PUBLIC HEALTH PAST & PRESENT

By David Heaton

Managing Editor SWUPHD Public Information Officer

The Poison Pump In 1831, England was hit for the first time by a wave of cholera, one of the most dreaded diseases of the time. A bacterial infection of the intestines, cholera causes profuse diarrhea and vomiting and has up to a 60% mortality rate if left untreated, sometimes causing death within hours after symptoms begin. Cholera killed millions of people in the 1800s as it spread from India to Russia, Europe, and North America. Most medical practitioners at the time believed that diseases like cholera spread through a poisonous mist in the air called "miasma". John Snow, a British physician, was skeptical of this theory and challenged it in an 1849 essay. A few years later, London was in the grip of another series of cholera outbreaks. On August 31, 1854 the worst outbreak hit the Soho district, causing most residents to flee and killing over 600 people over the course of a few weeks. With the aid of a local reverend, Dr. Snow took to the streets of Soho as the outbreak raged in an effort to track down the source. Going door to door to identify where the victims lived and what they had in common, he created a map that helped him narrow his search to a specific area surrounding a water pump on Broad Street. Dr. Snow wrote: "On proceeding to the spot, I found that nearly all the deaths had taken place within a short distance of the pump. There were only ten deaths in houses situated decidedly nearer to another street pump. In five of these cases the families of the deceased persons informed me that they always sent to the pump in Broad-street, as they preferred the water to that of the pumps which were nearer. In three other cases the deceased were children who went

to school near the pump in Broad-street. Two of them were known to drink the water, and the parents of the third think it probable that it did so… With regard to the deaths occurring in the locality belonging to the pump, there were 61 instances in which I was informed that the deceased persons used to drink the pump water from Broad-street, either constantly or occasionally… The result of this inquiry, then, is that there has been no particular outbreak or prevalence of cholera in this part of London except among the persons who were in the habit of drinking the water of the above-mentioned pump-well. I had an interview with the Board of Guardians of St. James's parish, on the evening of the 7th (of September), and represented the above circumstances to them. In consequence of what I said, the handle of the pump was removed on the following day." Source: Snow, John. Med. Times and Gazette, n. s. vol. 9, Sept. 23, 1854, pp. 321-322. Dr. John Snow's detective work helped end what he later called "the most terrible outbreak of cholera which ever occurred in the United Kingdom". He was able to show that contaminated water, not air, was responsible for the spread of cholera, and he traced the source of disease to nearby cesspools and sewage-polluted water from the Thames river, which was being piped directly to the pumps. Dr. Snow's use of statistics and investigation along with the simple removal of a pump handle marked the founding of epidemiology, or the science of studying patterns of health and disease at the population level. A new element of public health had emerged. Protecting the Public Renowned bacteriologist C.E.A. Winslow defined public health as "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations...communities and individuals." Public health has been practiced in various ways throughout history. The Chinese employed an early form of immunization against smallpox 3,000 years ago. In the Roman era, measures were taken to divert human waste in cities. Quarantine was used in medieval times to fight the spread of contagious illnesses. The 19th century saw the development of sewers, garbage collection, and landfills in industrialized countries where higher populations in urban areas increased the risk of disease. By the arrival of the 20th cen-

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tury, germ theory had been accepted and vaccines were being developed. World War I became the first major conflict where disease caused fewer casualties than combat.

Science was making amazing strides against smallpox, diphtheria, yellow fever, syphilis, typhoid, and bubonic plague. Tetanus and meningitis were largely conquered with antitoxins. Feared diseases that once took a high toll from the population were being subdued in the United States and other developed nations. In the 1950s, Jonas Salk and Albert Sabin introduced vaccines for polio, which has now been eradicated throughout most of the world. Smallpox, which once destroyed entire civilizations and killed millions annually until just a few decades ago, became the first disease to be completely eradicated as of 1979. Advances in public health have reduced infant mortality and have increased life expectancy to over 78 years for Americans. Traditional public health has usually included clean water, immunization, safe food, rule enforcement, passive surveillance, and some clinical programs. More recently, public health practice has entered new frontiers in technology, emergency preparedness, community involvement, and personal empowerment. Good public health practice protects the community's health by promoting wellness and preventing health problems from occurring in the first place. Doing More With Less The task of shouldering the responsibility of public health in society has largely fallen to government entities, since the emphasis is on populations and broad-based solutions. The Department of Health and Human Services (HHS) oversees public health on the federal level and includes the Surgeon General, Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH). The Utah Department of Health (UDOH) addresses public health issues on the state level, and finally the work on the ground in Utah is done by independent local health departments. These county-level organizations are charged with providing direct services to their communities, and do so today with increasing expectations and decreasing resources. Today the United States spends about $11,582 annually per person on health care, usually for treatment after we become ill. It is estimated that an investment of $1,000 per person (as recommended by the CDC) for public health activities would actually cut what we spend on healthcare in half. Traditionally, we in Utah have funded public health at one of the lowest rates in the nation, and so we're forced to do a lot with very little. Utah’s 13 local health departments get the majority of their budget from federal grants, which are obtained and distributed by the Utah Department of Health. Currently, the five counties covered by the Southwest Utah Public Health Department (SWUPHD) get $30 annually per person for public health, including $6.75 per head from county taxes. Funding public health has been a "backburner" issue for years, and increasing funding to prevent future problems is a tough sell for many people, especially in today's economy. The profession is also losing knowledge and wisdom as experienced members of the public health workforce retire. They, and others who leave for different employment, may not be replaced due to tightening budgets. Local health departments are charged with the responsibility of preventing disease, promoting wellness, and protecting the health of the population. Answering to a Board of Health composed of county commissioners and appointed citizens, the SWUPHD employs 85 staff and offers over 80 programs to promote and protect the health of the 257,390 residents of southwestern Utah, which includes Washington, Iron, Kane, Beaver, and Garfield counties.

“These services make the most impact at the local level and our health department will continue to do our best to offer science-based, effective programs to our communities," states Dr. David Blodgett, SWUPHD Director and Health Officer. "Much of what we do is preventive and unnoticed. Yet in reality, the difference between a third world country and a developed nation is a good public health system."