Sunday, January 9, 2011

Mission and Method

The early nineteenth-century French public health movement
Ann F. La Berge, Cambridge University Press, 1992

Drawing from official archives, this book is more a history of institutions than it is of the people who were affected by those institutions.  Instead it focuses on a select group of men who served on the Paris health council and as editors of the Annales d’hygiéne publique et de médecine légale and how they created and institutionalized the idea of public health and hygiene, as well as how they put those ideas into practice through their work on health councils, in their publications and in their investigations.

Public health measures have generally been dominated by two different missions, emergency measures whose primary purpose is to deal with epidemics and regulations for dealing with public nuisances and waste disposal.  The former measures were usually temporary, enforced only in times of crisis, and the latter measures were applied mainly to larger towns and cities, where the higher population density made such regulations a necessity.  The idea of public health prominent in late-eighteenth-century France was dominated by an Enlightenment approach that emphasized progress, rational reform, education, natural law, empiricism and humanitarianism.  It included preventive medicine as well as practices aimed at improving the quality of life, and reducing mortality and morbidity.

While it had its foundation in the Enlightenment, the public health movement developed amidst the competing ideologies of liberalism, conservatism, socialism and statism, with liberalism and statism dominating.  The liberals wanted a minimal amount of state intervention, preferring solutions that were local and individual with the private practice of medicine, while the statists felt that the state should assume the primary role in public health reform and management and that public health experts should serve as advisors to the state, even proposing a medical civil service.  The debate between liberalism and statism took place within the context of scientism, the idea that science was the key to progress and that the scientific approach was the best way to achieve positive knowledge.

During the Revolution the national government had accepted responsibility for national health, and both Napoleon and the Bourbons had continued the tradition.  By the 1820s several public health programs were in place including a nationwide vaccination program, a national health care program of both epidemic physicians and health officers, a national administration of sanitation and a Royal Academy of Medicine to replace the Royal Society of Medicine.  There were institutions at the national level as well as at the local level with municipal and departmental health councils.  There also arose the idea of a public hygienist.  These were not simply physicians, but rather physicians who were willing to practice empirical science in order to understand the causes of disease and death, who would undergo special training for their job and who would work in cooperation with other specialists including chemists and engineers.

A major component of the mission of public hygienists was to investigate all possible causes of disease and death and to make recommendations for their solution.  In the process they encountered a wide range of health problems and issues.  Not only were they involved in sanitary reform and ensuring the purity of food and drink, but they also examined more complicated social welfare issues such as prostitution, wet nursing, foundlings and child labor laws.  Their approach to such problems varied but they all recommended regulation, inspection, and legislation to help improve public health.

They were aided in their work by the existence of the Annales d’hygiéne publique et de médecine légale, which was unique to France.  It was the first journal in the West devoted to public health and legal medicine.  In it ideas were exchanged and research published.  The journal also reviewed or published most of the major French works on public hygiene and served as an international forum on public health issues, including the coverage of foreign developments and publications.  This commitment to promoting and publishing their ideas was also mirrored by their educational efforts at the local level.  Because many programs were voluntary (vaccination against small pox, for example), their effectiveness depended upon the public understanding the advantages of compliance and the public hygienists were instrumental in that education process by providing reports of their benefits that were based on more scientific foundations.

This period also saw the application of statistics to the effort to understand the contributing factors of disease and death, if not their causes.  Louis-René Villermé did extensive statistical studies of Paris and his findings linking poverty and death contributed to the notion of death as a social disease.

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