More than advances in medicine, it was improvements advocated by the public health movement of the early 1900s that led to a healthier US population. Our predecessors made enormous capital investments in systems for delivering clean, running water and disposing of waste and garbage. They fought the political battles necessary to pass laws protecting the safety of our food supply and the working conditions in our factories. They conducted major education campaigns. Classroom by classroom, civic gathering by civic gathering, at Ellis Island and in settlement houses, at grange halls and scout meetings, they educated the public about basic hygiene, disease prevention, home and occupational safety.
We enjoy the benefits of their efforts in the form of lower infant and child mortality rates, longer lives for men and women, and reductions in contagious illness and disease.
Along with these achievements came another development: our consensus as a people that a public infrastructure for improving and maintaining health is fundamental to decent living. Water purification, responsible human waste disposal, regular garbage collection, government oversight of grocery stores and restaurants, and enforced occupational safety practices are all customary today. We take them for granted. Earlier in the 20th century, however, these were not a given. They required major investments of political as well as financial capital. Our country committed itself, in grand scale and wide scope, to improving the well-being of our people. The health we enjoy here as we enter the 21st century is directly traceable to the physical and legal public health infrastructure developed early in the 20th.
The question now, for this new century, this new millennium, is whether there is a new, equally important and equally challenging frontier for public health?
Visionaries from our past can provide answers for our future. Charles-Edward A. Winslow, once a dean of Yale’s school of public health, gave us this vision of public health in 1920 in an address to new students:
Public health is the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health [emphasis added].
In other words, a goal of public health is to produce the social conditions that lead to good health. Beginning with this new millennium, we can extend our vision from what we (mostly) have achieved—systems for disease prevention and control, safety, and sanitation—to repairing our inequitable social system. We can look to addressing those socioeconomic realities, such as poverty, income and wealth disparities, ignorance, and unemployment, that weaken the public’s health.
Historical traditions support the notion that public health demands a wider perspective. At the turn of the 20th century, we knew that outdoor privies could make people sick, but it was a leap from that knowledge to the philosophical, social, and political conclusion that the answer was to fund and build an interconnected system of mains, pipes, and water purification facilities so that clean, running water was available to all. We knew that rural folk, living isolated without electricity and telephones, suffered a poorer quality of life and health than their urban counterparts, but it took a major change in thinking during FDR’s presidency to establish the Rural Electrification Administration and make the massive investments necessary to bring these services, which helped eliminate disease and premature death, to rural areas. Similarly, we know that people’s socioeconomic status affects their health and longevity. The question is whether we are willing to make a similar leap and change the social and economic machinery for the sake of our peoples health. The challenge for the public health professional in the new millennium is to develop the consensus that will make that happen.
A recent UNICEF report, The State of the Worlds Children 2000, documents that one in six children in the world’s wealthiest countries live in poverty, with 47 million living in families so poor that their health and well-being is at risk. Indigent children, the report shows, are more likely to have learning difficulties, drop out of school, use drugs, commit crimes, be jobless, and have children too early. The most disgraceful finding in UNICEF’s report is this: of the 29 countries in the Organization for Economic Cooperation and Development (OECD), next to Mexico, the United States has the highest percentage of children living in poverty. More than one in every five US children, or 22.4%, is poverty-stricken. (Twenty-six percent of Mexico’s children live in poverty.)
We know that the consequences of childhood poverty cited by UNICEF—learning problems, school dropouts, substance abuse, crime, early parenthood, and joblessness—all translate into poor health outcomes over a lifetime and become causes of social exclusion even into the next generation. A five-year study by the Centers for Disease Control and Prevention found that higher-educated adults are healthier than adults without high school diplomas; college graduates get sick less often than high school graduates; unemployed adults get sick more often than employed adults; and people in poverty get sick the most often. Researchers elsewhere have found a correlation between physical and mental health and the extent to which people feel in control of the negative circumstances in their lives, such as poverty and joblessness. A study from Scotland showed that poor women who received the same quality of care for breast cancer as women who were not poor actually had poorer outcomes because their overall health was poorer.
The authors of a Harvard School of Public Health study theorize that, at least in white men, chronic stress brought on by lower socioeconomic status triggers psychological factors, such as hostility, which in turn lead to negative physiological consequences such as higher blood pressure and higher blood sugar levels. The list goes on, and the specifics may vary, but the bottom line is this: people living in lower socioeconomic circumstances are excluded from partaking of the wealth of our social resources, and are consequently living in health-threatening conditions.
We can begin to address social exclusion in three ways: academically, through research; politically, by eliminating poverty; and socially, by addressing socioeconomic inequality, racism, sexism, and other forms of bias.