public stipends– Unemployment benefits– Disability benefits– Social assistance

Expenditure for Health(234,2 billion EUR 2002)

Statutory hlth. insur.56,8%

Employers7,7%

Government7,9%

Private12,2%

Priv.hlth.insur8,2%

Nursing care insurance7,2%

Expenditure According to Services (2000)

Treatment26,5%

Research4,5%Administration

5,3%

Nursing22,2%

Medicine etc26,0%

Accomodation6,5%

Prev.. Rehabilitation 8,9%

Preventive Health CareExample from Southern Italy

Manuti B et al.: BMC Public Health 2010, 10:350

Screening health habits

Alcohol

Drug abuse

Smoking

Sexual activities

Cancer screening

Cervical cancer

Mammography (breast cancer)

Colorectal cancer

0 10 20 30 40 50 60Percent

% of Eligible

Perception about health in high income countries

• Feeling of being responsible for its own health underdeveloped

• Unhealthy behavior not challenged• Attempts to improve health after falling sick

underdeveloped• Individualistic and favoring a rather liberal stance• Neglecting individual risk factors

– Favoring the ‘stress concept’ – ‘Obesity is not a disease’– Cholesterol and lipid fractions are no risk factors’– Favoring research in genetics and disease– Overestimating genetic influence on the occurrence of

disease

Perceptions towards health and disease in rural Thailand

• Thai health policy – ‘The individual as well has to take responsibility for her or his health’

• Usually motivation and good co-operation in primary and secondary prevention

• High level of tolerating insufficiencies in the health delivery system

• Knowledge in major risk factors of common diseases quite good

• Socio-economic gab between health officials and ordinary villagers

• Communication difficulties between medical doctors or other health officials and ordinary patients

Present status of heath delivery system in Thailand(Private view)

• Acceptable success of Primary Health Care efforts controlling infectious diseases

• Acceptable success in family planning• Acceptable success in assuring access to

curative medicine with continuous financial constrains for providers

• Continues reconstruction of health delivery system with unclear responsibilities for players

• Conflict of ‘rural doctors’ with MoPH

Intrusion into privacy for the sake of prevention

• Abstract of MPH thesis:• …….the control of alcohol consumption in

the community made use of restricting alcohol distribution and intervention on household level……

Tendency to please the health official in answering to interrogations

Answers of approx. 4700 T2DM patients from all over Thailand about compliance and their HbA1c values

Srivanichakorn et al. Primary Care Diabetes (2011) doi: 10.1016/jcd.2011.02.005

89.9

79.3

60.6

81.8

62.3

Take medicine as advised

Visiting doctor according to appointment

Food intake adjusted to having DM

Taking correct care of yourself

HbA1c >7%

0 20 40 60 80 100 120Percent

Conclusion• The history of public health is based on

developments in Europe• Within the Thai context the aspect of ‘Thai wisdom’

is advocated – traditional medicine • Involvement of medical doctors in public health in

Thailand and in highly income countries are limited but even more in the latter ones.

• Primary and active secondary prevention and public health initiatives can be initiated in communities in Thailand

• The perception about health and disease in both instances are significantly different