Public Health Overview: Journey

Responsibilities of Public Health England

• Improving public health by encouraging discussions, advising government and supporting action by local government, the NHS and other organisations
• Supporting public so that they can protect and improve their own health
• Protecting the nations health through the national health protection service, and preparing for public health emergencies
• Sharing information and expertise with local authorities, industry and the NHS to help improve public health
• Researching, collecting and analysing data to improve our understanding of health and come up with answers to public health problems
• Reporting on improvements in the public's health so everyone can understand the challenge and the next steps
• Helping local authorities and the NHS develop the public health system and its specialist workforce

1848 Public Health Act - Edwin Chadwick

• Edwin Chadwick: social reformer
• 1834 'Poor Law': Making the provision of poor relief so unpleasant, it would put off all but the most desperate
• Whilst working as secretary to Poor Law Commissioners, he investigated the issue of sanitation amongst the poor
• 1842: Chadwick published 'The Sanitary Condition of the Labouring Population of Great Britain' - Poor Law Commissioners didn't want to be associated with this report, therefore he funded the population himself.
• Chadwick's argument was economical:
• If the health of the poor improved, less people would week poor relief
• Much of poor relief was given to families of men who had died of infectious diseases
• Money spent on improving public health would be cost effective, saving money in the long term
• Most important steps to improve public health:
• Improve drainage and provision of sewers
• Removal of all refuse from houses, streets and roads
• Provision of clean drinking water
• Appointment from a medical officer for each town

The Public Health Act of 1848

• What got things moving for the Public Health Act 1948:
• Campaigning by the Health of Towns Association
• 1948 Cholera outbreak
• Act established a Central Board of Health
• However, they had limited power and no money
• Boroughs (e.g. Sunderland) who had already set up a Corporation were to assume responsibilities for:
• Drainage
• Water supplies
• Removal of nuisances
• Paving
• Local Boards of Health were obliged to be set up where the death rate was 23 per 100
• Limitation of the 1848 Public Health Act:
• Provided a framework that could be used by local authorities but did not compel action

1954: John Snow and the Broad Street Pump

• First comprehensive epidemiological study
• Analysis of the London Cholera outbreak fatalities of 1854:
• Linked these to one water pump in Broad street in Soho, London
• Established that cholera was a water-borne disease
• Summer 1954: Very hot, people were drinking cold water rather than boiling it for tea
• In this area, 13 pumps were supplying water from wells
• Cholera outbreak happened very rapidly
• Majority of those who died suffered violent illness and died within 1 or 2 days
• People began to flee; 75% of the population left in just a few days
• Snow immediately investigated and mapped the locations of the homes affected and the location of the pumps

Seebohm Rowntree and Poverty

• Most famous for study of poverty in York, published 1901, 'Poverty: a Study of Town Life'
• Survey to compare poverty in York (20,000 people living in poverty) to that in London
• Regarded as one of the founders of empirical sociology
• Changed perceptions of poverty and progression; the Liberal government of 1905-1915
• Rising of the Liberal Party and concern over National Efficiency- surveys demanded attention
• Identified the 'poverty line'
• Poverty viewed as an issue demanding worldwide attention, not the fault of the working class
• 'The Human Needs of Labour' (1918): Good practice in wages, working hours, wokring conditions and emplyees' welfare and status
• Some believe that his findings and beliefs motivated formation of the NHS
• 'The Human Factor in Business' in 1921; Addressed relationship between the needs of the employer and the employee- required reading for graduates joining the company in 1960s
• His initiative lead to the employment of a full-time industrial psychologist; worked to improve efficiency amongst workers & marketing
• He was a Quaker, his beliefs influenced his work;
• He wanted to help the poor, opposed Britain fighting in WWI, and was concerned about the problems alcohol caused for individuals, families and society - Linking individual health to public health
• Rowntree's reports helped bring about Liberal reforms of 1906-1912: Provision of free school meals, sickness and unemployment insurance for working men and the first state pensions
• Today: Relative poverty is measured and not absolute poverty: Defines poor people as poor if they lack resources to afford what is generally considered acceptable standard of living and a reasonable style of life

Tom McKeown: 1979

• The Role of Medicine: dream, mirage or nemesis:
• 'Medicine must not try to create health but aim to "assist us to come safely into the world and comfortably out of it, and during life to protect the well and care for the sick and disabled."'
• Before the NHS, 'public health' was the professional concern of Medical Officers of Health employed by the local government, defined by the environmental protection regulations set out in the Public Health Act of 1936.
• Tom and colleagues saw this as a crippling constraint upon any fully integrated medical service for the community as a whole...
• Created Community Medicine in 1973:
• Unified activities of scattered professional groups pursuing different aspects of their subject;
• Health problems in the community combined with social, administrative, economic, demographic and historical studies.
• Social medicine would have a global role

Smallpox Eradication 1966-1980

• "The eradication of smallpox shows that with string mutual resolve, teamwork and an international spirit of solidarity, ambitious global public health goals can be attained" Dr Margaret Chan, Director-General, WHO
• Strategies for Eradication
• Focussed less on mass vaccination, more on the elevation of surveillance and containment to a pre-eminent place
• Surveillance and notification to be set up or strengthened in every endemic country
• Discovery of the case was to be followed by: containment by vaccination of all contacts in ever-increasing distances from the affected household, and the discovery and follow-up of the sources of infection
• In India: nationwide 'house-hold searches' were carried out periodically; revealed vastly more cases of smallpox than had previously been suspected
• As the incidence of smallpox fell to low level, a system of rewards for reporting cases, offered to both the general public and the public health workers- ensured that the great majority of cases of smallpox were reported
• Eradication of Smallpox: 1979

The Whitehall Studies, Marmot

• Found that all major causes of death were determined by a social gradient; the lower the placement in hierarchy, the higher the risk.
• Focussed on one industry in which there is little heterogeneity within occupational grades and clear social divisions between grades- leaving no room for differing interpretations.
• Inverse association between grade of employment and mortality from CHD and a range of other causes was observed.
• Men in the lowest grade (others = messengers, doorkeepers...) had a three-fold higher mortality rate than men in the highest grade (administrators).
• Remaining grade differences in CHD mortality: job control, job support, blood pressure at work associated with "job stress", "lack of skill utilisation", "tension", and "lack of clarity" in tasks

The Barker Hypothesis

• Thrifty phenotype:
• Reduced foetal growth is associated with chronic conditions (CHD, DM, Stroke, Hypertension) later on in life.
• Increased susceptibility results from adaptations made by the foetus in an environment limited in its supply of nutrients.