Prof. Dr. med. Frank P. Schelp Professor Emeritus Charit é-University Medicine Berlin Germany

1. Overview of the History of Public HealthandPerception of Health and Disease in High and Middle Income Countries Prof. Dr. med. Frank P. Schelp Professor Emeritus Charité-University Medicine Berlin Germany Visiting Professor Faculty of Public Health Khon Kaen University, Thailand

2. Definition of Public Health • The approach to medicine that is concerned with the health of the community as a whole • Source: MedicineNet.com Webster’s New World Medical Dictionary

3. Main Public Health Activities • Prevention, promotion and protection • Communicable disease control • Selected health promotion • Organized immunization • Environmental health • Food standards and food safety • Screening programs • Health economy • Manpower improvements and supervision • Research

4. Curative medicine Patient oriented; Individual is only interested to seek help from health delivery service in case of sickness; Patient and medical personnel focus on the disease of patient; Medical personnel will gain patient’s gratitude and credit if she or he succeeds in curing the patient. Public Health Population oriented medicine; Prevents the occurrence of disease; Measures implemented are often not very popular; Interfere with lifestyle patterns: Smoking, alcohol drinking, eating, sexual behavior etc.; Statistical reasoning is not understood neither by curative sector nor by general public. Dichotomy:Curative Medicine and Public Health

8. Historical Chapters of Public Health • Prehistoric times • Sanitation, Housing • Greco-Roman World • Middle Ages 500 – 1500 • Mercantilism, Absolutism 1500 – 1750 • Enlightenment and Revolution 1750 – 1830 • Industrialism and the Sanitary Movements 1830-1875 • Bacteriological Era 1875 -

9. Western medicine trace it’s origin back to….. the ancient Greek healer • Hippocrates (460 to 377 B.C.) • he wrote a paper on air, water and places.

10. Air, water, places • …..whoever wishes to investigate medicine properly should proceed thus:

11. Hippocrates reaching was more or less forgotten For centuries academic teaching was based on books written by the roman healer GALEN Conflicting developments from ancient times to preventive medicine and public health

12. Christian believes disregarded the body and did not emphasize personal hygiene, sometimes even declaring cleaning of the body as sinful behavior • Believe of medical establishment that occurrence of disease was due to sinful behavior

13. For many centuries academic medicine was not able to contribute to the prevention of infectious diseases • Local authorities applied measures to prevent the spread of diseases sometimes with very drastic measures • Beginning of the 17th century the MIASMA theory was developed

14. Examples of Major Plaque Epidemics

15. Concept of transmissible diseases • Concept of transmissible diseases was already established especially in the context of the severe epidemics. • Urban authorities developed methods against the spread of diseases such as quarantine which was introduced by Venice during the 14th century. • At that time important medical centre such as in Padua (Italy) contributed to the fight against epidemics. • First description of some infectious diseases recognized as being transmissible.

16. Girolamo Cardano (1501 – 1576) • Distinguished epidemic louse-born typhus from measles. • Wrote a book about his knowledge about typhus “De Mado Recentiorum Medicorum Usu Libellus”)

17. Girolamo Fracastoro (1483 to 1553) Described Typhus even more accurately; Wrote a poem about Syphilis in naming the disease after a figure in the Greek mythology; Wrote the book “De contagione et contagiosis morbis eorumque curatione (1546) (“that the seeds of diseases are minute animals able to reproduce their kind”); The book can be considered to be the foundation of modern epidemiology

18. Public health in the second half of 17th century • In the middle of Europe at that time wars, epidemics, famines and impoverishment related to the pre-industrial production methods. • Institution of public (city) medics inaugurated who supervised drug sellers, midwives, surgeons and other medical professions. • Start of taking records about birth, deaths, illnesses and epidemics as well as climatic conditions. – Beginning of a scientific epidemiology.

19. One of the after-effects of the French revolution (1789 – 1799) was the increasing interest in public health and preventive medicine. • It was now possible for energetic and ambitious individuals belonging to the lower classes to influence matters of public health. • One of such individuals was Pierre Charles Alexander Louis, a Frenchman born in 1787 - stressed the necessity to recognize and acknowledge laws of life sciences also in medicine. • He recognized that blood letting, which was very common at that time, was in most cases of no advantage to the patients, instead, very often brought about a further deterioration in the health status of the patients and sometimes death. • He supported statistical method as the method of choice also for epidemiology.

20. The theory of a contagion vivum was widely rejected because people became more concerned with finding scientific proof of a cause-effect relationship; • Although even after the microscope was invented it was not possible to detect, for instance, the agent for cholera; • The controversy between miasma and the contagious vivum theory remained up to the time of • Pasteur, who may be recognised as the founder of modern bacteriology, • Henle, who saw bacteria and suggested that they are causing diseases as well as • Koch who discovered the agents for tuberculosis in 1882 and for cholera in 1883.

21. Development of Modern Public Health • Johann Peter Frank – wrote a “System of Medical Police (1779-1827). • He formulated and presented a coherent and detailed health policy which had considerable impact both within Germany, Hungary, Italy, Denmark and Russia

22. Sanitary movements in the first half of the 19th century in England • Edwin Chadwick (1800-1890) – fight for social justice for the poor of the lower classes (Sanitary conditions of the Labouring Classes of Great Britain • John Simon (1816- 1904) demanded improvement of hygienic measures • William Farr (1807 – 1883) – developed modern statistical methods and the epidemiological way of thinking

23. John Snow (1813 – 1858) • He investigated the cholera epidemic of 1853 to 1854 • He also was an anesthesiologist and administered chloroform to Queen Victoria for the delivery of her youngest son (Leopold) and for youngest daughter (Beatrice).

24. Examples of Discoveries in the Bacteriological Area

26. ‘Primary Care’ and ‘Primary Health Care’ • Primary care • Health services by providers who act as the principal point of consultation for patients within a health care system • Primary care physician • General practitioner • Family physician • Pharmacist • Nurse practitioner • Nurse • Clinical officer • Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care • Primary health care • Alma-Ata Declaration

27. Welfare system • 31% of GDP spend for entitlement programs of the government sector • 41% of the voting age adult population lives primarily on government transfers: • State pensions • Full scale public stipends • Unemployment benefits • Disability benefits • Social assistance

28. Expenditure for Health(234,2 billion EUR 2002)

29. Expenditure According to Services (2000)

31. Perception about health in high income countries • Feeling of being responsible for its own health underdeveloped • Unhealthy behavior not challenged • Attempts to improve health after falling sick underdeveloped • Individualistic and favoring a rather liberal stance • Neglecting individual risk factors • Favoring the ‘stress concept’ • ‘Obesity is not a disease’ • Cholesterol and lipid fractions are no risk factors’ • Favoring research in genetics and disease • Overestimating genetic influence on the occurrence of disease

32. Perceptions towards health and disease in rural Thailand • Thai health policy – ‘The individual as well has to take responsibility for her or his health’ • Usually motivation and good co-operation in primary and secondary prevention • High level of tolerating insufficiencies in the health delivery system • Knowledge in major risk factors of common diseases quite good • Socio-economic gab between health officials and ordinary villagers • Communication difficulties between medical doctors or other health officials and ordinary patients

33. Present status of heath delivery system in Thailand(Private view) • Acceptable success of Primary Health Care efforts controlling infectious diseases • Acceptable success in family planning • Acceptable success in assuring access to curative medicine with continuous financial constrains for providers • Continues reconstruction of health delivery system with unclear responsibilities for players • Conflict of ‘rural doctors’ with MoPH

34. Intrusion into privacy for the sake of prevention • Abstract of MPH thesis: • …….the control of alcohol consumption in the community made use of restricting alcohol distribution and intervention on household level……

35. Tendency to please the health official in answering to interrogations

36. Conclusion • The history of public health is based on developments in Europe • Within the Thai context the aspect of ‘Thai wisdom’ is advocated – traditional medicine • Involvement of medical doctors in public health in Thailand and in highly income countries are limited but even more in the latter ones. • Primary and active secondary prevention and public health initiatives can be initiated in communities in Thailand • The perception about health and disease in both instances are significantly different