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Sundhedsproblemer i industribyer (kommentar)

Sundhedsproblemer i industribyer (kommentar)


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Denne kommentar er baseret på klasseværelsesaktiviteten: Sundhedsproblemer i industribyer

Q1: Hvilke helbredsproblemer identificerede Edwin Chadwick i sine rapporter offentliggjort i 1842 og 1843?

A1: I sin rapport, Arbejdsbefolkningens sanitære tilstand, udgivet i 1842, hævdede Chadwick, at slumkvarterer, ineffektivt spildevand og urene vandforsyninger i industribyer forårsagede unødvendige dødsfald for omkring 60.000 mennesker hvert år. Året efter identificerede Chadwick en anden sundhedsfare. I Internering i byer, argumenterede han for, at traditionen med at holde døde kroppe i hjemmene indtil begravelsen fandt sted var ansvarlig for spredningen af ​​infektionssygdomme.

Q2: Undersøg kilder 1, 3, 4, 7, 9, 11 og 12. (a) Hvorfor var dunghills mere et problem om sommeren end om vinteren? (b) Forklar, hvorfor dunghills var ansvarlige for en betydelig mængde sygdom. (c) Angiv grunde til, at mange britiske gader havde dunghills i første halvdel af 1800-tallet. Hvilken af ​​disse grunde er den vigtigste?

A2: (a) Det varmere vejr om sommeren øgede den dårlige lugt af dunghills. (b) Dunghills var fulde af bakterier, der forårsagede sygdom. Kilde 1 viser børn, der leger i gryden, mens en kvinde søger efter objekter, som hun kan finde nyttige. Denne kontakt med dunghills resulterede ofte i, at folk blev syge. Sygdom blev også spredt af fluer, der tog bakterier fra gryden og efterlod dem på mad i husene. (c) Menneskeligt affald blev stablet op på gaden, fordi de fleste huse ikke havde rør til at fjerne kloakken. Af og til blev dette affald fjernet af natfolk (kilde 9). Som William Thorn påpeger i kilde 11, blev dette derefter solgt til landmænd som gødning. Selvom der blev tjent penge på dunghills, var hovedårsagen til, at de eksisterede manglen på kloakrør.

Q3: Undersøgelseskilde 6. Hvad fortæller det os om industribyer og folkesundhed? Forklar, hvorfor forandring ikke altid er det samme som fremskridt.

A3: I sin rapport fra 1842 sammenlignede Edwin Chadwick gennemsnitsalderen for dødsfald i forskellige områder i Storbritannien. Hans tal viser, at folk var mere tilbøjelige til at dø i en tidligere alder i industribyer (Bolton, Liverpool og Manchester) end i landdistrikter. Der var også en stor forskel mellem gennemsnitsalderen for død i forskellige sociale grupper, der bor i samme område. Chadwick hævdede, at nogle aspekter af det industrielle liv, som forurenet luft, påvirkede alle mennesker
der boede i området. Nogle ting som forurenet vandforsyning påvirkede imidlertid hovedsageligt de fattige.
Nogle historikere har brugt disse oplysninger til at argumentere for, at forandring ikke er det samme som fremskridt. I det 19. århundrede flyttede et stort antal mennesker fra landsbyer til industribyer. Som et resultat faldt den gennemsnitlige dødsalder og var derfor et eksempel på regression frem for fremskridt.

Q4: Undersøg kilder 5 og 13. (a) Hvorfor var rækkehuse billigt at bygge? (b) Hvorfor er der gravet en grøft mellem de to husrækker? (c) Angiv to grunde til, at huse ofte blev bygget tæt på floder og kanaler?

A4: (a) Rækkehuse i ryggen var billige at bygge, da dette design sikrede, at husene delte så mange vægge som muligt. Dette sparer plads og materialer. (b) Grøften tillod kloakken at løbe væk fra husene. (c) Dr. Robertson påpeger, at fabrikker normalt blev bygget på floder og kanaler. Da husene blev bygget tæt på fabrikkerne (så arbejderne ikke behøvede at rejse særlig langt for at arbejde), var de også tæt på floder og kanaler. Dette gav også arbejderne en bekvem vandforsyning.

Q5: Læs kilde 13. Hvorfor mener forfatteren, at nogle historikere har været for kritiske over for Edwin Chadwick?

A5: R. A. Lewis argumenterer for, at Chadwicks ideer om folkesundhed skabte stor fjendtlighed. Hans modstandere tyede ofte til at angribe Chadwicks karakter såvel som hans ideer. Dette har resulteret i en masse kilder, der er kritiske over for Chadwick. Lewis mener, at nogle historikere har behandlet disse kilder som nøjagtige frem for at være en del af en propagandakampagne. Som følge heraf mener Lewis, at historikere ofte har givet et ugunstigt indtryk af Edwin Chadwicks karakter.


Læringsmål

Efter afslutning af dette modul vil den studerende være i stand til:

  • Forklar udviklingen af ​​begreber om årsag og forebyggelse af sygdom.
  • Beskriv vigtigheden af ​​at studere de faktorer, der er forbundet med resultater på en systematisk måde i mennesker.
  • Diskuter nogle af de store historiske figurer og begivenheder, der spillede en rolle i udviklingen af ​​folkesundhed og epidemiologi.

Bemærk: fed skrift kan rulles over for at give en definition.


Anerkendt som 'miljøracisme'

Rene Miller er i øjeblikket involveret i en retssag mod svinefarmen, der sprøjter svineaffald videre til en mark på tværs af gaden fra hendes hjem. Foto: Alex Boerner

For at forstå Rene Millers knibe, skal du starte med grisene.

Deres befolkning i North Carolina steg mere end tredoblet på bare et årti, fra 2,8 millioner i 1990 til 9,3 millioner i 2000 - hvor den har opholdt sig mere eller mindre siden.

I 1986 rangerede North Carolina syvende i landet inden for svinekødsproduktion 30 år senere, det er kun nummer to til Iowa, med anslået 9 millioner grise på 2.217 svinefarme, ifølge det amerikanske landbrugsministeriums kvartalsvise undersøgelse af svin og den amerikanske folketælling i 2012 om Landbrug. Grisene har indvarslet en industri på 2,9 mia. Dollar om året, der beskæftiger mere end 46.000 mennesker i North Carolina. Men disse svin producerer også millioner af tons afføring. På bare et år producerede anslået 7,5 millioner svin i fem østlige North Carolina -amter mere end 15,5 mio. Ton afføring, ifølge en rapport fra 2008 fra General Accounting Office.

Ingen steder er virkningerne mere dybtgående end i Duplin County, hvor Miller og omkring 2,3 millioner svin bor - mere end andre steder i staten, ifølge Environmental Working Group, en forsknings- og fortalervirksomhed.

En nylig analyse af EWG af amts- og satellitdata viste, at cirka 160.000 nordkarolinere bor inden for en halv kilometer fra en svine- eller fjerkræfarm i Duplin, næsten 12.500 mennesker, mere end 20% af dens beboere, lever inden for dette område. Hvis du forlænger radius til tre miles, falder hele 960.000 nordkarolinere i den kategori. Det er næsten 10% af statens befolkning.

For Miller er disse tal ikke abstraktioner. De er hendes liv.

"Den duft er så dårlig," siger hun. "Du kan ikke gå udenfor. Du kan ikke gå udenfor og lave noget, fordi fluer og myg tager over. ”

Inden for en kilometer fra hendes ejendom ejer Murphy-Brown LLC-et datterselskab af Smithfield Foods, den største svineproducent i verden-5.280 svin, ifølge NC Department of Environmental Quality. Inden for to miles er der mere end 80.000 Murphy-Brown-ejede svin på syv forskellige gårde, ifølge en retssag Miller anlagde i 2014.

Halvtreds meter fra Millers familie kirkegård er en massiv open-air cesspool, der opbevarer grisernes affald-en stillestående pool indeholdende deres afføring, urin, blod og andre kropsvæsker-ofte omtalt som en "lagune", en af ​​omkring 3.300 laguner på tværs af stat. Når cesspoolen når sin kapacitet, bliver dens indhold flydende og sprøjtet ind i en mark på tværs af gaden fra Millers hus via et stort, sprinklerlignende apparat. Sprøjten frigiver en tåge af affald på marken, som ifølge retsdokumenter er omkring 200 meter fra Millers hjem ved sin nærmeste rotation.

Det system forhindrer cesspoolen i at flyde over, men Miller siger, at det også gør hendes liv elendigt.

Det er mere end bare lugten, siger hun. Den flydende affaldtåge driver videre til hendes ejendom, og "døde kasser" fyldt med rådnende svin sidder nær hendes families kirkegård og tiltrækker musvåge, myg og sværme af store sorte fluer. Efter at have brugt tid udenfor, siger hun, brænder hendes øjne og hendes næse vander.

Hun siger, at hun også lider af astma, som hun begyndte at udvikle kort efter, at hun i slutningen af ​​80'erne vendte tilbage til sit barndomshjem fra New Jersey for at passe sin skrantende mor.

Forskning udgivet af afdøde Steven Wing, professor i epidemiologi ved University of North Carolina's Gillings School of Global Public Health, knyttede lignende sundhedsmæssige bekymringer til nærheden til svinebrug.

Wing, der døde i november, beskrev sin forskning i en TED Talk fra 2013:

"I 1995 begyndte jeg at møde naboer til industrielle svineoperationer," sagde han. »Jeg så, hvor tæt nogle kvarterer er på svinekød. Folk fortalte mig om forurenede brønde, stanken fra svineoperationer, der vækkede dem om natten, og børn, der blev hånet i skolen for at lugte som svineaffald. Jeg studerede den medicinske litteratur og lærte om allergener, gasser, bakterier og vira frigivet af disse faciliteter - alle sammen i stand til at gøre folk syge. ”

Unge svin er samlet i stier på Butler Farms i Lillington, NC. Grisene lever på lamelgulve, som deres affald vaskes igennem og samles, før de pumpes ned i overdækkede laguner. Foto: Alex Boerner

Wings forskning viste en sammenhæng mellem luftforurening fra svinebrug og højere kvalme, stigninger i blodtryk, åndedrætsproblemer som hvæsende vejrtrækning og øgede astmasymptomer for børn og generelt nedsat livskvalitet for mennesker, der bor i nærheden.

"Luftforurenende stoffer fra rutinemæssig drift af indespærringshuse, tankrum og affaldssprøjter påvirker nærliggende kvarterer, hvor de forårsager afbrydelse af dagliglivets aktiviteter, stress, angst, slimhindeirritation, åndedrætsbetingelser, nedsat lungefunktion og akut forhøjelse af blodtryk, ”Wing og andre UNC -forsker Jill Johnston skrev i en undersøgelse fra 2014.

De fandt også ud af, at statens industrielle svineoperationer uforholdsmæssigt påvirker afroamerikanere, latinamerikanere og indianere. Dette mønster, konkluderede de, "er generelt anerkendt som miljøracisme".

Miljøracismeargumentet har vundet nogle magtfulde allierede, herunder den amerikanske senator Cory Booker, en demokrat i New Jersey, der i et podcastinterview for nylig fordømte North Carolina svineindustrien, som han kaldte "ond" for at udnytte sine afroamerikanske naboer.

"De fylder massive laguner med [affald], og de tager de lagunestoffer og sprøjter det over marker," sagde han til Pod Save America og mindede om en tur til North Carolina sidst i fjor. “Jeg så den tåge af ejendommen til disse massive svinebrug i sorte samfund. Og disse afroamerikanske samfund er som: 'Vi er fanger i vores eget hjem.' Det største firma dernede [Smithfield] er et kinesisk ejet selskab, og så har de forgiftet sorte samfund, grundværdien er nede, afskyelig ... Dette selskab outsourcer sine smerter og omkostninger til fattige sorte mennesker i North Carolina. ”

Booker, hvis far voksede op i Hendersonville og tog eksamen fra NC Central, fortalte INDY i en erklæring: "Jeg så på egen hånd i North Carolina, hvordan virksomhedernes interesser uforholdsmæssigt lægger miljø- og folkesundhedsbyrder på lavindkomstsamfund, at de aldrig ville acceptere i deres egne kvarterer. I North Carolina mishandler store virksomheders svinekødsproducenter små kontraktbønder og eksternaliserer deres omkostninger til sårbare samfund, forurener luft, vand og jord og gør børn og familier syge, mens de høster store økonomiske gevinster.

“Og desværre ved vi, at dette ikke kun er et problem i North Carolina. Lignende miljømæssige uretfærdigheder opstår lige nu overalt i USA. Dette er uacceptabelt for mig, og jeg er i gang med at finde måder, hvor den føderale regering kan begynde at løse dette problem på en meningsfuld måde. ”

I maj tog USA's repræsentant David Price, en demokrat, der repræsenterer dele af Wake og Orange amter, sit eget stød på en lovgivningsmæssig løsning. Han indførte svineloven, et lovforslag, der havde til formål at forbedre miljøstandarder for North Carolina's svineindustri.

"Det er et problem, vores stat har en enorm andel i," siger Price. »Det er et spørgsmål om at finde den politiske vilje til at komme foran kurven her. For hvis vi ikke gør sådan noget, hvis vi ikke får disse gårde videre til et mere sundt affaldsbortskaffelsessystem, vil vi leve for at fortryde det. ”

Mens Price's regning i øjeblikket svinder i udvalget, er dette spørgsmål allerede på vej gennem domstolene.

For tre år siden indgav Miller og mere end 500 andre indbyggere i North Carolina, hovedsagelig fattige og afroamerikanere, 26 føderale retssager mod Murphy-Brown, der påstod, at dens adfærd påvirker deres helbred og livskvalitet negativt. Retssagerne hævder, at Murphy-Browns moderselskab, Smithfield-som blev købt af det multinationale kinesiske selskab WH Group i 2013 for anslået 4,7 mia. Dollars-har de økonomiske ressourcer til at håndtere grisenes affald på en måde, der minimerer lugt og gener for nærliggende ejere.

Industrien afviser disse påstande.

"North Carolina's svinebønder er under et koordineret angreb af rovdyr, advokater mod landbrugsaktivister og deres allierede," sagde Smithfield Foods til INDY i en e-mail. "Retssagerne handler om én ting og kun én ting: et pengegreb."

Smithfield påpeger, at DEQ mellem 2012 og 2016 kun modtog 25 lugtklager, og af dem resulterede ingen i bøder eller meddelelser om overtrædelser.

"Mere end 80% af svinebrugene ejes og drives af familier," hævder Smithfield. "De producerer gode produkter, de gør det på den rigtige måde, og de stræber efter at være gode naboer."

Andre brancheforkæmpere har også påstået, at grådighed er kernen i disse påstande. Hog -landmænd er samvittighedsfulde naboer, argumenterer industrien. Og Smithfield og NC Pork Council, en handelsgruppe, der finansieres af kommercielle svineoperationer, påpeger begge, at retssagerne ikke beder landmænd om at ændre specifik adfærd. NC Pork Council, en handelsgruppe finansieret af kommercielle svineoperationer, har bebrejdet retssagerne for ivrige advokater, der "kan lide at sagsøge landmænd for så mange penge som muligt".

"De fleste landmænd bor på eller ved siden af ​​deres gårde og arbejder hårdt på at passe godt på jorden," siger Andy Curliss, administrerende direktør for svinekødsrådet. ”De er en integreret del af de samfund, de lever i. De gør tingene på den rigtige måde og stræber efter at være gode naboer. ”

I en e-mail siger Mark Anderson, en advokat, der repræsenterer Murphy-Brown, at virksomheden "aggressivt anfægter sagsøgernes påstande. Efter grundig undersøgelse konkluderede vi, at påstandene ikke er gyldige og ikke har nogen fortjeneste. ”

Men Miller siger, at hun ved, hvad hun har oplevet - og at livet på Veachs Mill Road er blevet forværret, siden svinehusene kom.

"Lige nu," siger hun, "er mit liv det værste, det nogensinde har været."


Konklusion

Selvom videnskaben udgjorde et fundament for folkesundheden, har sociale værdier præget systemet. Sundhedsstyrelsens opgave har ikke kun været at definere målsætninger for sundhedssystemet baseret på fakta om sygdom og sundhed, men også at finde midler til at implementere sundhedsmål inden for en social struktur. '' Grænserne for folkesundhed [har ændret sig] over tid med opfattelsen af ​​nye sundhedsmæssige og sociale problemer og med politiske, økonomiske og ideologiske ændringer inden for regeringen og nationen. "(Fee, 1987) Folkesundhedens historie har været en med at identificere sundhedsproblemer, udvikle viden og ekspertise til at løse problemer og samle politisk og social støtte omkring løsningerne.

På trods af de enorme succeser, der er skabt af videnskabelig opdagelse og sociale reformer, og på trods af en fænomenal vækst i offentlige aktiviteter inden for sundhed, er løsningen af ​​folkesundhedsproblemer ikke sket uden kontroverser. Gentagne gange er regeringens rolle i reguleringen af ​​individuel adfærd blevet udfordret. Så tidligt som i 1853 blev Storbritanniens sundhedsstyrelse f.eks. Opløst, fordi Chadwick, dets direktør, "krævede et bredt spillerum for statsindgreb i en tid, hvor laissez-faire var datidens lære". (Chave, 1984) Forholdet mellem folkesundhed og privat lægepraksis har også været meget debatteret. I 1920 modsatte og lykkedes New York Medical Society kraftigt at besejre et forslag til et system med offentlige landklinikker i hele staten. (Starr, 1982) Argumenter om omfanget af den offentlige sundhed og omfanget af den offentlige sektors ansvar for sundhed fortsætter den dag i dag.

Udviklingen af ​​et videnskabeligt grundlag for folkesundhed tillod en vis konsistens i det offentlige sundhedssystem i hele landet. Alle stater i USA er på en eller anden måde involveret i sanitet, laboratorieundersøgelser, indsamling af vitale statistikker, regulering af miljøet, epidemiologi, administration af vacciner, moder- og børns sundhed, mental sundhed og pleje af fattige. Hvordan lokale systemer gennemfører disse programmer, er meget forskellig fra område til område. Ændringer af værdier over både tid og sted har tilladt stor variation i implementeringen af ​​folkesundhedsprogrammer i hele landet.

Det følgende kapitel, der opsummerer det nuværende folkesundhedssystem i USA og folkesundhedsaktiviteter i seks stater, som udvalget har besøgt, illustrerer de forskellige tilgange til folkesundhed, der har udviklet sig i det nuværende system.


Sygdomme i industribyer i den industrielle revolution

Sygdom tegnede sig for mange dødsfald i industribyer under den industrielle revolution. Med en kronisk mangel på hygiejne, lidt viden om sanitær pleje og ingen viden om, hvad der forårsagede sygdomme (endsige helbrede dem), kan sygdomme som kolera, tyfus og tyfus være ødelæggende. Efterhånden som byerne blev mere befolkede, blev problemet værre.

En beskidt "Fader Themsen"

Kolera var en stærkt frygtet sygdom. Forårsaget af forurenet vand kan det spredes hurtigt og med ødelæggende konsekvenser. Ikke for ingenting fik sygdommen øgenavnet “Kong Cholera“. Det industrielle Storbritannien blev ramt af et udbrud af kolera i 1831-32, 1848-49, 1854 og 1867. Årsagen var enkel-spildevand fik lov til at komme i kontakt med drikkevand og forurene det. Da mange mennesker brugte flodvand som deres drikkevandskilde, spredte sygdommen sig let.

Et angreb af kolera er pludseligt og smertefuldt - men ikke nødvendigvis dødeligt. I London menes det, at 7000 mennesker døde af sygdommen i udbruddet 1831-32, hvilket repræsenterede en dødelighed på 50% af dem, der fangede den. 15.000 mennesker døde i London i udbruddet 1848-49. Sygdommen ramte normalt dem i en bys fattigere områder, selvom de rige ikke undslap denne sygdom.

Kopper opstod en stor forekomst i industribyer, selv efter Edward Jenners vaccine. Årsagen var enkel. Rigtig mange i industribyerne var uvidende om, at Jenner havde udviklet en vaccine. Da Storbritannien fortsatte sin vej til en befolkning, der hovedsageligt var centreret i byer, og landbrugsregionerne blev mindre befolket, blev traditionelle gamle koner og historier knyttet til dem (såsom koks, mælkepiger, Jenner osv.) Mindre kendt. Også de overfyldte lejemål i byerne var en perfekt grobund for kopper.

Tyfus og tyfus var lige så frygtede som kolera. Begge var også ret almindelige i den industrielle revolution. Tyfus blev forårsaget af inficeret vand, mens tyfus blev båret af lus. Begge blev fundet i overflod i industribyer.

Den største dræber i byerne var tuberkulose (TB). Sygdommen forårsagede spild af kroppen med lungerne angrebet. Lungerne forsøger at forsvare sig ved at producere det, der kaldes tuberkler. Sygdommen får disse knolde til at blive gule og svampede, og hosteanfald får dem til at blive spyttet ud af den syge.

TB påvirkede dem, der havde været dårligt fodret og var underernærede. Det påvirkede også dem, der boede i beskidte og fugtige hjem. TB kan spredes af en person, der trækker vejret i udåndet sputum af en, der allerede har sygdommen. I de overfyldte beboelser i industribyerne kunne en inficeret person meget let sprede sygdommen.

Selvom nøjagtige registreringer er svære at erhverve, menes det, at TB dræbte en tredjedel af alle dem, der døde i Storbritannien mellem 1800 og 1850.

Mikrober blev først opdaget i 1864 af Louis Pasteur. Indtil da blev alle former for teorier fremsat om, hvad der forårsagede sygdomme. En almindelig opfattelse - og en, der dateres tilbage til middelalderens England - var, at sygdommen blev spredt af dårlig lugt og usynlige giftige skyer (miasmer). Industribyer var bestemt plaget af dårlig lugt fra spildevand, industrielle forurenende stoffer osv. Størstedelen af ​​dødsfaldene var i industribyerne. Derfor konkluderede læger, de to gik sammen: død og dårlig lugt/gasser.

Sådanne overbevisninger forårsagede alvorlige problemer. I Croydon fejede tyfus gennem byen i 1852. Det lokale sundhedsstyrelse gik på jagt efter en lugt, der forårsagede sygdommen, men fandt intet. Faktisk havde spildevand sivet ind i byens vandforsyninger og forurenet vandet. Det gik ikke op for sundhedsembedsmændene, at vandet kunne være årsag til sygdommen, da datidens medicinske visdom dikterede en anden årsag.

Selv en stor reformator som Edwin Chadwick var overbevist om, at der blev båret sygdom i atmosfæren, som var blevet forgiftet af dårlig lugt. I 1849 overtalte han myndighederne i London til at rense kloakkerne i deres distrikter. Chadwick mente, at dette ville slippe af med den dårlige lugt og dermed sygdom. Hver uge blev anslået 6000 kubikmeter snavs fejet ind i Themsen - Londons vigtigste vandkilde. Kolera fik en chance for at sprede sig, og 30.000 londonere fik sygdommen i 1849 med 15.000 døende som følge heraf.


Industrialisering og sundhed

Gennem historien og forhistorien har handel og økonomisk vækst altid medført alvorlige befolkningssundhedsmæssige udfordringer. Efterkrigstidens ortodokse demografiske og epidemiologiske overgangsteori og Washington-konsensus har hver især opmuntret til den opfattelse, at industrialisering nødvendigvis ændrer alt dette, og at moderne former for hurtig økonomisk vækst pålideligt vil levere forbedret befolkningssundhed. En mere omhyggelig gennemgang af det historiske demografiske og antropometriske bevis viser, at dette er empirisk falsk og en fejlagtig oversimplificering. Alle dokumenterede udviklede nationer udholdt 'fire D'er' af forstyrrelser, afsavn, sygdom og død under deres historiske industrialiseringer. Den veldokumenterede britiske historiske sag gennemgås detaljeret for at undersøge de vigtigste faktorer. Dette viser, at politiske og ideologiske splittelser og konflikter-og deres efterfølgende løsning til fordel for arbejderflertalernes sundhedsinteresser-var nøglefaktorer for at afgøre, om industrialiseringen havde en positiv eller negativ nettoeffekt på befolkningens sundhed.

Industrialisering refererer til en proces, der er sket i historien om alle økonomisk 'udviklede' nationalstater, og som fortsat er et ambition for de fleste regeringer i de mange befolkninger, der i dag forbliver relativt uudviklede. Gennem industrialiseringen ændres økonomien i et land dramatisk, således at midlerne til fremstilling af materielle varer i stigende grad mekaniseres, da menneskeligt eller animalsk arbejde i stigende grad erstattes af andre, overvejende mineralske energikilder i direkte anvendelse til produktion af nyttige varer 1. Industrialisering er et særligt tilfælde af det næsten universelle fænomen menneskehandel og økonomiske ændringer. Det refererer til en periode med markant intensivering af sådan aktivitet, som i alle kendte tilfælde har resulteret i en irreversibel ændring i et lands økonomi, hvorefter produktion og international handel med varer forbliver permanent på et meget højere intensitetsniveau. Dette skyldes i høj grad, at den faktorielle stigning i produktionskapaciteten, der er muliggjort af det teknologiske skift i strømforsyningen, samtidig medfører en lang række ledsagende transformationer i de sociale relationer mellem arbejde, handel, kommunikation, forbrug og menneskelige bosættelsesmønstre og derfor uundgåeligt også indebærer dybtgående kulturelle, ideologiske og politiske ændringer.

Det ville være ekstraordinært, hvis en sådan gennemgribende proces ikke havde en række betydelige sundhedsmæssige konsekvenser. To af de ældste, mest veletablerede relationer mellem økonomisk aktivitet eller handel og befolkningssundhed anerkendes at være medieret gennem de epidemiologiske konsekvenser af for det første regelmæssig social interaktion mellem befolkninger, der tidligere ikke var udsat for hinandens sygdomsøkologi, og for det andet , den stadig tættere permanente bosættelse af befolkninger, der forekommer i form af byer, der indtager nodal eller strategiske punkter i handelsnetværk. Begge disse relationer er altid blevet forstået at være negative, hvad angår sundheden for de udsatte befolkninger 2-4. Det er altid blevet erkendt, at lokkemidlet og de materielle fordele ved økonomisk udveksling mellem folk, der besidder forskellige ressourcer og producerer forskellige varer, medfører øgede risici for den ledsagende udveksling af potentielt dødelige sygdomme. De historiske optegnelser fra de tidligt moderne bystater i Italien demonstrerer for eksempel deres regeringers opmærksomhed på en række folkesundhedsspørgsmål i forbindelse med sanitære problemer i tætpakket byliv og de periodiske trusler fra importerede epidemier 5. Den gradvise udvidelse af den internationale og interkontinentale handel, herunder naturligvis i personer selv, gennem de efterfølgende århundreder var præget af en række ekstremt dødelige epidemier af infektionssygdomme, mest tragiske af alle for de oprindelige befolkninger i Amerika. Således har en af ​​Frankrigs mest fremtrædende historikere berømt skrevet om en æra med stigende verdenshandel fra 1300 -tallet til det 17. som æra for 'l'unification microbienne du monde' 6.

På trods af disse velforståede, mangeårige negative sundhedsrisici forbundet med urbanisering og handel, er industrialiseringsprocessen derimod generelt blevet anset for at have et meget mere positivt forhold til menneskers sundhed. Der er naturligvis en meget indlysende intuitiv grund til dette. Det er udbredt forståelse, at industrialisering var en nødvendig igangsættende historisk proces, som alle nutidens ’succesfulde’ indkomstsamfund med høj indbygger har oplevet. Disse er generelt blandt de befolkninger med den højeste forventede levetid ved fødslen i verden i dag. Dette er blevet muliggjort af den avancerede medicinske teknologi, bedre fødevareforsyning og øget materiel levestandard som følge af den kontinuerlige proces med økonomisk vækst, de alle har oplevet lige siden industrialiseringen. Den tilsyneladende overbevisende logiske slutning er, at industrialiseringen har forbedret menneskers velfærd og sundhed. Denne konklusion er gentagne gange blevet støttet i løbet af det 20. århundrede af en række forskningsbaserede fortolkninger af forholdet mellem sundhed og den form for vedvarende økonomisk vækst, der er muliggjort ved industrialisering 7-13. Undersøgelsen af ​​britisk økonomisk historie har spillet en særlig afgørende rolle for at informere denne generelt positive vurdering, dels fordi den var den første nationalstat nogensinde til at industrialisere, men også på grund af den usædvanligt høje kvalitet og mængde af dens historiske medicinske, epidemiologiske og demografiske som samt økonomiske data. Dette skyldes hovedsageligt, at den britiske nationalstat som en rekordskabende og bevarende enhed har bevaret sin integritet gennem mange århundreder, hvilket har resulteret i en relativ overflod af beviser. 47

Den overvejende betydning af et sekulært fald i dødeligheden som det første og fremmeste velfærdsudbytte fra industrialiseringen har været et centralt træk ved den ortodokse konsensus gennem det sidste århundrede. I begyndelsen af ​​det 20. århundrede var det indlysende, at hurtig befolkningstilvækst havde ledsaget industrialiseringsprocessen i hvert moderne lands historie. I Sverige, det eneste land, hvis officielle vitale statistik pålideligt nåede tilbage til 1700 -tallet, var det også tydeligt, at befolkningstilvæksten i det 19. århundrede hovedsageligt havde været et resultat af faldende dødelighed, hvilket afspejlede forbedret befolkningssundhed. 48 I 1926 optrådte to uafhængige forskningsmonografier om Storbritannien 7, 8, der hver dokumenterede alle de vigtige fremskridt inden for medicinsk viden og institutioner, der skete fra slutningen af ​​det 17. til begyndelsen af ​​det 19. århundrede. Disse blev portrætteret som de sundhedsfremmende første frugter af den samme spirende ånd af rationel videnskabelig undersøgelse, der havde givet samtidig fremskridt inden for teknologi og industri. I 1929 var der skitseret en stor generel teori om 'demografisk overgang', som skulle blive den dominerende internationale 'udviklings'-ortodoksi i hele efterkrigstiden 14-16. Dette forestillede sig, at alle industrialiseringslande nødvendigvis skulle gennemgå et lineært evolutionært mønster af tre faser. Det primal mobil af økonomisk vækst forårsagede direkte et fald i de høje dødelighedsrater, der kendetegner første etape, ved at hæve levestandarden og gennem samfundets øgede evne til at drage fordel af lægevidenskab, hygiejne og sanitet. I overgangsfasen to steg befolkningstilvæksten derfor hurtigt, indtil forældrene i sidste fase tre justerede deres traditionelle fertilitetsadfærd ved at reducere deres fødselsrater for at afspejle de nye omstændigheder med meget højere overlevelsesrater for deres afkom.

I 1970'erne blev overgangsteorien tilsyneladende yderligere uddybet af to indflydelsesrige bidrag. For det første specificerede Omrans begreb om den epidemiologiske overgang tre typer af epidemiologisk regime, der er typiske for de tre faser af demografisk overgang 17. Hungersnød og pest dominerede den førindustrielle fase af høj dødelighed, efterfulgt af 'tilbagegående pandemier', efterhånden som overgangssamfund industrialiserede, blev rigere og deres medicinske teknologi avancerede. Endelig blev de mest udviklede samfund med høj forventet levetid i trin tre primært ramt af en rest af 'degenerative og menneskeskabte sygdomme'. For det andet Thomas McKeowns meget læste Den moderne befolkningstilvækst hævdede, at hovedårsagen til dødeligheden fald som følge af industrialiseringen, som specificeret i overgangsmodellen, ikke var medicinsk videnskab og teknologi, men primært stigende levestandard 10. The beneficial effect of economic growth on population health was initially transmitted primarily through a gradually rising per capita nutritional intake made possible by a better food supply and rising real incomes (purchasing power). McKeown founded this conclusion on his pioneering epidemiological analysis of the historical series of detailed cause-of-death data available for the whole population of England and Wales since the mid-19th century.

Although McKeown’s thesis, to the extent that it was evidence-based, applied only to the epidemiological history of one country, his findings were nevertheless taken to be broadly generalizable. This was partly because of McKeown’s persuasive skills and his impressively detailed epidemiological data. It was also the result of a widespread assumption, which pervaded the post-war era and which continues to be influential, that the demographic or epidemiological transition is itself a singular, generic process, which has occurred repeatedly following industrialization in all developed countries’ histories a . It follows from this assumption that it can therefore be adequately studied through a single well-documented example. It also followed that the currently non-industrialized countries of the 1970s might profitably learn from such a model and fashion their development policies accordingly.

The 1970s also witnessed the emergence of a resurgent, monetarism and neo-classical economics, which, during the course of the 1980s, replaced the social democratic ‘Keynesian’ with the neo-liberal ‘Washington’ consensus as the dominant programmatic set of policy prescriptions informing the macro-economic and lending policies of western governments and banks and the major Bretton Woods institutions of the World Bank and the IMF, located in Washington. The existence of McKeown’s well-publicized work made it much easier to press forward the neo-liberal economic agenda in the course of the 1980s, with its focus on maximizing capitalist, free market economic growth, not only in the ‘First World’ but also in the world’s least developed countries, since McKeown had apparently proved that the rising living standards facilitated by industrialization had been the principal cause of epidemiological transition in the past.

There had always been important dissenting voices, which disputed the general validity of McKeown’s work, notably, Sam Preston’s important cross-national statistical research. This indicated that during the course of the 20th century rises in societies’ overall investments in health-promoting technology and services—much of it state-organized and funded—was a more significant source of gains in average life expectancy than their rising per capita incomes 18, 19 . However, this was not the message that neo-liberal economists wanted to hear, intent as they were on ‘rolling back’ the state and freeing-up the market. Furthermore, during the 1980s, McKeown’s emphasis on the importance of nutrition also caught the eye of the highest profile practitioner of economic history. The Nobel prizewinner Robert Fogel b published a series of research papers during the late 1980s and early 1990s which presented a new source of long-run historical health data—the anthropometric evidence of American military recruits’ heights and weights 12, 20, 21 . He argued, along McKeownite lines, that this also showed that nutritional inputs were the most important driver of population health during the initial stages of industrialization. Thus, in the important World Development Report for 1991, compiled under the general direction of the leading neo-liberal, Lawrence Summers, Fogel’s work was given prominence and McKeown was cited but there was no reference to Preston’s alternative analyses 22 .

However, in Britain the 1980s also saw the publication of a major new work of long-term historical demographic reconstruction, which radically undercut the crucial assumptions of ‘transition’ theory and so, also of McKeown’s interpretation of the British epidemiological data from the mid-19th century onwards. The Cambridge Group for the History of Population and Social Structure succeeded in reconstructing the population history of England, including national trends in mortality and fertility, on the basis of a 4% sample of the data held in the 10,000 parish registers of England back to their instigation by Henry VIII in 1538 23 . Their work demonstrated, firstly, that England before industrialization was not a regime of high famine and pestilence mortality as envisioned in transition thinking. Secondly, the quadrupling of English population, which took place during industrialization between 1700 and 1870, was driven principally by the increased fertility of marriage and only to a relatively slight extent by a modest fall in mortality. Around 1700, expectation of life at birth had been approximately 36 years and by 1871 it still stood at no more than 41 years. Following this pioneering effort, there has been an enormous flow of further primary research exploiting Britain’s parish registers and much other relevant evidence, which has confirmed these two principal findings 24 .

McKeown had supposed, from within the perspective of modernization and transition thinking, that in addressing the epidemiological patterns of falling mortality, which he could track from the Registrar-General’s official cause of death data from ca. 1851 onwards, he was analysing a single secular trend, which would have started during the late 18th century when it was believed that the British industrial revolution had begun. However, one of the further important conclusions to emerge from the research of the demographic historians was that McKeown’s data series began in the middle of a strange, half-century-long period of stasis in the nation’s mortality. The national average expectation of life at birth had improved fitfully and gradually during the 18th century to reach a level of about 41 years by 1811 but thereafter it failed to register any further improvement above that level until the 1870s. This meant that during the whole of the period when the British economy experienced its historically unprecedented, sustained economic growth rates, while its steam-driven economy powered its way to global trading predominance during the long mid-Victorian boom, overall mortality rates failed to improve at all. Although health had apparently improved moderately during the initial phases of slow economic growth in the 18th century, when full-scale industrialization arrived with the diffusion of steam technology, factories and rail transport, there were then no further net gains in health for two generations. This is despite the fact that workers’ average real wages, which showed no overall improvement before 1811, now began definitely to rise throughout the rest of the 19th century 25 . This chronology is all wrong for the McKeown thesis. Mortality fell in the 18th century without the benefit of increased purchasing power for food (the fluctuating cost of food was the major budgetary item influencing the reconstructed average real wage trend), whereas overall health failed to improve between 1811 and 1871, despite enhanced purchasing power.

Further research on an independent body of evidence, British anthropometric data, has confirmed that late 18th-century improvements in height attainments were curtailed and then even reversed during the second quarter of the 19th century 26 . It is now clear from this and from other detailed demographic research on urban patterns of mortality during this period, that the principal reason for the failure of the national average life expectancy to register any further gains between 1811 and 1871 was due mainly to deteriorating health conditions in Britain’s industrializing towns and cities (Szreter and Mooney 27 ). All the available evidence for a variety of towns of very different sizes, from a Carlisle or a Wigan to Glasgow, exhibits the same patterns and trends. Urban life expectancies, though they had probably improved during the late 18th century, were well below the national average by the end of the first quarter of the 19th century. Thereafter they experienced a particularly deep crisis persisting for two decades during the 1830s and 1840s, followed by a return to the pre-crisis levels (dvs. still well below the static national average) in the 1850s and 1860s. From the 1870s onwards, urban life expectancies finally began to climb above the levels of the early 19th century and, in so doing, pushed the national average onto an upward trend, too (Britain by this time having become a predominantly urban society).

Thus, quite to the contrary of the dominant 20th-century consensus, the only abundantly documented historical case, Britain, shows that industrialization had a powerfully negative direct impact on population health, concentrated particularly among the families of the relatively disempowered, displaced migrants who provided a large part of the workforces in the fast-growing industrial towns and cities 28 . According to this viewpoint, industrialization is not a special case, but conforms to the more general pattern, throughout human history, that periods of increasing economic activity, because they are associated with increasing trade and urban settlement, are also intrinsically productive of increased health risks. Indeed, industrialization, because it is so extensive in its economic scale of transformation, may well exert its negative health effects more dramatically and rapidly than any of the historically earlier forms of more moderate increases in trade and economic activity.

There are a number of ways of seeking to explain these findings about 19th-century Britain in such a way as to reject this conclusion and to preserve instead the conviction that industrialization is, still, a special case and has been a positive influence on health. However, each of these collapses on closer examination. It is, for instance, not the case that such negative health effects as Britain’s towns experienced in the 1830s and 1840s were ‘merely’ the result of urban size or speed of growth or inadequate knowledge of health-preserving technology at that time. Towns of all different sizes from just 20,000 to over 100,000 inhabitants were affected. Most cities grew no faster in these two decades than any two of the previous six or seven decades. Nor was there an inevitable knowledge or ‘learning’ deficit. The technology for constructing urban water supply and the importance of sanitation and sewering was well-understood, as Edwin Chadwick’s summation of knowledge published in 1842 shows 29 the importance of personal hygiene, good food and cleanliness of the personal environment was also well-understood as Haines et al have ingeniously demonstrated 30 .

The heterodox thesis is that industrialization itself, like all forms of economic growth, exerts intrinsically negative population health effects among those communities most directly involved in the transformations which it entails. The case for this apparently paradoxical proposition grows much stronger when it is realized that in virtually all known cases of the industrialization of today’s successful developed economies, their historical demographic or anthropometric trends exhibit the same ‘trademark’ pattern of a negative inflection in the health trends during the decades in which industrialization most affected their populations. This is true, for instance of studies which have been published on populations in USA, Germany, France, Holland, Japan, Australia, Canada and Sweden 31 (Sweden has sometimes been considered an exception, but the most recent research has shown that the landless Swedish rural populace did suffer significant health consequences during the second quarter of the 19th century when their agricultural economy was first exposed to commercial pressures necessitating raised productivity, whereas later in the century it was the crucial role played by advanced government public health measures in the 1870s in anticipating the health problems of industrial urbanization, which minimized such negative effects when Sweden experienced its own industrialization) 32, 33 .

However, it is also true that in each of these cases, as in Britain, a period during which the health of the population was compromised by industrialization was ultimately resolved, so that continuing economic growth came eventually to be accompanied by generally rising health—even in the largest most densely populated cities—resulting in the high life expectancy societies of the present day. The crucial analytical point, of enormous policy relevance, is that this potential capacity of post-industrial economic growth to provide the material basis for generally enhanced population health is not intrinsic to the process of industrialization or of economic growth in itself.

As careful attention to the historical relationship between industrialization and health in the case of Britain and most other countries shows, the direct consequences of rapid economic growth on health are likely to be negative, for a set of long-understood epidemiological reasons. In fact the kind of dramatic transformation associated with the industrialization of an economy is especially likely to be negative in its immediate impact on health and welfare because of the profoundly disruptive nature of this change. The disruption is simultaneously multi-dimensional: social and familial relations, moral codes, ethical standards of behaviour, the physical and the built environments, forms of government, political ideologies and the law itself are all thrown into flux and tumult when a society experiences industrialization and the consequent population movements that are entailed. Such disruptions tend to cause forms of social deprivation to arise, which can lead to disease and ultimately to death for the most unfortunate and marginalized individuals—often children, migrants or ethnic minorities. These are the ‘four Ds’ of rapid economic growth: disruption, deprivation, disease and death 34 . They can only be addressed through political mobilization of the society to devise new structures, which can respond to the forces of disruption and remedy their consequences. This typically requires, at a minimum, massive investment in urban preventive health infrastructure, and an accompanying regulatory and inspection system, along with a humane social security system.

The classic, catch-22 problem, for societies experiencing the disorienting transformations of industrialization is that politics itself is profoundly disrupted, since the process throws up, by definition, a variety of newly powerful commercial and business ‘interest’ groups, typically very divided among themselves on ethnic, regional, industrial or religious lines, to challenge the incumbent governing classes. In British society and its industrial towns, an effective paralysis of the political will occurred for two generations between approximately 1830 and 1870 as successive national and local governments doggedly dodged the expensive issue of investment in urban preventive health infrastructure, even in the face of recurrent cholera visitations. The default ideology of this era, ‘laissez-faire, laissez passer’, reflected the political wisdom that in such a socially fissured society of vigorous competing interests, ‘every man for himself’ was the only general proposition which could command assent. In an as yet undemocratic ‘shopocracy’, dominated by the votes of those precariously trying to keep their heads above water in a roller-coaster market economy, the only electable governments were those which promised to keep national income tax or local rates to an absolute minimum—the most common electoral battle cries were ‘retrenchment’ and ‘economy’ 35 . As a result, whereas the ‘winners’ in this society invested and gambled huge amounts of capital in the railway mania, there was no adequate collective investment in even the basic urban health infrastructure of sewers and clean water and street paving (crucial for health in a horse-drawn economy) 36 . Whereas the paternalistic landed governing class had presided in the late 18th century over an increasingly generous national social security system, the Old Poor Law, spending was slashed under the deterrent ‘workhouse’ system of the New Poor Law of 1834, reflecting the evaporation of social trust between the classes in this disrupted and divided society 37, 38 .

After delaying for as long as they dared, from 1867 to 1928, in response to organized male working-class and subsequent feminist political pressure, the British propertied governing class passed a sequence of four major enfranchisement acts which ultimately granted the vote to all adults of both sexes on an equal basis. From 1867 onwards, this began to transform the electoral arithmetic and the politics of the health and social security needs of the wage labour class in society. The shift in political economy occurred first at municipal level. Under its visionary Mayor Joseph Chamberlain, an industrial magnate, the city of Birmingham pioneered a programme of ‘gas and water socialism’ as its opponents vilified it 39, 40 . Local monopoly services were bought, built and run by the city to provide revenue for an expanding preventive health and social services infrastructure. Once Chamberlain had proved both the electoral and the practical viability of this new political economy, all other major cities and eventually smaller towns, too, followed suit over the next three decades 41 . The towns were beautified but also, crucially, the urban death-rates came tumbling down as local authorities’ expenditure on the health and environmental needs of their mass electorates multiplied to the point where in 1905 the total amount spent by vigorous local governments actually exceeded (for the only time in Britain’s recorded history) the total spent by central government 42 . In December 1905, the ‘New Liberal’ administration won a landslide general election victory and ushered in an entirely new era of state activism with a host of centrally-organized and funded measures, such as old age pensions, labour exchanges, a school medical inspection service, free school meals for the needy, and national insurance against sickness and unemployment for workers. The politics of working-class interests had thus transmuted from the municipal to the national stage in Britain, something which would ultimately lead to the enactment of the welfare state.

The lessons of history, therefore, are that all economic exchange entails health risks and that industrialization typically results in a particularly concentrated cocktail of such health risks. From a policy point of view, it is particularly important that currently non-industrialized societies are neither encouraged nor forced to enter the industrialization process without a clear understanding of the difficult prospects which they face for at least a generation while undergoing this profoundly disruptive process. It may well be possible to avoid the undesirable fourth ‘D’ of death and possibly even the third ‘D’ of disease, given a sufficiently careful and thoroughgoing effort to manage and respond to the forms of deprivation which rapid economic growth produces as it transforms communities and relationships—something which Sweden may well have achieved during the last quarter of the 19th century. Like the Swedish case, the British historical case also suggests that extremely committed, well-informed, well-funded, devolved and democratically responsive forms of local government may be more important than the central state in effectively managing the immediate negative health consequences of industrialization. However, ultimately, the redistributive resources and authority of the central state in a democratic society will undoubtedly become important in ensuring that long-term sustained economic growth continues to be a benefit to the health and welfare of the whole population, rather than merely a source of ever-increasing private wealth to a small proportion of individuals favoured by birth and by chance, which is a tendency inherent in the normal working of unregulated, free market capitalism.

The apparently intuitively obvious notion that the economic growth of industrialization must be straightforwardly beneficial for health has, thus, been shown to be based on a misleading simplification of economic and demographic history, though one which was apparently supported by now-obsolete historical and epidemiological interpretations of history. It is now increasingly emphasized by historical researchers that politics and government have played an all-important role in ensuring that the wealth accumulated by the socially divisive and competitive processes of market economic growth is recycled and redistributed throughout a society to ensure that it contributes more equitably to the overall population health and welfare of the vast majority of the citizens involved in the process as producers and consumers 43, 44 . Unfortunately there is insufficient sign as yet that this understanding is informing the strategy of the most important international institutions which influence the future course of world development, notably the IMF and the WTO (the World Bank has been notably more ambivalent in its approach since the World Development Report of 1997). Policy prescriptions for the world’s poorest countries need to recognize that their state and local government capacity has been dangerously decimated during the last two decades of neo-liberal, free market fundamentalism 45, 46 .

Such transition thinking is an integral part of a more general, encompassing ‘modernization’ ideology, a set of ideas which trace their genealogy to the post-Enlightenment project to spread liberty, scientific reason and democracy to the world, which remains a profoundly influential motivating force in contemporary global history, in particular providing the ethical rationale for the project of international ‘development’.

Fogel had shot to fame in the 1970s with his co-author Stanley Engerman through their pioneering quantitative econometric history of slavery which startlingly concluded that slavery was an efficient economic system and that most black southern slaves had enjoyed a higher standard of living than freed wage-earners in the industrial north in the pre-civil war era: Fogel RW, Engerman SL, Time on the Gross. London: Wildwood House, 1974.


CHRONIC DISEASE INCIDENCE

In the United States, chronic illnesses and health problems either wholly or partially attributable to diet represent by far the most serious threat to public health. Sixty-five percent of adults aged ≥20 y in the United States are either overweight or obese ( 13), and the estimated number of deaths ascribable to obesity is 280184 per year ( 14). More than 64 million Americans have one or more types of cardiovascular disease (CVD), which represents the leading cause of mortality (38.5% of all deaths) in the United States ( 15). Fifty million Americans are hypertensive 11 million have type 2 diabetes, and 37 million adults maintain high-risk total cholesterol concentrations (>240 mg/dL) ( 15). In postmenopausal women aged ≥50 y, 7.2% have osteoporosis and 39.6% have osteopenia ( 16). Osteoporotic hip fractures are associated with a 20% excess mortality in the year after fracture ( 17). Cancer is the second leading cause of death (25% of all deaths) in the United States, and an estimated one-third of all cancer deaths are due to nutritional factors, including obesity ( 18).


Developments from 1875

The work of Italian bacteriologist Agostino Bassi with silkworm infections early in the 19th century prepared the way for the later demonstration that specific organisms cause a number of diseases. Some questions, however, were still unanswered. These included problems related to variations in transmissibility of organisms and in susceptibility of individuals to disease. Light was thrown on these questions by discoveries of human and animal carriers of infectious diseases.

In the last decades of the 19th century, French chemist and microbiologist Louis Pasteur, German scientists Ferdinand Julius Cohn and Robert Koch, and others developed methods for isolating and characterizing bacteria. During this period, English surgeon Joseph Lister developed concepts of antiseptic surgery, and English physician Ronald Ross identified the mosquito as the carrier of malaria. In addition, French epidemiologist Paul-Louis Simond provided evidence that plague is primarily a disease of rodents spread by fleas, and the Americans Walter Reed and James Carroll demonstrated that yellow fever is caused by a filterable virus carried by mosquitoes. Thus, modern public health and preventive medicine owe much to the early medical entomologists and bacteriologists. A further debt is owed bacteriology because of its offshoot, immunology.

In 1881 Pasteur established the principle of protective vaccines and thus stimulated an interest in the mechanisms of immunity. The development of microbiology and immunology had immense consequences for community health. In the 19th century the efforts of health departments to control contagious disease consisted in attempts to improve environmental conditions. As bacteriologists identified the microorganisms that cause specific diseases, progress was made toward the rational control of specific infectious diseases.

In the United States the diagnostic bacteriologic laboratory was developed—a practical application of the theory of bacteriology, which evolved largely in Europe. These laboratories, established in many cities to protect and improve the health of the community, were a practical outgrowth of the study of microorganisms, just as the establishment of health departments was an outgrowth of an earlier movement toward sanitary reform. And just as the health department was the administrative mechanism for dealing with community health problems, the public health laboratory was the tool for the implementation of the public health program. Evidence of the effectiveness of this new phase of public health may be seen in statistics of immunization against diphtheria—in New York City the mortality rate due to diphtheria fell from 785 per 100,000 in 1894 to 1.1 per 100,000 in 1940.

The Centers for Disease Control and Prevention (CDC originally the Communicable Disease Center), an agency of the U.S. Department of Health and Human Services, was founded in 1946 and was tasked with the mission of preventing and controlling disease and promoting public health. The CDC serves a key role in gathering and disseminating information on disease and disease prevention to the general public. Today it is a leading center of epidemiology.

While improvements in environmental sanitation during the first decade of the 20th century were valuable in dealing with some problems, they were of only limited usefulness in solving the many health problems found among the poor. In the slums of England and the United States, malnutrition, venereal disease, alcoholism, and other diseases were widespread. Nineteenth-century economic liberalism held that increased production of goods would eventually bring an end to scarcity, poverty, and suffering. By the turn of the century, it seemed clear that deliberate and positive intervention by reform-minded groups, including the state, also would be necessary. For this reason many physicians, clergymen, social workers, public-spirited citizens, and government officials promoted social action. Organized efforts were undertaken to prevent tuberculosis, lessen occupational hazards, and improve children’s health.

The first half of the 20th century saw further advances in community health care, particularly in the welfare of mothers and children and the health of schoolchildren, the emergence of the public health nurse, and the development of voluntary health agencies, health education programs, and occupational health programs.

In the second half of the 19th century, two significant attempts were made to provide medical care for large populations. One was by Russia and took the form of a system of medical services in rural districts after the communist revolution, this was expanded to include complete government-supported medical and public health services for everyone. Similar programs have since been adopted by a number of European and Asian countries. The other attempt was prepayment for medical care, a form of social insurance first adopted toward the close of the 19th century in Germany, where prepayment for medical care had long been familiar. A number of other European countries adopted similar insurance programs.

In the United Kingdom a royal-commission examination of the Poor Law in 1909 led to a proposal for a unified state medical service. This service was the forerunner of the 1946 National Health Service Act, which represented an attempt by a modern industrialized country to provide services to all people.

Later, prenatal care made a substantial contribution to preventive medicine, with the education of mothers influencing the physical and psychological health of families and being passed on to succeeding generations. Prenatal care provides the opportunity to educate the mother in personal hygiene, diet, exercise, the damaging effects of smoking, the careful use of alcohol, and the dangers of drug abuse.

Public health interests also have turned to disorders such as cancer, cardiovascular disease, thrombosis, lung disease, and arthritis, among others. There is increasing evidence that several of these disorders are caused by factors in the environment. For example, there exists a clear association between cigarette smoking and the eventual onset of certain lung and cardiovascular diseases. Theoretically, these disorders are preventable if the environment can be altered. Health education, particularly aimed at disease prevention, is of great importance and is a responsibility of national and local government agencies as well as voluntary bodies. Life expectancy has increased in almost every country that has taken steps toward reducing the incidence of preventable disease.


City Life in the Late 19th Century

Between 1880 and 1900, cities in the United States grew at a dramatic rate. Owing most of their population growth to the expansion of industry, U.S. cities grew by about 15 million people in the two decades before 1900. Many of those who helped account for the population growth of cities were immigrants arriving from around the world. A steady stream of people from rural America also migrated to the cities during this period. Between 1880 and 1890, almost 40 percent of the townships in the United States lost population because of migration.

Industrial expansion and population growth radically changed the face of the nation's cities. Noise, traffic jams, slums, air pollution, and sanitation and health problems became commonplace. Mass transit, in the form of trolleys, cable cars, and subways, was built, and skyscrapers began to dominate city skylines. New communities, known as suburbs, began to be built just beyond the city. Commuters, those who lived in the suburbs and traveled in and out of the city for work, began to increase in number.

Many of those who resided in the city lived in rental apartments or tenement housing. Neighborhoods, especially for immigrant populations, were often the center of community life. In the enclave neighborhoods, many immigrant groups attempted to hold onto and practice precious customs and traditions. Even today, many neighborhoods or sections of some of the great cities in the United States reflect those ethnic heritages.


Health Problems in Industrial Towns (Commentary) - History

Indholdsfortegnelse

ntario&rsquos Board of Health was first established in 1882. In 1884, the province&rsquos first medical officer of health started his job. By 1886, 400 boards of health were in operation throughout the province, in communities large and small. The promotion of healthy living in Ontario had begun.

During the late 1800s and early 1900s, governments were busy building and maintaining hospitals, cleaning up the urban environment, and making the water supply safe. Private organizations, such as benevolent societies and church groups, provided relief to the sick and did their best to control outbreaks of disease.


Click to see a larger image (60K)
Disinfecting railway cars for foot
and mouth disease, 1908
John Boyd fonds
Reference Code: C 7-3-1672
Archives of Ontario, I0003363

Click to see a larger image (92K)
The sale of &ldquounsanitary&rdquo ice cream, [ca. 1905]
Public Health Nursing Branch
Reference Code: RG 10-30-2, 3.02.5
Archives of Ontario, I0005187

Their work was part of the Victorian notion of social reform that flourished in Canada between 1880 and 1920: the belief that by promoting social causes-temperance, protection of children, improved working conditions, better schooling and medical care-traditional Christian values were being advanced.

The promotion of good health, to many reformers, pointed the way toward social progress and the advancement of society.

& ldquoM. H. O Hastings: I had no idea you needed cleaning up so badly&rdquo. A caricature
of Charles Hastings, Toronto&rsquos Medical Health Officer, and commentary
on his attempts to make Toronto cleaner and healthier, [ca. 1910-14]
Newton McConnell fonds
Reference Code: 301, 61
Archives of Ontario, I0006074

But by the 1900s, major outbreaks of diseases such as typhoid, cholera, and smallpox had overwhelmed the private system of care and the reformers&rsquo efforts. Governments of all levels had to step in.

In Ontario, the Provincial Board of Health took the lead. Soon, through pamphlets, lectures, bulletins, and regular visits from public health inspectors, Ontarians learned how to prevent disease and live healthier lives.

This new emphasis on prevention and education followed on the heels of the bacteriological revolution of the 1880s, as science began to uncover the mystery of what caused disease. Vaccines were discovered around the world - the first smallpox vaccine in Ontario was produced in 1886.


Click to see a larger image (68K)
A log building at a work camp, with a &ldquoSmallpox here&rdquo sign affixed to it, [between 1900 and 1920]
Porcupine area photograph collection.
Reference Code: C 320-1-0-2-5
Archives of Ontario, I0022414

Click to see a larger image (537K)
Influenza poster, 1918
Secretary of the Board of Health and Chief
Medical Officer of Health subject files
Reference Code: RG 62-4-9-450a.1
Archives of Ontario

The importance of clean water, pasteurized milk, and sanitary food practices was also now understood. By the early 1900s, most cities and towns in Ontario had by-laws to regulate the inspection of meat and milk, and inspectors to enforce those laws. Toronto, for example, instituted a city-wide milk campaign in 1921, to alert the public to the dangers of unpasteurized milk.

Nurses giving out free milk and weighing a child at a booth, T. Eaton Co. store, as part of the Toronto Milk Campaign, 1921
Public Health Nursing Branch
Reference Code: RG 10-30-2, 1.8.3
Archives of Ontario, I0005259


Class of boys drinking milk, Toronto milk campaign, 1921
Public Health Nursing Branch
Reference Code: RG 10-30-2, 1.8.15
Archives of Ontario, I0005262

Toronto&rsquos water system was first chlorinated in 1910, and other municipalities quickly followed that city&rsquos lead. And public health workers of all kinds-doctors, nurses, and building and food inspectors-became more organized and professionalized.

The Honourable Manning Doherty milking a cow in front of the
Ontario Legislature, Toronto milk campaign, 1921
Public Health Nursing Branch
Reference Code: RG 10-30-2, 1.8.2
Archives of Ontario, I0005265

Thus, by 1900, the real beginnings of health education-public hygiene, as it was called-had taken root in Ontario.

The gospel of public hygiene spread throughout the province. Medical inspection of public schools began after 1908, so that children could get the medical care and preventive education they needed. Centralized disease reporting in the province helped health workers and governments target those communities most in need. And the establishment of various health promotion agencies-such as the Canadian Association for the Prevention of Tuberculosis, formed in 1900-meant that the government could work with a wide array of health professionals to educate Ontarians about how to prevent and treat many diseases.

Children being measured at the school clinic, [ca. 1905]
Public Health Nursing Branch
Reference Code: RG 10-30-2, 3.03.2
Archives of Ontario, I0005191

By the 1920s, divisions of Preventable Diseases, Public Health Education, Laboratories, Sanitary Engineering, Industrial Hygiene, and Material and Child Hygiene and Public Health Nursing were all established by the provincial government. And, in 1921, the Ontario Division of Public Health Education was formed, marking the start of a new era in health education.


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