With the dominance of medicine over the past two hundred years many historical health concepts have gone through various changes. The definition of health is dependent on one’s perspective, be it lay, professional or from influences of specific cultures or social ideals and health policies of a particular time or place (Fleming & Parker 2012, p.30, Naidoo & Wills 2000).
An exploration through history will reflect on the health philosophies of the ancient Greeks and Romans, the Middle Age’s concept of quarantine and isolation and the religious theories of disease including a brief insight into the renaissance. Subsequently, a discussion of health concepts of the past two centuries including 19th century sanitary reform, the dominance in the 20th century of the medical model of health care. This paper will look at the shift away from the medical model and the 21st century concept of health promotion and multidisciplinary care, using allied health professionals. I will argue that attention to the achievements and failures of the historical concepts of health, equips allied health professionals with an opportunity to objectively decide which of these practices have relevance or are useful in developing new approaches for positive health outcomes.
In ancient times religion and science were tied in together when it came to health and everyday living. The ruins throughout Greece and Italy stand as testament to their ingenuity with creating and building infrastructure, but also of the people’s belief in the power and influence of the ancient Gods to heal illness (Krieger 2012, p.47, Hays 1998, p.9). According to Tountas (2009) the ancient Greeks were the first to break with mystical notions of health re-orienting ‘medicine toward a more naturalistic and humanistic perspective’ to define health as ‘equilibrium between man and his environment’. The Greek scholar Hippocrates’ (c.460BC–c.370BC), defined the humoral conception of health, , with the balance of these being responsible for health, interacting together with lifestyle and environment, including individual constitution, clean air, diet and clean water. He noted in his writings, regarding the workers and slaves, that neglect of diet affected their health, yet, work was not considered an influencing factor on humoral balance (Tountas 2009, p.186-187, Fleming & Parker 2012, p.28, Turner 2000, p.13, Krieger, pp.43-44, Noviik and morrow, 2008, p.5). Others such as Empedocles, Aristotle and later Galen extended Hippocratic humoral theory to link other elements (Hays 2009, pp.9-13). No matter which variation, these theories were an attempt to rationalise individual incidents of sickness and the differences in health status in the populace in relation to ‘underlying principles and environmental exposures’ (Krieger, p.46). According to Krieger (2011, p.47) Greek politics had influence stating ‘not only nature but politics informed the conceptualization of “balance” in Greek humoral theory’.
Tountas (2009, p.187) noted that ancient Greek physicians were itinerant craftsmen, earning their reputation for skill from the successes of previous visits (Veith 1980, p.532). The diversity of their practice included leech craft, magic and what is known today as allied health professions including dietetics, nutrition, occupational therapy, health promotion and pharmacy (Tountas 2009, p.187, Turner 2007 p.13, Veith 1980, p.533).
The ancient Greeks placed emphasis on the individual, with importance on personal hygiene, exercise, health education, as well as public health policy and physical, environmental and social factors (Tountas 2009, p.186, Fleming & Parker 2012, p.28, Novik & Morrow 2008, p.5) These ancient ideals were not altruistic but to benefit the elite and the military (Fleming & Parker 2012, p.28).
Ancient Roman philosophy was about the importance of the state, a population based approach with the social and financial benefits of keeping the public healthy. Their belief was, ill health was related to bad air, bad water, swamps, sewage, rubbish and poor personal hygiene. The Roman civilization is well known for engineering and administration systems. Applying these principles and taking measures for prevention and minimising risk of disease by the setting of policy, law and law enforcement, town planning to establish systems for sewerage, paving and guttering, aqueducts for clean water, public bath houses and rubbish removal (Fleming & Parker 2012, p.28).
Contrary to the practices of the ancients, medieval Europe was a time of filth, poverty, little education, pandemics and epidemics. The wisdom of the ancient understanding of the relationship between infrastructure, sanitation, hygiene, clean water, nutrition and health were disregarded (Fleming & Parker 2012, p.29, Hays 1998, p.36).
Disease was rampant, mortality rates escalated and life expectancy dropped. Many people traveling during crusades and wars, overcrowded populations and living conditions, lack of sanitation, infestations of vermin and commercial trade all contributed to the spreading of infectious disease. These factors lead to dysentery, diarrhoea and typhoid fever and influenced the spread of smallpox, measles, influenza, tuberculosis and the plague (Hays 1998, p.36). Cholera, pulmonary anthrax, leprosy and bubonic plague flourished with the profusion of black rats that easily moved around spreading plague to other areas. The cause was unknown at the time with the current medical paradigm consisting of humours and miasma and people believing corrupted air transformed into sticky miasmas causing infection and death (Cipolla 1992, pp.2-5, Hays 1998, p.37).
Italian cities were the first to set up health boards to deal with the problems caused by epidemics, temporary at first in 1348 with permanent boards formed by early 15th century. It was a critical move from makeshift actions toward prevention (Cipolla 1992, pp.1-2). These diseases spurred authorities to enforce law and reporting regulations and use the limited measures available – quarantine, isolation, segregation and expulsion, these measures continued into the 19th century (Fleming & Parker 2012, p.29, Novik & Morrow 2008, p.6).
The justification for these actions was based on perceptions that disease moved from place to place, possibly by imported goods and/or person-to-person contact. Without any real comprehension of disease processes and their spread, physicians held to the contagion theory of disease. Prevalent was a strong influence from religion and superstition. Before scientific understanding of the causation of disease or infection, sickness was seen as an indication of sins of the soul or straying from the path of righteousness, a ‘divine judgement’ from God, as a punishment or test (Fleming & Parker 2012, p.29, Novik & Morrow 2008, p.6, Turner 2000, p.14, Hays 1998, pp.15,28,36). Hays (1998, p.30) states that the ideas of the cause and cure of disease during the Middle Ages although coexisting uncomfortably included God’s will, contagion, individual responsibility and morality, heredity along with the ‘interaction of cultural beliefs and expectations’.
By the Renaissance religion was still very influential. With the emergence of physicians, scientists and other academics explanations based on belief, religion and superstition were challenged. Reason and rational thought allowed for basic scientific investigation into the development and nature of disease. Poverty, poor sanitation, filth and overcrowding were a major part in the spread of disease and continued into the enlightenment (Fleming & Parker 2012, p.29, Turner 2000, p.14, Hays 1998, p.89).
Eventually a decline of religious, superstitious and monarchical dogma, gave way to scientific thinking during the Enlightenment, encouraging speculation and debate regarding the possible cause and cure of disease. Many beliefs coexisted, miasmic, contagious and Galenic theories but there were others (Hays 1998, p.130). With infectious disease as the principle cause of mortality and morbidity, science had a profound impact on health and medicine. (Yuil 2002, p.22-26). These scientific advances laid the foundations of modern philosophies, questioning the previous traditions. This was the beginning of the medical model of health and its dominance. (Yuil 2002, p.23, Fleming & Parker 2012, p.29).
The 19th century was an environmentalist era, from their economic and social ideals rose concerns for health and poverty (Berridge 1999, p.24). Infectious disease continued to be prevalent in both America and Europe, however, debate between contagion and miasmic theories on the cause of disease outbreaks continued.
Connections to the influences of health, such as environmental and socio-economic factors were beginning. 19th century London physician John Snow demonstrated the connection between cholera and water when he removed a water pump handle and prevented the further spread of cholera. By 1851, microscopic analysis identified cholera in water supplied by unscrupulous companies. This highlights the conflict faced by public health with the power and profitability of political, legal and vested interests. (Vlahov et al. 2004, p.1134, Krieger 2011, pp.66&71, Berridge 1999, p.23, Yuil 2002, p.22 Szreter 2005, p.27-28). This was a time of sanitary reform, the Shattuck Report of 1850 and the 1842 report on sanitary conditions… by Edwin Chadwick, both recognising the connection between the filthy environment, poor sanitation, socio-economic factors and disease. Chadwick believed in the miasma theory and his ‘central premise was that filth breeds sickness, sickness breeds unemployment, and unemployment breeds poverty’ (Krieger 2011,p.72). Eventually leading to the Public health act 1848 directing local authorities to provide a sewer system, however, after two decades this had not occurred. From the 1860’s, with the power of the vote, elected civic leaders of a new generation recognised the need for investment in health amenities and social services and significant improvements in health began. (Krieger 2011,p.72, Szreter 2005, p.26-32).
Australian legislation and sanitary reforms were based on British models. Although several health acts were passed during the 1800’s and early 1900’s they were ineffective. The initial measures of public health were limited to vaccination and quarantine. History reports there was a failure to acknowledge the reality of high infant mortality, typhoid, smallpox and plague epidemics (Bryder 1994, p.314-319).
The 1918/19 influenza epidemic following First World War tested commonwealth powers of quarantine and provided the stimulus for of an effective health administration. However the 1920 reformed Department of Public Health was not very successful. The medical profession wielded power with regard to local health reform; being blamed for the failed attempt to reform maternity services. Over the years Doctors refused to co-operate with changes, only agreeing when it kept them in control (Bryder 1994, p.320-322).
In the past infectious diseases were the main contributors to morbidity and mortality, although infectious disease such as HIV/AIDS and others need attention, the post war shift of the 20th and 21st centuries to chronic illnesses such as heart disease and diabetes, the principle causality is social, specifically, an unhealthy lifestyle (Yuil 2002, p.24). A multidisciplinary team of Allied health professionals are best placed to helping those with chronic disease. The 1974 Lalode report identified the determinants of health as lifestyle, environment, human biology and health care services.
The dominant medical model of health has a biological basis, simplistically; no illness or disease equals health (Fleming &Parker 2012), however this is changing as the World Health Organisation (WHO) takes a holistic view and defines health as ‘a state of complete physical, mental and social well-being rather than a mere absence of disease or infirmity’ (World Health Organisation 1947).
The emergence of health promotion has inspired changes in approach to health. The 1986 Ottawa charter, a foundational document for health promotion, recognises ‘health and its maintenance as a major social investment and challenge’. Raphael (1998) states ‘Health promotion is an ethical and principled discipline; it is because of its values-based approach that it is effective’. History shows that there is no direct link between economic growth and positive repercussions on health. While necessary, economic growth needs other factors such as political, social, and cultural, to transform the wealth created into improved health for the populace (Szreter 2005, p.29-30).
As quoted in Scally and Womack (2004) of Marx and Engels ‘that ‘‘History does nothing, it … fights no battles. It is … real living man, who does everything”. According to Scally and Womack (2004) reflecting on history allows for the analysis of current practice and challenges, which can help professionals in questioning that which isn’t appropriate or applicable, for example a lesson learnt from history is the recognition of tobacco use as a health hazard.
I have argued that attention to the achievements and failures of the historical concepts of health, equips allied health professionals with an opportunity to objectively decide which of these practices have relevance or are useful in developing new approaches for positive health outcomes.
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