The Determinants of Health from a Historical Perspective - Essay Example

 The Determinants of Health from a Historical Perspective Britain in the 19th century was undergoing all the classic symptoms of a society that has seen too much economic development too fast, one of which was a drastic decline in the public health situation. But there was a great improvement in people's health from the beginning of the 19th century to its end, and this was due to a massive exercise of social and political will, driven by both economic and humanitarian causes. Medical developments in the period were the instruments used to improve the situation, but the main driver behind the change towards better public health was social reform. As Simon Szreter puts it while discussing the situation in this period: The increased wealth generated by economic growth held out the possibility of healthy "progress" for the majority in society. But this favorable outcome.... had to be devised with the aid of medical science and fought for politically. It could only be achieved if the serious health challenges brought on by economic change, industrial wage labor, and urban living were met with the appropriate political resolution to implement far-reaching preventive health measures, requiring the deployment of substantial social and economic resources....”( Szreter ,1997) In order to understand the health improvement and its causes it is necessary to look at the dismal situation in terms of disease, infant mortality, quality of food, filth in the surroundings and the work environment in 19th century Britain through a snapshot created from documented history: The most life-threatening hazard facing city-dwelling Victorians is cholera, closely followed by typhoid fever and typhus. Four epidemics of cholera – in 1831/32, 1848/49, 1853/54 and 1866 – kill about 140,000 people, with more than 60,000 perishing in the second epidemic alone. ....In London, there are still open cesspools, and the sewers run straight into the Thames..... Urban workers are stunted in growth and afflicted by debilitating diseases such as rickets, tuberculosis and bronchitis. Long hours of toil and poor diet weakens their resistance. .....much of the food consumed by the working classes is adulterated by foreign substances, contaminated by chemicals or fouled by animal and human excrement. The infant mortality rates in the.... inner city rates were dramatically higher, 300 deaths per thousand on average .... Puerperal fever...was the main cause of death in childbirth during the 19th century....patients under a doctor's care have only a 50% chance of being better off than if they and their diseases had been left alone. ( McVeigh,2000) This then, is the situation in which most of industrial Britain found itself in the beginning of the 19th century, and we first examine how developments in medicine and hygienic concepts facilitated improvements in health standards. To our 21st century perceptions, the answers must seem pretty simple: remove the filth and improve the sanitary and health services. But to the 19th century mindset, ideas on infection and sanitation and their relevance to health was yet to be established, and this is where the role of medicine came in. The role of sanitation in a disease like cholera was first commented on by a surgeon called John Snow. John Snow......published in 1849 his opinion that cholera was spread by the pollution of drinking water by sewage......Snow’s original publication received little official attention, the miasmatists being bent on campaigning vigorously against filth in general as a cause of ‘poisoned air’. Two of the three persons most celebrated for their interest in health in Victorian times, Edwin Chadwick and Florence Nightingale, remained miasmatists all their lives. ..... Nevertheless, the realization of the miasmatists that cholera was at its worst in insanitary places led to widespread national protests against the evils of the open sewers, the defective drains, the foul ditches and the refuse-littered streets of the towns of the 1840s.(Seaman,1995) It was soon apparent through medical theories that the rich and the powerful were as vulnerable to diseases like cholera as the poor and the destitute, because the entire environment was unhealthy, and posed a risk. The threat of suffering and painful death, and a clean environment coming up as the only resolution pressed public opinion towards sanitary and social reform, which would have a positive and direct impact on public health. The second very important medical contribution was in the form of figuring out the reason for infection and trying to prevent it through a basic antiseptic, and this input came in from Joseph Lister: It was also in 1865 that, the Edinburgh surgeon Joseph Lister began dipping bandages and ligatures into carbolic acid, and pouring the acid directly into wounds, greatly decreasing the rate of death from gangrene. This was the first use of antiseptics to reduce infection after surgery”. This did decrease mortality rates during operations, and the theories of germs and infections that came subsequently made doctors and midwives realize that puerperal fever could be contained by simply washing hands between attending to each mother thus drastically reducing deaths during childbirth.(Sebastian, Amyes,2001) But it was primarily through the work of reformers like Chadwick that Victorian Britain began to grasp its health problems and their impact, and begin to deal with them. He is known as the originator of the “Sanitary Idea”, the man who changed the perception of an entire generation on public health through his reports on sanitary conditions and various other social ills like child labor. But Chadwick was not motivated purely through humanitarian fervor: “Chadwick was appalled at the number of people admitted to the workhouses and became convinced that if the health of the working population could be improved then there would be a drop in the numbers of people on relief”.(Bloy,2002) Here we note that one of the reasons social and sanitary reforms were instigated was the realization that the bad standards of public health meant an unhealthy working force, and a large number of poor who were not contributing members of the society but rather a burden who needed to be kept up in workhouses. Thus the very economics of the times which had given rise to the laissez faire society became the main motive why improvement of public health became an important social issue begging reform. The government had to step in in the interests of national economy. Unprecedented population growth outstripped economic growth during the 1800s. For this reason, government began to move towards a more central interventionist stance on social and economic matters, including public health, to mitigate some of the impacts of uncontrolled capitalism...... It came about more due to the need to protect the workings of a free trade economy than out of a concern for public welfare. There was both a fear that the prevailing insanitary conditions could threaten the livelihoods of the rich and a belief that improvements would make cities not only healthier but more efficient.(Fisher, Cotton, 2005) Legislations like the 1844 Metropolitan Buildings Act, 1847 Town Improvement Clauses Act , the Public health acts of 1848 and 1875 and the 1866 Sanitary Act all arose to address the need for healthier, cleaner cities to maintain a prosperous economy and the sanitary reforms they resulted in had a significant impact on the standards of public health. Behind all this was the public support of the socially aware members of the powerful upper class. Improved water systems and sanitation greatly decreased the number of deaths due to waterborne diseases. The greatest decline occurred during the latter part of the nineteenth century, when water and sanitation systems in Britain were improved. Also in the nineteenth century, the hygiene movement and its public health accomplishments reversed the deterioration of the British environment that was associated with the growth of urban centers during the Industrial Revolution. The socially conscious citizens of an increasingly prosperous society drove their economic and political institutions to improve the urban environment, thereby improving health and well-being for the society. ( Frank, Mustard,1994) Also part of social reform was the agency of those like Florence Nightingale, who took over training of nurses so as to provide better health care, and whose ambition was to provide the same sort of medical care in a “deterrent workhouse” for the poor as was generally available to the more affluent. This was a radical departure from the medical provisions of the Poor Law which meant to deter people from “becoming poor” by making conditions worse inside the workhouses than it was outside. Even a working man in possession of a job was liable to incur the stigma of pauperism if he could not afford to pay for the medical care required by a member of his family and was forced to apply for medical relief under the poor law. According to the poor law board, 'the receipt of medical relief constitutes a pauper, be it in what form it may, whether it be medical relief, or relief in food or money, or in any other form'. In principle, the medical relief system was humane: in time of sickness, no one should lack the necessary medical care, medicine, and food. In the context of the Victorian poor law, however, a man who applied for medical relief for his sick child had to accept the degrading status of pauper in order to receive it. (Trygve, Tholfsen,1977 ) Slowly but surely public opinion in Britain began to turn from desiring cleanliness for economic purposes to more humanitarian reasons, and Nightingale was very much a part of this movement towards improved public health: “ Her chief contribution was not as a nurse tending individuals but as an administrator and politician: suggesting hospital reforms, forming commissions and committees, and performing miracles in sanitation and hospital development”.(Timko,2003) She and others of her kind were an inspiration, and she generated a national following, and was supported by the Queen Victoria. Though the Poor Law was not abolished before the next century, there were already voices of dissent in all socially aware agencies in the middle of the 19th century, and even in the press. Reformist voices like that of Thomas Perronet Thompson begun to be heard, who contended that the artificially high price of food due to the laissez faire system gave rise to paupers, the need for workhouses and less food for the working classes. The new poor law and its system of “slow death” confirmed that parliament knew and cared nothing about the people. Clearly, the Poor Law Amendment Act could not operate without free trade, for the corn laws—by keeping food prices artificially high—created paupers. Although Thompson conceded that shorter hours and better wages would help the laboring classes, he insisted that the factory question had been widely misunderstood. The real issue was not overwork but dear food. A factory hand was, in effect, obliged to work longer hours to buy less food, and yet higher wages would not automatically increase the availability of bread. ( Turner , 2004) Less food and low nutrition has long been acknowledged as a factor in health standards, which can be easily identified by low height, stunted growth, high mortality rates and short lifespan. Some experts have concluded that it is not medical intervention but better nutrition that resulted in health improvement towards the later half of the 19th century. McKeown and Brown.... found that the bulk of the change in mortality rates could not be explained through medical intervention because there were no effective treatments for the major causes of death during most of this period. Furthermore, a large decline in mortality from airborne diseases could not be easily explained by the improved water and sanitation systems at the end of the 1800s. McKeown's conclusion was that the decrease in mortality was due to improved prosperity and nutrition.(Frank, Mustard,1994) Low health in Victorian Britain was also attributable to poor nutrition, as were high infant mortality rates, and poor health for both the child and the mother, which meant low health standards in the general population. In the nineteenth century as in the twentieth, the babies most likely to die soon after birth were those born prematurely or underweight. Many working-class women were undernourished, ..... The lack of meat, eggs, green vegetables, and fruit in the diet made a woman anemic. All these factors contributed to premature delivery and babies who were seriously low in birthweight.(Mitchell, 1996) By the end of the 19th century though, food conditions had improved. This was due to an expanding economy, better education and higher wages which were related in complex ways with the prevalent environment of social reform, of a realisation that if the poor remained poor, the country could not go forward as a whole. This led to better health indicators, including increasing heights in the population: “Above all, economic growth was manifest in the physique of the people. After a check to increase in the average height of the population between 1830 and 1860 as the problems of the cities were tackled, the population grew steadily taller, a sure sign of improved living conditions and more food”. ( Floud, 1997) Public health began to be seen as a source of communal pride in late Victorian society and political circles, which was a sea-change from the earlier purely economic motives. Thus the health improvement in the British public was a result of predominantly social movements, motivations, and initiatives, supported by the medical system, but largely gaining momentum in the public opinion due to the blatantly obvious impact of public health on the economy. Human society at any particular time and any particular venue decides the health standards that ought to be maintained for its continued survival and prosperity and Victorian England was no exception. On a broad level, of course, social and cultural factors have always played an important part in determining the way in which public health and medical services were organized. The value system of a society helps to shape the public's attitudes, beliefs, and behavior in regard to health and illness. Health institutions, like all social institutions, reflect a society's definition of what constitutes an acceptable and appropriate organization of health activity. ....As an inherently social and cultural activity, public health is thus an integral part of the social system, and can be fully understood only in terms of existing social forces. (Suchman,1963 ) Works cited Bloy, M.(2002) Edwin Chadwick (1800-1890).Victorian Web. Retrieved October 20, 2006 from http://www.victorianweb.org/history/chad1.htm. Fisher, J., Cotton, A. (2005)Delivery of water and sanitation services to the poor in nineteenth century Britain. Well Briefing 10. Retrieved October 20, 2006 from http://www.lboro.ac.uk/well/resources/Publications/Briefing%20Notes/BN%20Learning.htm Floud, R.(1997). The People and the British Economy, 1830-1914. Oxford: Oxford University Press. p. 6. Frank, J.W., Mustard, J.F. (1994).The Determinants of Health from a Historical Perspective. Daedalus. 123: 4. p. 1 McVeigh, D. (2000). Public Health and Technology during the 19th Century. An Early History of the Telephone 1664-1865" Retrieved October 20, 2006 from http://www.ilt.columbia.edu/projects/bluetelephone/html/health.html Mitchell, S. (1996).Daily Life in Victorian England. Westport, CT: Greenwood Press. p. 193. Seaman, L.C.B. ( 1995). Victorian England: Aspects of English and Imperial History 1837-1901. London:Routledge. p. 49. Sebastian, G. Amyes, B. (2001).Magic Bullets, Lost Horizons: The Rise and Fall of Antibiotics. London: Taylor & Francis. p. 3. Suchman, E. A. .(1963). Sociology and the Field of Public Health. New York: Russell Sage Foundation. p. 15. Szreter, S.Economic Growth, Disruption, Deprivation, Disease, and Death: On the Importance of the Politics of Public Health for Development. Population and Development Review. 23: 4. p. 693. Timko M. ( 2003). Florence Nightingale - Fantasy and Fact. World and I.18 : 7. p. 284. Trygve R. Tholfsen, T.R. (1977).Working Class Radicalism in Mid-Victorian England. New York: Columbia University Press. p.194. Turner M. J.( 2004) Independent Radicalism in Early Victorian Britain. West Port, CT: Praeger. p. 85. Read More