Throughout human history, the major problems of health that men have faced have been concerned with community life, for instance, the control of trans
missible disease, the control and improvement of the physical environment (sanitation), the provision of water and food of good quality and in sufficient supply, the provision of medical care, and the relief of disability and destitu
tion. The relative emphasis placed on each of these problems has varied from time to time, but they are all closely related, and from them has come public health as we know it today.
s a n i t a t i o n a n d h o u s i n g. Evidence of activity connected with commu
nity health has been found in the very earliest civilizations. Some four thou
sand years ago, a people of whom little is known developed a great urban civi
lization in the north of India. Sites excavated at Mohenjo-Daro in the Indus valley and at Harappa in the Punjab indicate that these ancient Indian cities were consciously planned in rectangular blocks, apparently in accordance with building laws. Bathrooms and drains are common in the excavated buildings.
The streets were broad, paved, and drained by covered sewers. These drains were laid some two feet or less below the level of the street, and they consisted for the most part of molded bricks, cemented with a mortar of mud. Within the houses better materials were used, and in at least one instance there is a re
port of drain pipes made of pottery and embedded in gypsum plaster against the possibility of leakage.
Finds dating from the Middle Kingdom (2100—1700 B.C.) give some idea of conditions in Egypt. The archeologist Flinders Petrie discovered the ruins of the city of Kahun, which had been built at the royal command according to a unified plan. Care was taken to drain off water by means of a stone masonry
2 A History o f Public Health
gutter in the center of the street. The ruins of Tel-el-Amarna, dating from the fourteenth century B.C., are essentially like those of Kahun. One detail, how
ever, deserves mention. The remains of a bathroom were found in one of the smaller houses.
Two thousand years before the Christian era, the problem of procuring an adequate supply of drinking water for larger communities had in considerable measure already been solved. For example, the Cretan-Mycenean culture had large conduits. Excavations have also revealed that Troy had a very ingenious water supply system. Just as in any place where drinking water supply sys
tems were accepted facts, the disposal of wastes was likewise regulated and the sewer age system was well developed. In palaces, such as that of Knossos on Crete, which dates from the second pre-Christian millenium, there were not only magnificent bathing facilities, but also water flushing arrangements for the toilets. Water pipes in private houses, the remains of which are still clearly evident at present among the ruins of Priene in Asia Minor, were probably in
stalled at an early date, even though in many places, water was usually drawn from public wells.
Impressive ruins of sewerage systems and baths testify to the achievements of the Incas in public health engineering. They established well-drained cities that were adequately supplied with water, thus providing a good basis for the health of the community. The Incas were also aware that other elements of the physical environment could have an effect upon health. Thus, they recognized the connection between acclimatization and ill-health. Troops from the high
lands served in the hot valleys under a rotation system, remaining there only for a few months at a time.
c l e a n l i n e s s a n d g o d l i n e s s. Cleanliness and personal hygiene are to be found among present-day primitives and were unquestionably practiced by pre
historic and early historic men. Primitive peoples generally dispose of their excretions in a sanitary manner, but their reasons for this behavior are not necessarily identical with ours. Throughout large periods of human history, cleanliness has been next to godliness because of religious beliefs and practices.
People kept clean so as to be pure in the eyes of the gods and not for hygienic reasons. Cleanliness and hygiene were emphasized on such grounds among the the Egyptians, the Mesopotamians, the Hebrews, and other peoples.
An interesting example of the connection between cleanliness and religion is the Inca feast, Citua. Every year, in September, at the beginning of the rainy season, which was associated with disease, the people led by the Inca carried out the health ceremony. In addition to prayer, propitiatory offerings to the gods, and other religious practices, all homes were thoroughly cleaned.
d i s e a s e a n d t h e c o m m u n i t y. As long as man has lived on earth, disease has plagued him. Sickness is associated with life, and man everywhere endeav
The Origins o f Public Health 5
ors to deal with it as best he can. Studies in paleopathology have shown not only the antiquity of disease, but also that it has always occurred in the same basic forms, such as infection, inflammation, disturbances of development and metabolism, traumatism, and tumors. For example, schistosomiasis, prevalent in Egypt today, has been found in kidneys 3000 years old, and tuberculosis of the spine has been diagnosed in the skeletal remains of pre-Columbian Indians.
Furthermore, pictorial evidence from Egypt suggests the existence of poliomy
elitis and achondroplastic dwarfism. However, while the basic types have not changed, the incidence and prevalence of illness have varied from time to time and from place to place. Knowledge of such changes in the occurrence of dis
ease is essential for an understanding of the health problems faced by commu
nities in the course of human history and of the thoughts and actions of those who dealt with them.
Faced with problems of endemic or epidemic disease, communities and in
dividuals have acted in terms of some prevailing concept of the nature of ill
ness. On the primitive level of knowledge, this action is generally couched in super natural terms. Modern medicine, on the other hand, seeks to understand and to manage illness by studying normal and morbid structures and processes in the body. Modern medicine identifies and differentiates many distinct dis
eases, defining the disease as clearly as possible in terms of its symptoms, loca
tion, and cause. This concept of distinct disease entities is, however, of com
paratively recent origin.
Ancient and medieval physicians did not generally distinguish different dis
eases as such, but they were concerned rather with various groups of symptoms exhibited by sick people. Such evidences of disordered health were explained by theories about the abnormal mixture of the body fluids (humoralism) or about the constricted and relaxed states in the solid parts of the body (solidism). As long as such conceptions of disease prevailed, physicians could not, in the na
ture of the case, concentrate on specific seats of disease.
However, the transmissibility of certain diseases was noted long before their causes were known, and certain communicable diseases have been recognized for many centuries. There is not any doubt that the ancient world was repeat
edly visited by epidemics. The possible existence of smallpox in Egypt around 1000 B.C. was suggested by M. A. Ruffer. He examined a mummy of the Twentieth Dynasty, in which the skin was “the seat of a peculiar vesicular or bulbous eruption which in form and general distribution bore a striking resem
blance to that of smallpox.” In the /¿W w e read of Apollo with his darts inflict
ing epidemic illness on the army before Troy; and in the O ld Testament of the Bible in the book of I Samuel we are told that the hand of the Lord was against the Philistines who were smitten so that “emerods broke out upon them.”
For thousands of years, epidemics were looked upon mainly as divine judg
4 A History o f Public Health
ments on the wickedness of mankind, and it was believed that these punish
ments were to be avoided by appeasing the wrathful gods. In Egypt, for in
stance, Sekhmet, goddess of pestilence, produced epidemics when aroused and abated them when she was mollified. This theurgical theory of disease lasted for several millennia, but alongside it there gradually developed the idea that pestilence is due to natural causes involving especially climate and the physical environment. This great liberation of thought took place in Greece and culmi
nated during the fifth and fourth centuries B.C. in the first attempts at a ratio
nal, scientific theory of disease causation. This is not to say that Greek medi
cal thought was completely devoid of religious aspects, but more and more the great physicians and thinkers of Greece oriented themselves in terms of this world.