Public health is "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 ofhealth of apopulation and the threats it faces is the basis for public health.[3] Thepublic can be as small as a handful of people or as large as a village or an entire city; in the case of apandemic it may encompass several continents. The concept ofhealth takes into account physical,psychological, andsocial well-being, among other factors.[4]
There is a significant disparity in access to health care and public health initiatives betweendeveloped countries anddeveloping countries, as well as within developing countries. In developing countries, public health infrastructures are still forming. There may not be enough trainedhealthcare 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 poormaternal andchild health, exacerbated bymalnutrition and poverty and limited implementation of comprehensive public health policies. Developed nations are at greater risk of certain public health crises, including childhood obesity, although overweight populations in low- and middle-income countries are catching up.[8]
From the beginnings ofhuman civilization, communities promotedhealth and foughtdisease at the population level.[9][10] Incomplex,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 modernurban nation worldwide.[11] The public health initiatives that began to emerge initially focused onsanitation (for example, the Liverpool andLondon sewerage systems), control ofinfectious diseases (including vaccination andquarantine) and an evolving infrastructure of various sciences, e.g. statistics, microbiology, epidemiology, sciences of engineering.[11]
A community health worker in Korail Basti, a slum inDhaka, Bangladesh
Public health has been defined as "the science and art ofpreventing disease", prolonging life and improvingquality of life through organized efforts and informed choices ofsociety,organizations (public and private),communities andindividuals.[2] Thepublic can be as small as a handful of people or as large as a village or an entire city. The concept ofhealth takes into account physical,psychological, andsocial well-being. As such, according to theWorld Health Organization, "health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".[4]
Public health is related toglobal health which is the health of populations in the worldwide context.[12] 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".[13] International health is a field ofhealth care, usually with a public health emphasis, dealing with health across regional or national boundaries.[14] Public health is not the same as public healthcare (publicly funded health care).
The termpreventive 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".[15]: 1 Preventive medicine specialists are trained asclinicians and address complex health needs of a population such as by assessing the need fordisease prevention programs, using the best methods to implement them, and assessing their effectiveness.[15]: 1, 3
Since the 1990s many scholars in public health have been using the termpopulation health.[16]: 3 There are no medical specialties directly related to population health.[15]: 4 Valles argues that consideration ofhealth 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.[16]: 163 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.[15]: 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 ofprimary care rather than a specialty in its own right.[15]: 3 Valles argues that the termsocial medicine has a narrower and morebiomedical focus than the term population health.[16]: 7
Many diseases arepreventable through simple, nonmedical methods. For example, research has shown that the simple act ofhandwashing with soap can prevent the spread of manycontagious diseases.[21] In other cases, treating a disease or controlling apathogen can be vital to preventing its spread to others, either during an outbreak ofinfectious disease or throughcontamination of food orwater supplies.
A dilemma in public health ethics is dealing with the conflict betweenindividual rights and maximizingright to health.[23]: 28 Public health is justified byconsequentialistutilitarian ideas,[23]: 153 but is constrained and critiqued byliberal,[23]deontological,principlist andlibertarian philosophies[23]: 99, 95, 74, 123 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.[23]: 154
The definition ofhealth is vague and there are many conceptualizations. Public health practitioners definition of health can different markedly from members of the public orclinicians. 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.[23]: 230 Such vagueness can be a problem forhealth promotion.[23]: 241 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.[16]: 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'sthe 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.[24]: 85 [25] 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.[26]: 8 [25]: 7 [27]: 81
ASomali boy is injected with inactivated poliovirus vaccine (Mogadishu, 1993).
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 andsanitation (for exampleLondon sewerage system); control ofinfectious diseases (includingvaccination andquarantine); an evolving infrastructure of various sciences, e.g. statistics, microbiology, epidemiology, sciences of engineering.[11] Great Britain was a leader in the development of public health during that time period out of necessity: Great Britain was the first modernurban nation (by 1851 more than half of the population lived in settlements of more than 2000 people).[11] This led to a certain type of distress which then led to public health initiatives.[11] Later that particular concern faded away.
A major public health concern indeveloping countries is poormaternal and child health, exacerbated bymalnutrition and poverty. TheWHO reports that a lack ofexclusive breastfeeding during the first six months of life contributes to over a million avoidable child deaths each year.[29]
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.[30] In a June 2010 editorial in the medical journalThe Lancet, the authors opined that "The fact that type 2 diabetes, a largely preventable disorder, has reached epidemic proportion is a public health humiliation."[31] The risk oftype 2 diabetes is closely linked with the growing problem ofobesity. The WHO's latest estimates as of June 2016[update] highlighted that globally approximately 1.9 billion adults wereoverweight in 2014, and 41 million children under the age of five were overweight in 2014.[32] Once considered a problem in high-income countries, it is now on the rise in low-income countries, especially in urban settings.[33]
Health inequalities, driven by the social determinants of health, are also a growing area of concern in public health. A central challenge to securing health equity is that the same social structures that contribute to health inequities also operate and are reproduced by public health organizations.[35] In other words, public health organizations have evolved to better meet the needs of some groups more than others. The result is often that those most in need of preventative interventions are least likely to receive them[36] and interventions can actually aggravate inequities[37] as they are often inadvertently tailored to the needs of the normative group.[38] Identifying bias within public health research and practice is essential to ensuring public health efforts mitigate and don't aggravate health inequities.
Most governments recognize the importance of public health programs in reducing the incidence of disease, disability, and the effects ofaging and other physical and mental health conditions. However, public health generally receives significantly less government funding compared with medicine.[45] 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.[46] Public health programs providingvaccinations have made major progress in promoting health, including substantially reducing the occurrence ofcholera andpolio and eradicatingsmallpox, diseases that have plagued humanity for thousands of years.[47]
The 2010ISCD study "Drug Harms in the UK: amulti-criteria decision analysis" found thatalcohol scored highest overall and inEconomic cost,Injury,Family adversities,Environmental damage, andCommunity harm.
Many health problems are due to maladaptive personal behaviors. From anevolutionary psychology perspective, over consumption of novel substances that are harmful is due to the activation of an evolvedreward system for substances such as drugs, tobacco,alcohol,refined salt,fat, andcarbohydrates. New technologies such as modern transportation also cause reducedphysical activity. Research has found thatbehavior 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, with theHarvard University'sT.H. Chan School of Public Health categorizing such films as "impact filmmaking."[50] In fact,film festivals andcompetitions have been established to specifically promote films about health.[51] 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.[52] Public libraries can also be beneficial tools for public health changes. They provide access to healthcare information, link people to healthcare services, and even can provide direct care in certain situations.[53]
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:[54][55][56][57]
Assessing current services and evaluating whether they are meeting the objectives of thehealth care system
Ascertaining requirements as expressed byhealth 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
Some programs and policies associated with publichealth promotion and prevention can be controversial. One such example is programs focusing on the prevention ofHIV transmission throughsafe sex campaigns andneedle-exchange programs. Another is the control oftobacco smoking. Many nations have implementedmajor 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 limitingpassive (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.[58]
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 theCOVID-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.[59]
Simultaneously, while communicable diseases have historically ranged uppermost as aglobal health priority,non-communicable diseases and the underlying behavior-related risk factors have been at the bottom. This is changing, however, as illustrated by theUnited Nations hosting its first General Assembly Special Summit on the issue of non-communicable diseases in September 2011.[60]
There is a significant disparity in access to health care and public health initiatives betweendeveloped countries anddeveloping countries, as well as within developing countries. In developing countries, public health infrastructures are still forming. There may not be enough trainedhealth 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 extremepoverty. For example, many African governments spend less than$100 USD per person per year on health care, while, in the United States, thefederal government spent approximately $10,600 USD per capita in 2019.[61] 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 enforcing this rule would not count as money spent on health care.
Amalaria test inKenya. Despite being preventable and curable, malaria is a leading cause of death in many developing nations.[62][63]
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 anepidemiological shift andpolarization 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 poormaternal and child health, exacerbated bymalnutrition and poverty. TheWHO reports that a lack ofexclusive breastfeeding during the first six months of life contributes to over a million avoidable child deaths each year.[29]Intermittent preventive therapy aimed at treating and preventingmalaria episodes among pregnant women and young children is one public health measure inendemic countries.
Since the 1980s, the growing field ofpopulation health has broadened the focus of public health from individual behaviors andrisk factors to population-level issues such asinequality, 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, andsocial relationships; these are known as "social determinants of health". The upstream drivers such as environment, education, employment, income, food security, housing,social inclusion and many others effect the distribution of health between and within populations and are often shaped by policy.[64] 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.[65] The new public health advocates for population-based policies that improve health in an equitable manner.
The health sector is one of Europe's most labor-intensive industries. In late 2020, it accounted for more than 21 million employment in theEuropean Union when combined with social work.[66] According to theWHO, several countries began theCOVID-19 pandemic with insufficient health and care professionals, inappropriate skill mixtures, and unequal geographical distributions. These issues were worsened by the pandemic, reiterating the importance of public health.[67] In the United States, a history of underinvestment in public health undermined the public health workforce and support for population health, long before the pandemic added to stress, mental distress, job dissatisfaction, and accelerated departures among public health workers.[68]
Health aid to developing countries is an important source of public health funding for many developing countries.[70] Health aid to developing countries has shown a significant increase after World War II as concerns over the spread of disease as a result ofglobalization increased and the HIV/AIDS epidemic in sub-Saharan Africa surfaced.[71][72] 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.[72] 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.[70] Health aid has seen an expansion through multiple channels including private philanthropy,non-governmental organizations, private foundations such as theRockefeller Foundation or theBill & Melinda Gates Foundation, bilateral donors, and multilateral donors such as theWorld Bank orUNICEF.[72] 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 partners, particularly among bilateral development agencies and funding organizations, theSwedish International Development Cooperation Agency (Sida) spearheaded the establishment of ESSENCE,[73] an initiative to facilitate dialogue between 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 theOECD amounted to $12.47 billion which amounted to 11.4% of its total bilateral aid.[74] In 2009, Multilateral donors were found to spend 15.3% of their total aid on bettering public healthcare.[74]
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 thepoverty 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.[70] For example, recently, health aid was funneled towards initiatives such as financing new technologies likeantiretroviral medication,insecticide-treated mosquito nets, and new vaccines. The positive impacts of these initiatives can be seen in the eradication of smallpox andpolio; however, critics claim that misuse or misplacement of funds may cause many of these efforts to never come into achievement.[70]
Economic modeling based on theInstitute for Health Metrics and Evaluation and theWorld Health Organization has shown a link between international health aid in developing countries and a reduction in adult mortality rates.[72] 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.[70] 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.[70]
To address current and future challenges in addressing health issues in the world, theUnited Nations have developed theSustainable Development Goals to be completed by 2030.[75] These goals in their entirety encompass the entire spectrum of development across nations, however Goals 1–6 directly addresshealth disparities, primarily in developing countries.[76] These six goals address key issues inglobal public health,poverty, hunger andfood security, health, education,gender equality andwomen's empowerment, andwater andsanitation.[76] 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.[77][78]
Mass burials during the second plague pandemic (a.k.a.the Black Death; 1346–1353) intensified urban responses to disaster on the basis of earlier practices. Miniature from "The Chronicles of Gilles Li Muisis" (1272–1352). Bibliothèque royale de Belgique, MS 13076–77, f. 24v.
From the beginnings ofhuman civilization, communities promotedhealth and foughtdisease at the population level.[9][10] 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.[79][80][81] The latter reputation is mainly based on the absence of present-daybioindicators, especiallyimmunological andstatistical tools developed in light of thegerm theory of disease transmission.[82][83]
Public health was born neither inEurope nor as a response to theIndustrial Revolution. Preventive health interventions are attested almost anywhere historical communities have left their mark. InSoutheast Asia, for instance,Ayurvedic medicine and subsequentlyBuddhism fostered occupational, dietary and sexual regimens that promised balanced bodies, lives and communities, a notion strongly present inTraditional Chinese Medicine as well.[84][85] Among theMayans,Aztecs and other early civilizations in theAmericas, population centers pursued hygienic programs, including by holdingmedicinal herbal markets.[86] And amongAboriginal Australians, techniques for preserving and protecting water and food sources, micro-zoning to reduce pollution and fire risks, and screens to protect people againstflies were common, even in temporary camps.[87][88]
Western European,Byzantine andIslamicate civilizations, which generally adopted aHippocratic,Galenic orhumoral medical system, fostered preventive programs as well.[89][90][91][92] These were developed on the basis of evaluating the quality of localclimates, includingtopography, wind conditions and exposure to the sun, and the properties and availability of water and food, for bothhumans and nonhumananimals. Diverse authors ofmedical,architectural,engineering andmilitary manuals explained how to apply such theories to groups of different origins and under different circumstances.[93][94][95] This was crucial, since under Galenism bodily constitutions were thought to be heavily shaped by their materialenvironments, so their balance required specific regimens as they traveled during differentseasons and between climate zones.[96][97][98]
Incomplex,pre-industrialized societies, interventions designed to reduce health risks could be the initiative of different stakeholders. For instance, inGreek andRoman antiquity, army generals learned to provide for soldiers' wellbeing, including off thebattlefield, where most combatants died prior to the twentieth century.[99][100] InChristianmonasteries across theEastern Mediterranean and western Europe since at least the fifth centuryCE,monks andnuns pursued strict but balanced regimens, including nutritiousdiets, developed explicitly to extend their lives.[101] Androyal, princely andpapal 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.[102]
Incities, residents and rulers developed measures to benefit the generalpopulation, which faced a broad array of recognizedhealth risks. These provide some of the most sustained evidence for preventive measures in earlier civilizations. In numerous sites the upkeep ofinfrastructures, including roads, canals and marketplaces, as well aszoning policies, were introduced explicitly to preserve residents' health.[103] Officials such as themuhtasib in the Middle East and theRoad master in Italy, fought the combined threats ofpollution throughsin,ocular intromission andmiasma.[104][105][106][107] Craftguilds were important agents of waste disposal and promotedharm reduction through honesty andlabor safety among their members. Medical practitioners, including public physicians,[108] collaborated with urban governments in predicting and preparing for calamities and identifying and isolating people perceived aslepers, a disease with strong moral connotations.[109][110]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 bothIslam and Christianity likewise promoted moral and physical wellbeing by endowing urban amenities such as wells, fountains, schools and bridges, also in the service ofpilgrims.[111][112] In western Europe and Byzantium, religiousprocessions commonly took place, which purported to act as both preventive and curative measures for the entire community.[113]
Urban residents and other groups also developed preventive measures in response to calamities such aswar,famine,floods andwidespread disease.[114][115][116][117] During and after theBlack Death (1346–53), for instance, inhabitants of theEastern Mediterranean andWestern 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.[118][119][120] The latter included the establishment ofquarantine facilities and health boards, some of which eventually became regular urban (and later national) offices.[121][122] Subsequent measures for protecting cities and their regions included issuing healthpassports for travelers, deploying guards to createsanitary cordons for protecting local inhabitants, and gathering morbidity and mortality statistics.[123][124][125] Such measures relied in turn on better transportation and communication networks, through which news on human and animal disease was efficiently spread.
With the onset of theIndustrial 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 asLeeds andManchester. This rapidurbanization exacerbated the spread of disease in the largeconurbations that built up around theworkhouses andfactories. These settlements were cramped and primitive with no organizedsanitation. 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 ofslums and theper capitadeath rate began to rise alarmingly, almost doubling inBirmingham andLiverpool.Thomas Malthus warned of the dangers of overpopulation in 1798. His ideas, as well as those ofJeremy Bentham, became very influential in government circles in the early years of the 19th century.[126] 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.[126] The 18th century saw rapid growth in voluntary hospitals inEngland.[127]
The practice ofvaccination began in the 1800s, following the pioneering work ofEdward Jenner in treatingsmallpox.James Lind's discovery of the causes ofscurvy amongst sailors and its mitigation via the introduction offruit on lengthy voyages was published in 1754 and led to the adoption of this idea by theRoyal Navy.[128] Efforts were also made to promulgate health matters to the broader public; in 1752 the British physician SirJohn Pringle publishedObservations on the Diseases of the Army in Camp and Garrison, in which he advocated for the importance of adequate ventilation in themilitarybarracks and the provision oflatrines for the soldiers.[129]
SirEdwin Chadwick was a pivotal influence on the early public health campaign.
The first attempts at sanitary reform and the establishment of public health institutions were made in the 1840s.Thomas Southwood Smith, physician at theLondon 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 thePoor Law Commission in the 1830s, along withNeil Arnott andJames Phillips Kay.[130] Smith advised the government on the importance ofquarantine and sanitary improvement for limiting the spread of infectious diseases such ascholera andyellow fever.[131][132]
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 governmentengineering projects to alleviate the conditions that allowed for the propagation of disease.[126] TheHealth of Towns Association was formed at Exeter Hall London on 11 December 1844, and vigorously campaigned for the development of public health in theUnited Kingdom.[133] Its formation followed the 1843 establishment of the Health of Towns Commission, chaired by SirEdwin Chadwick, which produced a series of reports on poor and insanitary conditions in British cities.[133]
Public Health Office, Bristol, 1900
These national and local movements led to thePublic 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 theLiberalgovernment ofLord John Russell, in response to the urging of Edwin Chadwick. Chadwick's seminal report onThe Sanitary Condition of the Labouring Population was published in 1842[134] and was followed up with a supplementary report a year later.[135] 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), withJoseph Bazalgette later creatingLondon's sewerage system (1858–1875).
The Vaccination Act 1853 introduced compulsorysmallpox vaccination in England and Wales.[136] By 1871 legislation required a comprehensive system of registration run by appointed vaccination officers.[137]
TheInfectious Disease (Notification) Act 1889 (52 & 53 Vict. c. 72) 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.[138]
Example of historical public health recommendations during the1918 flu pandemic inNew Haven, Connecticut, United States
In the United States, the first public health organization based on a state health department and local boards of health was founded inNew York City in 1866.[139]
DuringThe Weimar Republic, Germany faced many public health catastrophes.[140] TheNazi Party had a goal of modernizing health care withVolksgesundheit, German forpeople's public health; this modernization was based on the growing field ofeugenics and measures prioritizing group health over any care for the health of individuals.[141] The end of World War 2 led to theNuremberg Code, a set of research ethics concerning human experimentation.[142]
The science ofepidemiology was founded byJohn Snow's identification of a polluted public water well as the source of an 1854cholera outbreak in London. Snow believed in thegerm theory of disease as opposed to the prevailingmiasma theory. By talking to local residents (with the help ofReverend Henry Whitehead), he identified the source of the outbreak as the public water pump on Broad Street (nowBroadwick Street). Although Snow's chemical and microscope examination of a water sample from theBroad 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 handle.[143]
Snow later used adot 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 theSouthwark and Vauxhall Waterworks Company was taking water from sewage-polluted sections of theThames 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 ofepidemiology.[144][145]
In the global context, the field of public health education has evolved enormously in recent decades, supported by institutions such as theWorld Health Organization and theWorld 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. Moreover, integrating technology or digital platforms to connect to low health literacy LHL groups could be a way to increase health literacy.[152] 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.[153]
In theUnited States, the Welch-Rose Report of 1915[154] 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 theRockefeller Foundation.[155] The report was authored byWilliam Welch, founding dean of theJohns Hopkins Bloomberg School of Public Health, andWickliffe Rose of the Rockefeller Foundation. The report focused more on research than practical education.[155][156] 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.[155][157]
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 formedical professionals. However, in 1978, 69% of American students enrolled in public health schools had only abachelor's degree.[150]
Schools of public health offer a variety of degrees generally fall into two categories: professional or academic.[165] The two major postgraduate degrees are theMaster of Public Health (MPH) or theMaster of Science in Public Health (MSPH). Doctoral studies in this field includeDoctor of Public Health (DrPH) andDoctor 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.
Professional degrees are oriented towards practice in public health settings. TheMaster of Public Health,Doctor of Public Health,Doctor of Health Science (DHSc/DHS) and theMaster of Health 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.[166][167][168]
Academic degrees are more oriented towards those with interests in the scientific basis of public health andpreventive 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 theMaster 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 adissertation research project.
Louis Pasteur (1822–1895) conducted research that laid the foundation for our understanding of the causes and preventions of diseases.
Robert Koch (1843–1910) used his discoveries to establish that germs "could cause a specific disease"[173] and directly provided proofs for thatgerm theory of diseases, therefore creating the scientific basis of public health,[174] saving millions of lives.[175]
Charles V. Chapin (1856–1941) public health advocate and researcher credited with planting "the roots of quality in public health" in the United States[176]
Nora Wattie (1900–1994) led the development of public health services and sanitation, and education in improving women and child health in the poorestslums ofGlasgow, for which she received theOBE.[178]
Jonas Salk (1914–1995) developed one of the firstpolio vaccines and campaigned vigorously for mandatory vaccinations.
Ruth Huenemann (1910–2005) She became a pioneer in the study ofchildhood obesity in the 1960s studying the diet and exercise habits of Berkeley teenagers.[179]
Since the 1959Cuban Revolution, theCuban government has devoted extensive resources to the improvement ofhealth conditions for its entire population via universal access to health care. Infant mortality has plummeted.[148]: 483 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, especiallyVenezuela, as well as Oceania and Africa countries.
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.[182] In Bolivia, a similar push came after their 1952 revolution.[183]
Ghanaian children receive insecticide-treated bed nets to prevent exposure tomalaria transmitting mosquitos.
Though curable and preventive, malaria remains a major public health issue and is the third leading cause of death in Ghana.[184] 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.[185] These methods include reducing breeding sites, screening doors and windows, insecticide sprays, prompt treatment following infection, and usage of insecticide treated mosquito nets.[185] 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.[186][185]
TheFrench 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.[187] 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.[188][189] For example, there was a long battle over apublic 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.[190]
Public health issues were important for theSpanish 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.[191] 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.[192][193][194] As in the U.S., food safety became a public health issue, particularly focusing on meat slaughterhouses and meatpacking.[195]
Even during theMexican Revolution (1910–20), public health was an important concern, with a text on hygiene published in 1916.[196] During the Mexican Revolution, feminist and trained nurseElena Arizmendi Mejia founded theNeutral 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.[197][198] The Mexican state promoted the health of the Mexican population, with most resources going to cities.[199][200]
PHS had its origins inthe system of marine hospitals that originated in 1798. In 1871, these were consolidated into theMarine Hospital Service, and shortly afterwards the position ofSurgeon General and the PHSCC were established. As the system's scope grew to include quarantine authority and research, it was renamed the 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.[205]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% oftotal public health spending. Spending in support of public health in the United States peaked in 2002 and declined in the following decade.[206] State cuts to public health funding during theGreat Recession of 2007–2008 were not restored in subsequent years.[207]As of 2012, a panel for theU.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."[208][206] As of 2018[update], about 3% of government health spending was directed to public health and prevention.[47][209][210] This situation has been described as an "uneven patchwork"[211] and "chronic underfunding".[212][213][214][215]TheCOVID-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 acommon good.[47]
Taiwan has a well-established public health infrastructure anchored by theNational Health Insurance (NHI) system that was introduced in 1995 and provides nearly universal coverage, reaching an estimated 99.9% of residents.[216] Health expenditure is traditionally moderate; public and private funding combined accounted for 6.1–6.5% of GDP in recent years, below the OECD average of over 9%. The NHI is financed through a balanced mix of income-based premiums—shared roughly equally among individuals, employers, and government—and supplementary levies on savings and lottery winnings.[217] Despite high utilization, administrative costs are exceedingly low, at around 1–1.6%, allowing for efficient resource allocation and system-wide effectiveness.[218]
Taiwan's public health system is supported by strong institutions like theTaiwan Centers for Disease Control (CDC) and theCentral Epidemic Command Center (CECC), created after the2002–2004 SARS outbreak. During theCOVID-19 pandemic, these agencies quickly enacted travel screenings, contact tracing, mask rationing, digital quarantine systems, and daily transparent communications via text alerts and social media.[219] Taiwan was recognized in 2020 as one of the most effective pandemic responses globally, with minimal lockdowns and exceptionally low infection and death rates according to assessments by Wired, Time, the Commonwealth Fund, and other international observers.[220]
Beyond epidemics, public health priorities have included ongoing vaccine campaigns—reaching over 90% first-dose COVID coverage by 2022 — immunization against infectious diseases, and chronic disease management.[221] However, Taiwan faces pressing challenges such as an aging demographic, with projections indicating nearly 37% of the population will be over 65 by 2050. Additionally, the health system grapples with issues like hospital overcrowding due to patient preference for large medical centers, and growing fiscal pressures on NHI sustainability amid rising utilization and medical costs. These challenges are driving a shift toward bolstering primary care, refining referral systems, and balancing revenue mechanisms to preserve Taiwan's high-performing public health framework.
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Public health: the development of a discipline. Vol. 2 Twentieth century challenges (2011), covers 1920 to 2010.
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