Preventive medicine and society. chadwick’s proposal.Edwin Chadwick (1800-1890) was a barrister who came to the same conclusion as Petty had done two hundred years before. He promoted the notion that disease amongst the poor was the major reason they couldn't look after themselves. He maintained that the enormous level of government expenditure on Poor Law relief would be dramatically reduced if the poor were healthy. In this rather roundabout economic, as opposed to medical, way he became the father of British and American public health. His report, The Sanitary Conditions of the Labouring Population of Great Britain (1842), made the awful conditions of working people so apparent to the upper classes that they simply had to listen. He showed that, while the upper classes lived on average to the age of 44 and while only one in ten of their children died in the first year of life, the comparable figures for the working classes were 22 years and one child in four. He maintained that a cleaner environment with decent water supplies and adequate sewage disposal were the answers. Chadwick proposed the formation of a centralized public health authority with a full-time staff, and after several years of debate the Public Health Act of 1845 established a three-man General Board of Health. But even once water and sewage systems were widely introduced it was still clear that these weren't the total answer to health, and slowly it became apparent that housing, food, working conditions and personal health services were just as important. Chadwick's influence didn't stop at sewage and water mains though-he pushed for an even greater link between 'health' and 'welfare'. Even though there was already a definite move towards community services and the realization that health was a national asset, the puritan work ethic still ruled supreme and the fear was that anyone and everyone would rather receive welfare than work. This meant that welfare benefits put the person in a position lower than 'the situation of the dependent labourer of the humblest sort'. It is ironic that even today 'health' and 'welfare' are still bound together in the same bureaucratic machinery both in the UK and the US even though they are uneasy bedfellows much of the time. But in spite of often conflicting pulls, public health made great strides in the last quarter of the nineteenth century. The work on bacteria by Pasteur and Koch took scientific endeavor a giant leap forward and placed the whole of disease on a different plane from supplying clean water and the disposal of sewage. Quite quickly it became apparent that public health measures were far more effective in controlling almost all common infectious diseases than was curative, personal medicine, and the seeds of medical discontent were sown that are still with us to this day. When public health officials were making such an enormous impact on the nation's health doctors were relatively powerless to achieve much. The emphasis on sanitation, the absence of doctors from major decision-making bodies and the link between public health and 'welfare' made public health unattractive and unrewarding to doctors. Unfortunately, there were more fundamental problems too-problems which we still have today. In the nineteenth century voluntary hospitals were preoccupied with treating disease and they had a monopoly of medical education dating back a century. Clinical medicine, then as now, attracted interventionists whereas what preventive medicine needed was people who were happy with an absence of disease. Prevention seemed dull by comparison with the glamour of effecting cures, and even today when so many of the medical profession pay lip-service to the importance of prevention only a tiny fraction (1 -2 per cent in the UK) of any westernized nation's health budget is spent on prevention -mainly because medicine has become almost entirely an active, interventionist profession. Interestingly, the Hippocratic Oath itself could also be said to be an enemy of public health and prevention, insisting as it does that doctors put the needs of their patients before anything else. Doctors from the Middle Ages onwards (until the advent of the National Health Service in the UK, and still in the US today) have been private entrepreneurs selling their skills on a one-off basis to anyone who could afford them. So it was at the turn of the century in the UK. Doctors were wedded to a group of individuals who provided their personal income and it was clearly in their interests to ensure that nothing they did professionally jeopardised their patients' health and their own livelihood. Patients felt that in such a system they were paying for highly personalised care and didn't want to hear about 'bad news' outside this one-to-one doctor/ patient contract. This contrasts sharply with medicine in Eastern Europe where the physician's first duty is to strengthen the State by maintaining the health of its people. Everything in the doctor/patient relationship is secondary to this. Although most of us in the West find this approach unpalatable the benefit is that public health measures are more easily accepted and acted upon. *4/72/5* GENERAL HEALTH «Viagra Online» |