PUBLIC HEALTH

PUBLIC HEALTH. Public health as a concept and as a program of coordinated state or communal action did not exist in early modern Europe. Not until the late seventeenth century did regimes and individuals began to perceive the health of the population as an area of legitimate, ongoing government action. Such realizations eventually led to more concentrated efforts in formulating principles of public health and launching sustained programs designed to improve health and lengthen life. Governments before the eighteenth century were, of course, not oblivious to collective health, but public health initiatives were ad hoc and piecemeal in nature. Public health fell overwhelmingly within the purview of other aspects of governing: the regulation of markets; restrictions on the practice of obnoxious trades such as tanning or slaughtering; the prevention of fires; and the provision of poor relief—to name only the most obvious and significant. Repeated waves of epidemics, especially plague, but also smallpox, syphilis, dysentery, influenza, and perplexing incidents of considerable lethality such as the mysterious English sweat of the 1480s, caused governments to swing vigorously into action to combat them or prevent their spread.

Epidemics as a presence or a threat conditioned many early modern public health responses. The plague of the mid to late 1340s (known since the nineteenth century by the anachronistic name of the Black Death) played a major role in shaping policies. Equally influential was the appearance of syphilis in the late fifteenth and early sixteenth centuries. These two diseases produced a standard set of responses—quarantines, cordons sanitaires, avoidance, flight, closing public baths, shutting up infected houses, and banning assemblages of people—that persisted at least until the eighteenth century and often considerably longer. The steps taken to fight or forestall pestilences depended to a large degree on how people understood their propagation. Since antiquity two concepts of how disease spread competed. Some believed in contagion—that disease circulated through contact with infected people or goods. Others adopted a miasmatic theory—that disease resulted from an insalubrious condition of the environment, a disturbance in the airs, waters, and places described in the ancient Hippocratic corpus. Whereas once historians argued that these two interpretations were mutually exclusive and antagonistic, it is now generally accepted that they could be combined and that both shaped (and still shape) responses to epidemic situations.

Western Europe lived beneath the shadow of plague until 1721 (Brockliss and Jones, 1997), and plague disappeared from eastern Europe and Russia only toward the end of the eighteenth century. Throughout early modern times, public health was intimately concerned with two measures taken to prevent the incursion or recurrence of plague: quarantines and cordons sanitaires. These methods required the coordination of government efforts often crossing territorial borders and covering huge stretches of land. While such cooperation was hardly perfect in an age lacking efficient police forces, evidence suggests that both measures could successfully retard the spread of disease. Once plague struck, however, cities constituted boards of health from their sitting magistracies (choosing, in other words, people with power and status but not necessarily those possessing medical experience or training) for the duration of the emergency. Physicians and surgeons were seldom members of such boards. Although granted wide and expansive powers for a time, boards of health tended to disappear once the threat vanished. Nonetheless, the ordinances that governed city life on a day-to-day basis continued to contain crucial elements of what would later be termed public health. Such regulations pertained not only to cities, of course. Still, evidence is more complete and available for urban sites than for the countryside and control was crisper within still-walled towns. This, too, would change in the late seventeenth and eighteenth centuries. Another institution that we today consider essential to public health is the hospital. Hospitals in early modern times served as multipurpose establishments, although some were set up and run especially for particular patients: those suffering from plague or syphilis, for instance. Hospitals, however, functioned coterminously as places to heal the sick, as homes for the aged or chronically ill, and as refuges for the destitute (and thus, formed a central element of poor relief). Hospitals provided vital economic resources for a community as employers, but also as prominent landowners and even as moneylenders.

Beginning in the late seventeenth century, public health slowly developed a more comprehensive field of action and a more tightly defined program. As states centralized authority and as rulers gathered the reins of power more firmly into their own hands, they and their ministers began to envision the wealth of nations in broader ways. According to the principles of mercantilism and its sister discipline, populationism, the riches of a state could no longer be weighed merely in bullion. Rather the true strength of a polity lay in its productive potential, and that capacity itself depended on the presence of a large, healthy, and industrious population. Thus, advocates of what in German came to be known as Medizinische Polizei ('medical police'), denoting a series of policies rather than a police force), foremost among them, Johann Peter Frank (1745–1821), constructed broad programs of public health that ranged from traditional concerns with the fighting of epidemics, the maintenance of hospitals, and the provision of potable water supplies to far more ambitious social policies that included the early education of children and maternal welfare.

In order to formulate rational and purposeful policies, however, it was first necessary to understand which conditions promoted health or caused illness. Thus, medical police stimulated a political arithmetic that amassed and studied information pertaining to commerce, population, and natural resources, as well as vital statistics (birth, death, and morbidity rates). Cities had often collected mortality statistics, especially during epidemic outbreaks. The London Bills of Mortality from the Great Plague of 1665–1666 are perhaps the most famous (but by no means the only or earliest) example of this genre. In the seventeenth and eighteenth centuries, however, the political arithmeticians, such as the Englishman John Graunt (Natural and Political Observations on the Bills of Mortality, 1662) or the German Johann Süssmilch (Die göttliche Ordnung in den Veränderungen des menschlichen Geschlechts, 1775 [The godly order in human affairs]) sought to discover patterns of mortality as a basis for the rational planning of state affairs, including but not limited to public health. These advances in political economy paralleled other trends in the eighteenth century: a new valuation on individual worth and a greater tendency to view human happiness, including physical well-being, as a positive good. These perceptions laid the groundwork for the development of public health as a humanitarian enterprise and as an accepted program of state action. Still, it would take several decades and, to some extent, the impact of cholera in the nineteenth century for states to establish health departments as permanent agencies, staffed by professionals possessing strong executive powers, or ones that functioned on a national, rather than merely on a local or municipal level.

PUBLIC HEALTH

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