Recent Advances in Public Health

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City Slums

  • Medieval and Renaissance towns had failed to reach the standards of public health seen in Roman times - but the Industrial Revolution (which started abut 1750) made things even worse
  • The towns of the medieval period were not densely packed with rows and rows of buildings as we see them today. Within a town there were gardens for growing vegetables and keeping pigs and chickens. There were also orchards of fruit trees.
  • Industry and changes in agriculture brought more people into the towns. The spaces filled up with factories and poor quality housing. Anyone who owned land could build on it without planning permission and there were no building standards regulations.
  • People didn't believe the government had the right to tell people what to do with their land. They expected "no-intervention" policies from the government (laissez-faire).
  • Attempts at providing fresh water and removing sewage and rubbish were often inadequate. Sewage was discharged into rivers, overflowing cesspits or even into the street. Smoke from houses and factories filled the air.
  • Diseases like smallpox, influenza, typhus and typhoid fever were common.
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  • Cholera reached Britain from the East in 1831. It was an epidemic by 1832.
  • Cholera spreads when infected sewage gets into drinking water. It causes such extreme diarrhoea that sufferers often die from loss of water and minerals. Both rich and poor people caught the disease. The government started to introduce regulations about the burial of the dead, but the epidemic declined and interest was lost.
  • People did not know what caused cholera so epidemics recurred in 1848, 1854 and 1866.
  • In 1842, Edwin Chadwick published a 'Report on the Sanitary Condition of the Labouring Population of Great Britain'. His revolutionary idea was that improved public health provision and a healthy workforce would save money rather than cost money.
  • The report and statistics describing levels of sickness and mortality shocked some of the privileged classes. People campaigned for improvements and in 1844 the Health of Towns Association was set up.
  • Responding to calls from the Health of Towns Association, the governent introduced a Public Health Bill. It was opposed at first, but was finally passed when a new cholera epidemic broke out. It became the first Public Health Act, in 1848.
  • The main provision of the act was for Central and local Health Boards. The local boards had to be approved by ratepayers and the Central Board lasted until it was dismantled in 1854.
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Defeat of Laissez-Faire

  • The connection between contaminated water and cholera was discovered by John Snow in 1854. He studied the occurrence of a cholera outbreak in the Broad Street area of London and noticed that the victims all used the same water pump. So he removed the handle from the pump - and ended the outbreak.
  • Snow was proved right about the spread of disease when Pasteur discovered germs.
  • In 1871 and 1872 the government responded to proposals of the Medical Officer of Health, Sir John Simon. It formed the Local Government Board and divided the country into "sanitary areas" administered by medical officers of health. Another Public Health Act was brought in by Disraeli's government in 1875 along with the Artisans' Dwellings Act. The 1875 Act was more effective as it forced local councils to act on public health.
  • The Artisans' Dwellings Act allowed for compulsory purchase of slum housing and rebuilding by local councils (although ths act was hardly used). This Act owed much to the work of Octavia Hill, who was concerned with the terrible conditions in which people were living and so developed a model housing scheme. Hill was determined that people should have access to green spaces for their health and well-being so she campaigned to save open spaces from being built on and co-founded National Trust in 1895.
  • Victorian engineering produced improvements in the form of brick-lined sewer networks and steam-driven pumped water systems such as the Boughton Pumping Station.
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Life in 1900

  • Slums were still a feature of big cities and industrial towns at the start of the 20th century.
  • Poor people were often housed in tenements - these were damp, insanitary and had no running water. Large families lived together in one room and shared a toilet with their neighbours.
  • The poor worked long hours for low wages. Many people couldn't afford to see a doctor when they were sick or provide their children with three decent meals a day.
  • There were 140 infant deaths for every 1000 births, today it's less than 5.
  • Patient medicines continued to be popular. They had secret recipes and were sold with extravagant claims, bu they often did more harm than good.
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  • In 1889, Charles Booth surveyed living conditions in London's East End and published 'Life and Labour of the People in London' - it showed a clear link between poverty and ill health.
  • A similar survey was made in York by Seebohm Rowntree, a member of the family that made Rowntree's chocolate. His work, published in 1901, would go on to heavily influence the policies of the Liberal Chancellor David Lloyd George.
  • The other famous chocolate makers, the Cadburys, tried to provide quality homes and improve lifestyles for workers at their factory in Bournville, near Birmingham. Titus Salt did a similar thing in Saltaire in Yorkshire.
  • These philanthropist businessmen were great examples of how to make money and treat your workers well.
  • When the Boer War broke out in 1899, army officers found that 40% of volunteers were unfit for military service mostly due to poverty-related illnesses linked with poor diet and living conditions. Similar problems were encountered during the First World War. Britain, like the Romans, realised i needed a healthy population to have an efficient army.
  • Many workers organised Friendly Societies, which were often linked to trade unions. Workers paid a subscription each week and in return received medical help and other benefits.
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Liberal Reforms

  • By 1906 the link between poverty and ill health had been well and truly established. The newly-elected Liberal government realised it had to take action. Many MPs were especially worried about losing votes to the relatively new Labour party - which promised to look after interests of the working classes.
  • So under the guidance of Lloyd George (Chancellor of the Exchequer at the time of the reforms. He became Prime Minister in 1916) the Liberals started to introduce measures that are still important to our social security today: Free school meals (1906), School medical inspections (1907), Old Age Pension Act (1909), Labour Exchanges (Job Centres) (1909), National Insurance Act (1911).
  • Lloyd George had to overcome a lot of opposition from the House of Lords to get many of these reforms through.
  • National Insurance wasn't compulsory and it only covered people who paid in. These people could then get sick pay and medical treatment from a panel doctor working for the scheme. The scheme also provided unemployment pay.
  • The reforms weren't perfect but they marked the start of the modern welfare state.                                   
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Women in the Medical Profession

  • Women were not allowed to attend universities in the early 19th century. As a result, they couldn't qualify as doctors. Many Victorian men regarded women as being less able to work in jobs requiring professionalism, intelligence or lack of squeamishness.
  • It's likely that the first British woman to qualify as a doctor had to pretend to be a man. Margaret Ann Bulkley was born some time in the 1790s. She's thought to have trained at Edinburgh University as 'James Barry'. After qualifying in 1812, she joined the army in time to serve at the Battle of Waterloo and was eventually promoted to Assistant Surgeon. She served in the army for 46 years and was only found out when she died in 1865.
  • Elizabeth Blackwell was the first woman in modern times to be awarded a medical degree in her own name from a western training college (1849).
  • The first British women to practise openly as qualified modern doctors both had to train privately or abroad. Their names were Elizabeth Garett Anderson and Sophia Jex-Blake. 
  • Garrett Anderson was trained privately before being accepted as a qualified doctor by Society of Apothecaries in 1865. She used the society's rules to force it to recognise her but afterwards they changed their rules to stop other women from doing the same. She was awarded a medical degree by the University of Paris in 1870. Sophia Jex-Blake gained entry to Edinburgh University but was refused a degree when her entry was declared unlawful. Then co-founded London School of Medicine for Women in 1874+went to Uni of Bern.
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Changes of Women in the Medical Profession

  • The need for women in professional roles increased during the world wars (1914-1918 and 1939-1945).
  • The 1975 Sex Discrimination Act meant that equal opportunities for men and women had to be available in all jobs.
  • Today around 45% of doctors are women and female GPs could soon outnumber their male counterparts.
  • Women are still under-represented at the top level though - they make up only 28% of consultants.
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Social Problems and Social Change

  • After the First World War, Lloyd George promised to make Britain a land 'fit for heroes'. A Ministry of Health was set up in 1919 and grants were given to build council houses.
  • But the First World War had drained Britain's resources. An economic slump in the 1920s caused rising unemployment. The government cut back spending on welfare.
  • During the 1930s, things got worse when there was a global economic depression. By 1932, 22% of British workers were unemployed. Poverty and unemployment were particularly bad in Wales, Scotland and the North of England.
  • Homes in poor areas often had no electricity or sanitation The 1930 Housing Act planned to clear slum housing. Progress was slowed down by the depression.
  •     The Second World War (1939-1945) broke down social distinctions and brought people together whose lives had been very separate. The raising of mass armies made powerful people take notice of the health problems of the poor. Also the evacuation of children increased awareness in rural middle England of how disadvantaged many people were.
  • Air raids, especially the Blitz of 1940, prompted the government to set up the Emergency Medical Service. This provided a centralised control of medical services and offered free treatments to air raid casualties. It proved successful under great pressure.
  • After the Second World War people looked for improvements in society. Such feelings led to the 1945 victory for the Labour Party.
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Introduction of the NHS

  • Sir William Beveridge published his famous Beveridge Report in 1942. In it he called for the state provision of social security 'from the cradle to the grave'.
  • The report became a bestseller. In it Beveridge argued that all people should have the right to be free from want, disease, ignorance, squalor and idleness. He called these the five 'giants'.
  • Aneurin Bevan was the Labour Minister for Health who introduced the National Health Service.
  • Compulsory National Insurance was introduced in 1948 to pay for the NHS. Doctors and dentists were wooed with a fixed payment for each registered patient. They were also allowed to continue treating private fee-paying patients.
  • By 1948 nearly all hospitals had joined the NHS and 92% of doctors had.
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Benefits of NHS

  • The development of ante- and post-natal units with specialist doctors and nurses has reduced the risk of both infant and maternal mortality.
  • Life expectancy for women in England and Wales has risen from 70 in 1948 to 82 in 2008.
  • A whole programme of free childhood vaccinations has been introduced - from the BCG (against tuberculosis) in 1948, to measles, mumps and rubella in 1988.
  • Between June 2008 and May 2009 over 16 million people were treated as inpatients by the NHS. A further 75 million attended outpatient appointments.
  • The NHS provides free ambulances, accident and emergency care, major surgery, chemotherapy, physiotherapy, health visitors and more.
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Problems of NHS & WHO

  • Right from the start the demand for NHS services was greater than expected. In 1950 spending was about £350 million - twice the original budget. Today it runs at over £3500 million.
  • Successive governments have reduced how much of the NHS is free - charges have been reintroduced for things like prescriptions and dental checkups. Aneurin Bevan resigned over prescription charges. Long waiting lists and doubts about the quality of treatment have led many to take out private health insurance or pay for treatment outside the NHS.
  • Even successes sometimes have their downsides - longer life expectancies have meant more need for care of the elderly and increased costs for the NHS.
  • The World Health Organisation (WHO) was set up in 1948 as part of the United Nations. It has been very successful in increasing the number of children vaccinated worldwide.
  • Its other major success was the total eradication of smallpox. It also works hard trying to eliminate polio, malaria and tuberculosis.
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DNA, Genetics and Genetic Conditions

  • The understanding of inheritance has been a slow development going back into prehistory - to whenever someone noticed that children looked a bit like their parents and could inherit characteristics from them.
  • The structure of DNA was first described in 1953 by Francis Crick and James Watson. They relied heavily on the work of Rosalind Franklin and Maurice Wilkins. All except Franklin shared in the 1962 Nobel Prize for Physiology or Medicine. Franklin died four years earlier in 1958.
  • The Human Genome Project has identified all the genes in human DNA. The task was huge as there are between 20000 and 25000 genes. Scientists are now in the process of analysing the results.
  • Since prehistory, humans have tried to change the characteristics of animals in the form of selective breeding and manipulate individual genes to give genetically modified organisms (genetic engineering). Many people worry about the safety and ethics of this research.
  • Some conditions are genetic meaning they can be passed on through generations.
  • Recently, research into genetic conditions have increased. Scientists can now test for certain genetic conditions in the womb and sometimes produce synthetic proteins to replicate genes.
  • Scientists are now looking at curing inherited conditions using techniques such as gene therapy, which tries to replace disease-curing genes with good ones.
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Pharmaceutical Industry

  • In the late 1800s the chemical industry in places like Germany and Switzerland was booming. This lead to the growth of the modern pharmaceutical industry.
  • For the first time, it was possible to manufacture drugs and medicines on a large scale and make them available to lots of people.
  • The late-19th and 20th centuries saw the discovery and mass production of aspirin (1899), insulin (1921), sulphonamides (1932) and more.
  • Penicillin was first produced commercially by American pharmaceutical firms during the Second World War. It helped to save the lives of countless Allied soldiers.
  • Antibiotics are still used today to treat a huge range of bacterial infections.
  • The pharmaceutical industry has also made widespread vaccination possible. As a result of vaccination programmes beginning in the 1950s, polio has nearly been eradicated. More recent vaccinations to become available include those against meningitus C and the HPV virus.
  • After the thalidomide tragedy many countries passed laws which introduced more stringent testing for new medicines.
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Advances in Communication and Technology

  • Many of the medical advances over the course of the last century have been made possible by improvements in communication technology. 
  • Scientists from all over the world are able to share their ideas and findings by phone, email and the internet. Long-distance travel has also become cheaper and easier - allowing researchers to attend international seminars and conferences.
  • Government-funded research tends to get shared more. Companies tend to keep research secret so that they can patent new treatments. On the other hand, few new medicines would be developed if there wasn't any profit in it - the research process is hugely expensive.
  • Developments in technology mean doctors can more accurately diagnose and treat conditions.
  • Medical imaging using sound waves (ultrasound) enables doctors to build up a picture of what's happening inside the body. This technique was first developed around 50 years ago.
  • A more recent development is the MRI scanner (1973), which uses radio waves and magnets to visualise the internal structures of the body.
  • The use of fibre-optic cables inside an endoscope allows people to look inside the body. During keyhole surgery, endoscopes containing small instruments are used to operate the patient.
  • Technology is used for people to monitor their own health (e.g. pregnancy tests).
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  • HIV (Human Immunodeficiency Virus) is thought to have originated in Africa, but the disease it causes (AIDS-Acquired Immune Deficiency Syndrome) was first identified in America in 1981.
  • In 2007, around 33 million people worldwide were thought to be infected with the HIV virus. Two-thirds of those live in sub-Saharan Africa.
  • Drugs such as antiretrovirals can be used to treat people with HIV. Antiretrovirals block the virus from replicating and so slow down the progression into AIDS. They can be very effective, but they're also expensive which is a major problem in developing countries.
  • The WHO is coordinating efforts to look for vaccines and cures, but neither is available yet.
  • Better health promotion, sex education and free condoms can all help to reduce the spread of infection.
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Problems & Role Changes

  • Overuse of antibiotics is leading to the evolution of superbugs which are resistant to our antibacterial drugs.
  • The drug thalidomide was used in the 1960s to treat morning sickness in pregnant women - many babies were born with under-developed limbs as a result.
  • Mistrust of modern medicine and technology has led some people to consider treatment using alternative therapies, e.g. acupuncture, homeopathy and herbal remedies.
  • Mainstream doctors have expressed concern about alternative medicine, believing that it might do more harm than good. However, some medical practitioners are now working with alternative therapists to see if a complementaru approach will result in patient benefits.
  • Over the course of the last century, medicine has changed a lot. In 1900, there were very few drugs available for doctors to prescribe their patients and even less specialist diagnostic equipment for them to use - why people were usually seen at home. Now they're seen at clinic. 
  • Training has had to become better regulated.
  • Since 1919, nurses had to be registered and have a full nursing qualification. All medical professionals have to regularly update sills - Continuous Professional Development (2001).
  • Advances in medical technology allow many people to take some control over their own treatment. Things like pregnancy tests means they can be done at home.
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