Research note: the rise of public health

Arwen Schepers and Daniel Gallardo Albarrán. Show Author details

Unlike today, governments did not care that much about public health in the past. Authorities acted in their own best interest and this meant that public health policies were often based on low-cost principles or what was in line with their political views. This started to change more notably during the 19^th century, but why? To answer this question, this post looks at the development of public health in Western Europe (United Kingdom, France and Germany) and focuses on two types of factors (scientific and social) that greatly influenced politics.

The beginnings of the germ theory of disease

Medical scientific breakthroughs of the 19^th century increased the understanding of disease causation and led to the development of the germ theory of disease. The work of Louis Pasteur in the 1860s played an important role since, although he was not the first one linking germs and disease, his discoveries were very influential in the medical community. This prompted a change in household behaviour, whose members had a villain to point to when caring for their health. For charities and the sanitation movement, Pasteur’s germ theory of disease was an important milestone. In the past they had been making recommendations without a medical basis, which sometimes caused more negative results than positive. 

Despite a growing understanding of disease causation, social change was not an automatic process as there were frequent setbacks. Businessmen at the time, with political power, did not see the value of improving sanitation. The upper classes could protect themselves against the worst dangers of poor hygiene, so they would rather invest their money in ways that fostered their own interests. In Britain, the government refused to take an authoritative stand at first, which led to lively debates about the benefits of sanitation, while public investment slowed down. Only later in the second half of the 19^th century did the British government start putting in increasing amounts of money to provide clean water supply and efficient sewerage. 

In Germany, the leading medical scientist was Robert Koch, whose ideas improved the bacteriological analysis of water and led to discovery of various pathogens, such as tuberculosis or cholera. The German government welcomed this bacteriological approach because it was cheaper than improving overall social conditions. Also, it did not call the public order in question like the hygienists did and it allowed for centralized organisation and universal solutions, considering that the pathogens are the same.

It may be important to highlight that not all of Koch’s ideas, or their interpretation, led to increasing public health awareness. While this approach was useful to the German government, Koch was accused of being too monocausal in his deduction. With his theory, he ignored the social circumstances of individuals that can be critical to their health, such as housing and nutrition. In addition, the bacteriological approach was used by the German Empire as a political tool to interfere in other states’ affairs, that Bavaria and the Hanseatic city Hamburg firmly resisted (for some time).

However, all in all, scientific discoveries provided better arguments to sanitarians and politicians interested in improving the health condition of urban citizens.

Social movements

This section argues that social movements advocating for public health increasingly gained power to influence local and national governments. This began when a number of prominent European thinkers, shifted the perspective from individual characteristics to environmental conditions, when considering the determinants of health. 

In England, a well-known social reformer, Edwin Chadwick, was asked by the British government to write a report on the sanitary state of the British labouring classes. The report was finished in 1842 and was one of the major socio-hygienic investigations of that time. Chadwick believed that poverty was not the cause of disease, but rather a result of it. If filth could be removed, there would be less disease. Chadwick’s sanitary notion was the basis for the Public Health act in 1848, and he envisioned that every house should be connected to networks providing clean water supply and sewerage services. Many water supplies were built in the years following the Public Health Act, although sewerage systems lagged behind. As a final note, it is worth mentioning that Chadwick was influenced by Louis-René Villermé, a Frenchman who studied the poor during the first half of the 19^th century and showed that poverty and wealth were a primary determinant of mortality.

In Germany, Rudolf Virchow believed in a multicausal theory of disease. He analysed a typhus outbreak in Upper Silesia in 1848 and established the main factors of the outbreak were poverty and slum housing, due to the political subjugation to Prussia. Consequently, he thought that a free and unlimited democracy was needed to eradicate typhus, because free citizens would never accept their current conditions. While the Prussian government did not undertake action, the political role of medicine did expand in local authorities and Virchow continued to advocate for the improvement of social measures.

Next to prominent thinkers, associations of doctors and public hygienists called for public health in political circles and made efforts to educate people on the subject. Consider the Paris Health Council that was founded in 1802. This was partially a societal movement and partially governmental, as a way to fulfil the right to health that was incorporated after the French Revolution in 1789. In addition, journals were published with the aim to educate both the literate population and public officials, such as the Annales D’Hygiène Publique. This was first published in 1829 and was a central part of the public health movement, as it published the recent investigations and recommendations for the public. Two prominent thinkers mentioned above, Villermé and Parent-Duchâtelet, were among the founders as well as contributors. Similarly, in Germany Virchow created Die Medicinische Reform to publish his research and opinion in the form of one-liners. Additional outlets were created with the aim of providing statistics regarding food and health (Festschrift) and publishing the pioneering work of German scientists. Finally, in England Public Health covered not only the socio-hygienic aspects of public health, but also engineering aspects about the construction of the sewers.

In sum, the intellectual influence of thinkers and associations was a positive force influencing councils’ perspective on public health. The institutionalization of some of these groups later on and their collaboration with official institutions indicate a change in behaviour and acceptance of these scientific findings within governments.

Conclusions

What explains the rise of public health during the 19^th century? This post argues that two factors were critical: scientific breakthroughs and social movements. Medical advances provided the necessary knowledge to understand disease causation and improve hygienic recommendations, while prominent thinkers and various associations focused on the environmental circumstances of the population as a critical determinant of its health; socio-hygienic investigations supported their views and journals played an important part in distributing this knowledge. Although health progress was far from linear, these factors gradually trickled down throughout society and a new state emerged, much more focused on the health of its citizens than ever before. 

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