Public Health History
Nasty, brutish and short. That's how life was before the development of public health. Poor sanitation, unregulated food processing, lack of control of mosquitoes, inadequate prenatal care, and other poor health conditions led to unnecessary illnesses and deaths. In the year before Florida's state health department was created in 1889, about 40 percent of the population fled Jacksonville due to a yellow fever epidemic which sickened a third of those who stayed and killed over 400. Similar epidemics of cholera and yellow fever struck the state almost annually, one of which almost wiped out the population of St. Joseph in 1841. In most cases, limited medical care was available for the sick and weaker people died, but not before infecting many others. Many survivors were carriers, continuing to pass the diseases to others as a result of poor sanitary practices.
Control of infectious diseases was the major reason for establishment of public health services and remains a major focus today. Throughout history, as one communicable disease has been eradicated, another evolves to take its place. Early settlers battled animal-borne diseases such as malaria, dengue fever, and yellow fever. Current residents must be protected against lyme disease and Rocky Mountain spotted fever.
Diphtheria and smallpox were the deadliest of the early childhood diseases. Once controlled, polio took their place. Most recently, haemophilus influenza type B meningitis became the most deadly childhood killer before immunizations once again stopped its expansion. Cholera plagued early coastal dwellers, now vibrio is a problem, infecting oysters and shellfish and those who eat them. Syphilis and gonorrhea were once widespread, with syphilis infecting one of every six men tested in the 1940s and over 60,000 gonorrhea cases annually in the 1970s. Both have been reduced substantially, but thousands have contracted AIDS. Dengue fever is returning from South America and new diseases such as Ebola hemorrhagic fever and hantavirus are on the horizon.
Each new threat has been matched by a public health response. Through the years, arthropod-borne diseases such as yellow fever, malaria, and dengue fever were reduced through mosquito control programs and quarantines. Monitoring of sentinel chicken flocks warns officials of increases in St. Louis encephalitis in wild animals so that populations may be protected. Hookworm, once estimated to infect 60 percent of the population has almost disappeared through clinic treatment and improvements in public sanitation.
First smallpox, then other childhood diseases such as diphtheria and polio, were eliminated or reduced to minuscule numbers through immunization programs. Inspection and treatment programs for food, water, and milk plus effective sewage and solid waste disposal programs have cut incidence and death rates for enteric diseases. Disease intervention, treatment, and counseling programs are slowing the spread of sexually transmitted diseases.
In the late 19th century, tuberculosis used to be a major killer with the median age of death in the late teens or early twenties. Deaths are infrequent now, with the median age at death over 65. Tuberculosis screening and treatment programs have saved thousands, but we must now combat TB patients with HIV and spread of the disease among the homeless. Continued vigilance is required to stop new diseases imported from other countries and control the spread of indigenous diseases.
In 1920, life expectancy was only 55.3 years, in 1998, it was 77.5 years. In 1920, for every 1000 births, ten mothers died, 65 babies were stillborn, and over 100 infants died before they reached their first birthday. By 1998, less than one mother in 10,000 died, only 8 of 1000 babies was stillborn, and only 7 of 1000 infants died during the first year of life. Infant mortality per 1,000 births has steadily declined from 29.7 in 1955 to 28.4 in 1965, 17.7 in 1975, 11.3 in 1985, and 7.2 in 1998. The rate for whites has dropped from 23.6 in 1960 to 5.8 in 1998; for nonwhites, from 46.1 to 11.4. Public health prenatal, infant and child care programs were a major part of this improvement. Current programs are aimed at reducing the number of substance-abused newborns, infants born with HIV, and congenital defects.
As the risks of death during birth or from infectious disease early in life declined, control of chronic diseases has become more important. Public health has focused on the reduction of risks associated with chronic disease (poor nutrition, substance abuse, exposure to carcinogens in the environment) to help residents live longer, more productive lives. Public health personnel must monitor radiation hazards and pollution by toxic substances, many of which have only recently been discovered to be harmful.
Public health is now battling new scourges such as penicillin-resistant gonorrhea and other infectious diseases which have mutated to become immune to most antibiotics. Recent vaccines for herpes zoster and AZT for HIV-positive pregnant women are being administered to curb these diseases. Environmental health staff are working to prevent epidemics in hurricane-stricken areas and the pollution of shellfish-harvesting areas from flooded septic tanks. Each year brings new diseases, new chronic disease risks, and more natural disasters. Public health forces must be mustered to fight each new threat or new epidemics will spread.
Before 1965 and the inception of Medicaid, the primary substance abuse problem was the abuse of alcohol. Marijuana and psychedelic drugs were used occasionally but were not viewed as a major public health concern. Heroin use was largely confined to the urban ghettoes. Now the substance abuse problem has shifted to the abuse of cocaine and users are frequently upper and middle class workers. Many deaths can be attributed to impaired drivers who have abused alcohol or drugs. Public health workers must battle the effects of these substances on the abusers and their families. Maternal and child health staff are now fighting the effects of crack cocaine on newborns as well as fetal alcohol syndrome.