PUBLIC
HEALTH
Public Health is the protection and
improvement of the health of the public through community action, primarily by
governmental agencies.
Public health includes four major
areas:
1. The promotion of positive health
and vitality;
2. The prevention of infectious and
non-infectious disease as well as injury;
3. The organization and provision of
services for diagnosis and treatment of illness;
4. The rehabilitation of sick and
disabled persons to their highest possible level of function.
Inclusion of these four major areas
among the concerns of public-health agencies was expressed on a 
worldwide scale in 1948, when health
was defined by the World Health Organization, or WHO, to include physical,
mental, and social well-being and not merely the absence of disease or
infirmity.
Promotion of Health
This broad area of health promotion
represents, in a sense, a rediscovery of ancient concepts. As long ago as 3000
BC, cities on the Indian subcontinent had developed environmental sanitation programs
such as the provision of underground drains and public baths. Essential aspects
of health were woven into daily activities, including personal hygiene, health
education, exercise, codes of conduct and self-discipline, dietary practices,
food and environmental sanitation, and treatment of minor ailments and
injuries. By 1400 BC, this society's so-called science of life, or Ayurveda,
mainly featured total health care through health promotion and education,
although advances were also made in curative medicine and surgery.
This tradition was also highly
developed in ancient Greece and Rome and has persisted to the present,
but it has been overshadowed during the 20th century by the great
advances in the prevention and treatment of disease. Only in recent decades has
a resurgence of interest in positive health occurred. This is evidenced by: the
important research conducted on the effect of malnutrition in pregnant women on
the physical and mental development of their children, and research on the effects
of diet supplementation in improving the health and vitality of undernourished
populations; by the studies of optimal levels of temperature and other
environmental conditions affecting human comfort and ability to function; and
by the widespread recognition of the value of physical exercise in achieving
positive health and well-being.
Disease Prevention
Humanity remained largely powerless
to prevent disease until the conclusive proof of the germ theory in the last
quarter of the 19th century by Louis
Pasteur in France and Robert Koch in Germany. Their bacteriological findings led
to the first epidemiological revolution: the conquest of infectious disease.
Environmental sanitation—safe water supplies, improved sewage disposal systems,
pasteurization of milk, and sanitary control of food supplies—resulted in the
virtual disappearance of cholera and typhoid fever and the marked reduction in diarrhea
and infant mortality in industrial countries. The discovery of effective
vaccines, based on the growth of the science of immunology, led not only to the
recent worldwide eradication of smallpox but also to the marked decline in such
diseases as diphtheria, tetanus, whooping cough, poliomyelitis, and measles.
Lack of adequate sanitation facilities, however, still impedes the developing
countries in their efforts to reduce the toll of diarrhea in infants and
children—the main cause of death in the world today. Malaria, tuberculosis,
influenza, and other infectious diseases also remain as major health problems
in many countries.
The world now stands on the
threshold of the second epidemiological revolution: the conquest of
non-infectious diseases. These are not only the leading causes of mortality in
the industrial nations but have become increasingly important in the developing
nations as well. Epidemiologists have developed effective methods for the
prevention of heart disease, certain kinds of cancer, stroke, accidents,
chronic obstructive lung disease, and cirrhosis of the liver; and application
of these methods has already resulted in dramatic reductions in death rates. In
the United States from 1968 to 1978, for example, the
age-adjusted death rate for coronary heart disease declined by 25% , and the
age-adjusted death rate for stroke showed an even more dramatic decline of 38%.
These advances were achieved largely through public-health programs for the
control of high blood pressure and through health education of the public on
the hazards of eating saturated fats and cigarette smoking.
Provision of Medical Care
Three basic systems of medical care
exist in the world today: public assistance, health insurance, and National
Health Service. The first is dominant in 108 countries constituting 49% of the
world's population; the countries are located in Asia, Africa, and Latin America. For the great majority of the
people in these countries, whatever medical care is available is provided
through a public-assistance system for the poor. This includes government
hospitals and health centers financed by general taxation. The system and its
facilities are generally underfinanced, overcrowded, and understaffed. In
addition to such systems administered by health departments, programs may exist
that are operated by social security agencies for industrial or white-collar
workers. Where they exist, these programs usually cover only a small part of
the population. In all these countries a small stratum of landowners,
businesspeople, officials, and professionals use private doctors and hospitals
for their care.
The health-insurance system is
dominant in 23 countries constituting 18% of the world's population. These
industrialized nations with a capitalist economy are located in Western Europe and North America, but also include Australia, New Zealand, Japan, and Israel. In most of them a mix of
governmental and non-governmental insurance exists. In some, however—Canada, Denmark, Finland, Iceland, New Zealand, and Norway—the entire population is covered by
governmental medical-care insurance. Although most of the countries finance
their programs through social security taxes on employees and employers, a
considerable portion of the cost is borne by general governmental funds. In Canada, Denmark, Iceland, Ireland, Italy, and New Zealand the program is funded entirely, or
almost entirely, by general taxation. Most national health-insurance programs
in the industrial nations are based on fee-for-service private practice.
Doctors and other practitioners contract with the government or with authorized
sick funds to provide care.
In countries without a national
health service, such as the United States, health care is financed by private
insurance and government health schemes such as Medicare and Medicaid (for the
elderly and poor respectively). In developing countries, government pays only
for basic health care while more advanced facilities are paid for by the
wealthy. Rich countries spend around 8 per cent of their gross national product
(GNP) on health care—poor countries less than 1 per cent of a far lower GNP. In
China traditional and modern medicine are integrated
with a strong emphasis on preventative medicine; in Chile, a 40% reduction in infant
mortality was achieved through a special health program. In the developed
world, health finance problems are increasingly focused on the rising costs of
high technology medicine and ageing populations.
The system of National Health
Service is dominant in 14 countries constituting 33% of the world's population.
They include nine nations in Europe, four in Asia, and Cuba; all are either industrialized or
undergoing rapid industrialization. National health services cover the entire
population. Financing is almost always through general governmental funds, and
services are provided by salaried doctors and other health personnel who work
in government hospitals and health centers. Practically all services are
included and provided free of charge, and administration is unified by health
departments. Regional integration of facilities, which is almost impossible to
realize under the health-insurance program, is one of the important
achievements of national health services.
The worldwide trend is towards a
national health service. Among the industrial capitalist nations, for example, Britain in 1948 was the first to establish
such a service. The entire population is covered; hospital specialists are
government employees, but the general practitioners are still not salaried
doctors working in community health centers. Instead they work as solo doctors
or in small partnerships, usually in their own offices, and have a contractual
relationship with the government. In the developing countries, transition
towards a national health service is facilitated by the fact that both the
public assistance and the social security health systems in these countries generally
have developed on the basis of government hospitals and clinics employing
salaried doctors. Costa Rica, for example, is now moving towards
merging the two systems to form a complete national health service.
Rehabilitation
During the past several decades, a
great many rehabilitation programs and services have been developed to mitigate
the functional disability resulting from disease and injury and to restore
individuals to their maximum possible function in society. Not only physical
restoration but also vocational and social rehabilitation are being given
increasing emphasis as a major aspect of public-health services. This is
consistent with the focus on health rather than disease adopted by WHO. Today
health is considered a state of physical, mental, and social well-being, rather
than merely the absence of illness or infirmity. In the Alma-Ata Declaration of
1978, the member countries of WHO committed themselves to “Health for All”. The
guiding principle of all health departments—local, state, provincial, regional,
and national—is to achieve this goal as fully and rapidly as possible.
