Big Issues: The Foundations of Public Health

We’re trying to reach a consensus on a common definition of global health. Some of you have already contributed aspects of this: study, research. You guys talked about how to use data. Why is Brazil doing better than other neighboring countries? Why is Mauritius doing better?

So it’s study, research—and practice. That emphasizes what was said earlier by Christian: improving health, achieving equity in health, for all. That’s one definition of global health: whether you are for-profit or nonprofit, these are the attributes that we want to see you bringing to all. You set a minimum standard, minimum deliverables, that everybody should have.

But let us go back and look at our history. This is before the Middle Ages. And I don’t want to puncture your optimism or your ego, but we are not the first people thinking about global health. It really started way before us.

They were actually pretty occupied with public health in ancient civilizations—in Egypt, in Ethiopia, in China. They really had some sophisticated engineering capacity. The way they planned their cities or towns, they actually took into consideration hygiene and sewage disposal and really were very methodical how they grouped houses. So that is not new.

That was the time also that they started to think about disease causality. They started saying, “If we do this, it leads to that.” Unfortunately, that knowledge of health and well-being was deposited in one civilization only. It didn’t cross boundaries. It was really the isolationist view.

Now we move to the Middle Ages. And this is a period where people became more or less aware that, “It’s not enough for us to protect ourselves; we probably have to share with others in order to protect us.” During the 14th century plague, in Italy, especially, they had a way of letting other countries or other townships know that there is a disease—they use sailors.

And there were even situations where if a ship is coming to dock and they suspect that there’s somebody on that ship with the plague, the ship would not be allowed to come on shore—you stay on the high sea for 40 days. My understanding is that the word “quarantine” comes from an Italian word for 40 days.

So they develop these public health offices and dispatches. Dispatching people to say, “Don’t come to Venice; dock here.” That was a concept developing during that time.

And we come to European imperialism, when the Europeans started to conquer the rest of the world. And probably that is what brought about the concept that we now term health disparity. The conquerors found that there is a difference between we the invaders and the invadees—some of them were not surviving in the harsh conditions of this rainforest. People dying due to malaria or yellow fever. So there was a consciousness of, how can we improve? They started to think about the colonies, the countries that we are conquering, that if we improved the health in those countries, we may be able to conquer them; we may be able to take their goods.

I think the very perfect global health scenario emerged during the Industrial Revolution, when they really came to terms with the idea that health is not a domain for only health practitioners, doctors or nurses. Economists were needed, lawyers were needed. It became more of a multi-disciplinary approach. And one person who is credited for that, in the 1840s, is Chadwick, who was a politician in the UK and brought up the Public Health Act, which talked about construction of buildings, sewer disposal, treatment of diseases.

Another important thing that happened then was that people really followed up their observations. “If you see something, say something”—that’s not new. John Snow made an important epidemiological discovery when there was a cholera outbreak in London. He was able to determine that people living around the river who were getting their water from different portions or zones of the river were disproportionately affected by the cholera. And that allowed them to know which water station the problem was originating from. And that became one of the foundations for public health.

After World War II, we all decided that we will not do this to ourselves anymore—let us now think of us as a globe and have international organizations and institutions. That is the birth of the World Health Organization, the United Nations agencies for food, children, security. Some non-governmental organizations came in. In the U.S., some very rich individuals, organizations like the Rockefeller Foundation, began to support health programs.

And that brings us to where we’re at. What I call contemporary global health started in the 1990s. When we started seeing, probably around ’81, the introduction of HIV into our population and then we started to realize that we are all at risk. We went back to the Industrial Revolution and realized, “We’ve done this before in our history. It’s supposed to be interdisciplinary; it’s supposed to be multidisciplinary. “

The World Bank, each year, comes out with a report called the World Development Report. In 1993, they devoted their whole report to how to invest in health. And that was a game changer. That was when, like some of you have already said, we realized that it pays off to invest in health. And not only looking at hypertension or diabetes or pneumonia; thinking about investing in the determinants of health, things that could bring on ill health. Education, the number of years you spend in school, has a correlation with income, and also health. So that was an impetus. Can we invest in health to make a change?