A History of Public Health [revised expanded] 1421416018, 9781421416014

Citation preview

A History of Public Health

A History of Public Health Revised Expanded Edition

GEORGE ROSEN Foreword by Pascal James Imperato, MD, MPH&TM Introduction by Elizabeth Fee Biographical Essay & New Bibliography by Edward T. Morman

© Copyright 1958 by MD Publications, Inc., New York, New York © 1993, 2015 Johns Hopkins University Press Reprinted by permission of Paul P. Rosen, MD All rights reserved. Published 2015 Printed in the United States of America on acid-free paper 2 4 6 8 9 7 5 3 1 Johns Hopkins University Press 2715 North Charles Street Baltimore, Maryland 21218-4363 www.press.jhu.edu Library of Congress Cataloging-in-Publication Data Rosen, George, 1910–1977, author. A history of public health / George Rosen ; foreword by Pascal James Imperato ; introduction by Elizabeth Fee ; biographical essay and new bibliography by Edward T. Morman. — Revised expanded edition. p. ; cm. Includes bibliographical references and indexes. ISBN 978-1-4214-1601-4 (pbk. : alk. paper) — ISBN 1-4214-1601-8 (pbk. : alk. paper) — ISBN 978-1-4214-1602-1 (electronic) — ISBN 1-4214-1602-6 (electronic) I. Title. [DNLM: 1. Rosen, George, 1910–1977. 2. Public Health—history. WA 11.1] RA424.R65 614.4—dc23 2014016735 A catalog record for this book is available from the British Library. Special discounts are available for bulk purchases of this book. For more information, please contact Special Sales at 410-516-6936 or [email protected]. Johns Hopkins University Press uses environmentally friendly book materials, including recycled text paper that is composed of at least 30 percent post-consumer waste, whenever possible.

CONTENTS

Foreword by Pascal James Imperato, MD, MPH&TM Public Health, Past and Present: A Shared Social Vision by Elizabeth Fee George Rosen, Public Health, and History by Edward T. Morman Preface to the 1958 Edition I The Origins of Public Health Sanitation and Housing Cleanliness and Godliness Disease and the Community II Health and the Community in the Greco-Roman World GREECE Problems of Disease Diphtheria Malaria The Nature of Disease Airs, Waters, and Places Colonization and Medical Care Hygiene and Health Education Occupational Health Public Health Administration ROME The Legacy of Greece Water Supply and Sanitation Climate, Soil, and Health Disease: Endemic and Epidemic The Workers’ Health The Provision of Medical Care Baths as Well as Bread and Circuses Public Health Administration

III Public Health in the Middle Ages (500–1500 A.D.) The Decline of Rome The Middle Ages The Growth of Cities Sanitary Problems of Urban Life Protecting the Consumer Disease in the Middle Ages Leprosy—The Great Blight The Living Dead The Black Death Quarantine What Causes Epidemics? The Organization of Public Health The Provision of Medical Care Hospitals and Welfare Institutions The Regimen of Health The Medieval Achievement in Public Health IV Mercantilism, Absolutism, and the Health of the People (1500–1750) Brave New Worlds Causes and Consequences The Old Public Health and the New Science New Diseases for a New World The English Sweat Jail Fever and the Black Assizes The Red Sickness The Rickets, or the English Disease Scurvy—The Black Death of the Sea The Diseases of Workers The Great Pox The Small Pox Malaria and Other Diseases Contagion or Epidemic Constitution? Leeuwenhoek and His “Little Animals” Foundations of Public Health Administration Political Arithmetic: The Bookkeeping of the State Toward a National Health Policy The Town and the Public Health Street Cleaning and Drainage The Water Supply—Toward Private Enterprise

The Lame, the Halt, and the Blind An Age of Transition V Health in a Period of Enlightenment and Revolution (1750–1830) A Seed Time of History Enlightenment and Reason Of Human Welfare An Increase of Population The Campaign against Gin A Slaughter of Innocents All Manner of Conditions and Men Lunacy and Conscience Hospitals and Dispensaries Improvement of Town Life Health in National Policy A Health Code for Enlightened Despots Health and the Rights of Man A Parochial Health Policy The Bookkeeping of Life and Death The Geography of Health and Disease Advice to the People on Their Health The Prevalence of Disease Variolation—Like Cures Like The Cow Pox and a Country Doctor A World of Coal and Iron VI Industrialism and the Sanitary Movement (1830–1875) The Satanic Wheels The Old Poor Law Mobilizing the Labor Force The Doctrine of Philosophical Necessity The View of Political Economy Bentham and the Philosophic Radicals Enter Mr. Chadwick The New Poor Law Urban Growth and the Problems of Town Life Reduce Taxes by Preventing Disease! The Sanitary Condition of the People The Health of Towns Commission The General Board of Health

Exit Mr. Chadwick “How Quaint the Ways of Paradox!” Two Steps Forward, One Step Back Eppur se muove Urbanism and the Origins of American Public Health in the Nineteenth Century A Bookseller Turns Crusader The New York Sanitary Survey of 1864 A Premature National Health Department Social Revolution, Industrialism, and Public Hygiene in France National Unification and Health Reform in Germany An Era of Statistical Enthusiasm Women and Children First A Period of Great Epidemics —And Some Smaller Ones Miasma versus Contagion—an Epidemiological Conundrum First Steps toward International Health Organization VII The Bacteriological Era and Its Aftermath (1875–1950) The Specific Element in Disease “A More Rational Account of the Itch” A Disease of Silkworms A Revolutionary Anatomist Fights a Rearguard Action Ferments and Microbes The Silkworm Disease and the Germ Theory A Botanist Plays Host to an Unknown Doctor Antisepsis and Asepsis in Surgery Bacteriology and the Public Health The Vanishing Diseases VIII The Bacteriological Era and Its Aftermath (Concluded) Economic and Social Trends in a Changing Society The Welfare of Mothers and Children The Health of the School Child A New Kind of Nurse Appears Voluntary Action for Health Teaching the People about Health The Rise of Scientific Nutrition The Health and Welfare of the Worker Better Medical Care for the People The Responsibility of Government for the Advancement of Health

“No Man is an Iland . . .” “That untravell’d world, whose margin fades . . .” Bibliography Access to Primary Sources in the History of Public Health Classified Bibliography of Secondary Sources Subject Index Name Index

FOREWORD

Pascal James Imperato, MD, MPH&TM FORMER COMMISSIONER OF HEALTH OF NEW YORK CITY DEAN AND DISTINGUISHED SERVICE PROFESSOR STATE UNIVERSITY OF NEW YORK DOWNSTATE MEDICAL CENTER SCHOOL OF PUBLIC HEALTH

In his preface to the first edition of this volume, George Rosen cogently noted that to understand the present, we must view it “in the light of the past from which it has emerged and of the future which it is bringing forth.” He emphasized that advancement into the future required close attention to the past and how it created the possibilities of the present. In setting forth these essential principles that characterize continuity across time, he was in effect saying that the past is never irrelevant. Rather, it informs both the present and the future and helps to shape new ideas and scientific discoveries. When the first edition of this volume appeared in 1950, the conquest of infectious diseases seemed almost assured. New antibiotics and vaccines held the promise of relegating many of these diseases to archival status. For a time, both medical and public health practitioners witnessed the decline in prevalence of what had once been plagues of both adults and children. As they did so, the focus of attention shifted to chronic diseases. However, within a short time, antibiotic resistance, the emergence of newer infections, the reemergence of known infections, and the impacts of globalization shifted many public health efforts back to where they had been when Rosen was writing this book. Thus it is that today, infectious diseases are not only in second place globally as the cause of death but also the leading cause of death among those younger than fifty years old. Several factors have brought about this dramatic return to the past, including world population growth, which in turn has resulted in major population movements. These geographic shifts include encroachment into previously uninhabited environments resulting in exposure to the vectors and reservoirs of diseases previously unknown or little known in humans. At the same time, there has been massive migration to urban environments with weak sanitary infrastructures. Increased transnational and transcontinental population movements have also resulted in the transportation of diseases and insect vectors. The globalization of the world’s food supplies has resulted in the distribution of products contaminated either at the source of production or during various phases of processing. Likewise, global industry and commerce and less than adequate quality production standards have created products that harbor harmful and even deadly chemicals. Human behaviors that alter the environment and bring about climatic changes have directly altered the larger biotope, and thus facilitated the growth of vector and animal reservoir populations. In many resource-poor countries, population growth has outstripped the capacity of public health infrastructures, leading to an expansion of unsanitary environments.

The list of infectious diseases that has emerged over the past forty years is lengthy. It includes HIV/AIDS, Legionnaires’ disease, Ebola virus disease, Cryptosporidium parvum diarrhea, Escherichia coli 0157:H7 hemorrhagic colitis and hemorrhagic uremic syndrome, Lyme disease, severe acute respiratory syndrome (SARS), avian influenza, West Nile virus infection, and many others. In the absence of a specific vaccine and antiviral agents, the prevention and control of Ebola virus disease uniquely depend on long-established public health interventions discussed in detail by Rosen in this volume. These include patient isolation, concurrent disinfection of everything associated with the patient and his or her environment, identification and surveillance of contacts, and modern versions of quarantine. Enhancing the prevention and control of epidemics and outbreaks of Ebola virus disease, such as those of the late twentieth and early twenty-first centuries, requires the development of effective vaccines and therapeutic agents. Most of the emerging infections are zoonotic in nature. The reemerging infections, by contrast, are often the result of human behaviors that facilitate transmission. Refusal to have children immunized out of fears that vaccination could cause adverse consequences has resulted in modern outbreaks of measles, pertussis, and poliomyelitis. The prevalence of sexually transmitted diseases such as human papillomavirus infection and herpes virus infections has risen in recent decades because of altered human attitudes and behaviors and individual failure to employ recommended modes of prevention. The current public health landscape thus includes not only the challenges inherent in the prevention and control of chronic diseases but also those associated with communicable diseases. On the global scene, essential public health infrastructures that provide potable water supplies, sewage disposal, sanitary environments, and safe food and drug supplies are being seriously stressed. It is clear that a number of public health problems, once a fixture of the distant and not-so-distant past, are largely being addressed with long-established interventions extensively covered in George Rosen’s volume. The epidemiology, detection, prevention, and control of most of these emerging and reemerging infections have not appreciably changed over time. These facts point out the enduring value of Rosen’s A History of Public Health. For its pages cover not only the public health problems of the past but also some of the public health problems cast against the canvas of a rapidly changing globalized society. Rosen brought to his writing of this book a unique sense of the intimate relationships between the social and biological determinants of disease and an insightful understanding of the continuity of past, present, and future in the conduct of human affairs. His global account of public health’s long and fascinating history benefited from his skills as a historian and from his experiences as a public health practitioner. Although he is best remembered as a medical historian, Rosen also practiced public health. His public health roles practiced in a diversity of venues greatly enriched Rosen’s scholarly understanding of the challenges faced across time by those entrusted with protecting and promoting collective well-being. Initially trained as a clinician at Beth-El Hospital (now Brookdale Hospital) in Brooklyn, New York, he went into private practice for five years. Toward the end of his private practice, he served as a clinic physician in the New York City Department of Health’s Bureau of Tuberculosis Control. In this pre-antibiotic era, the prevention, control, and treatment of tuberculosis were daunting, and only the most courageous physicians volunteered for this service. He served as a junior health officer for two years in the health department from 1941 to 1943. Rosen added administrative experiences to the clinical skills he already possessed. During World War II, he served in the Preventive Medicine

Service of the Surgeon General’s Office and in the European Theater of Operations. After his discharge, he returned to the New York City Department of Health as a district health officer, where he was responsible for overseeing the broad scope of functions and services the department offered. These ranged from maternal and child health clinics to environmental sanitation. Thus, he was responsible for maintaining the public health in a densely populated area of New York City. In so doing, he acquired a vast field-based knowledge of the diverse interventions required to protect the health of the public. In 1949, Harry S. Mustard, MD, Commissioner of Health of New York City, asked George Rosen to become director of the Bureau of Health Education. Mustard, an academician, had turned to Rosen because he viewed him as someone who could bring new ideas to the bureau. Mustard was also attracted to Rosen because he possessed a PhD in sociology (awarded in 1944 by Columbia University) and a Master of Public Health degree, awarded by Columbia in 1947. Rosen then served for seven years as director of the Division of Health Education and Preventive Services of the Health Insurance Plan of Greater New York. He was concurrently professor of public health education at Columbia University’s then Faculty of Public Health and Administrative Medicine. At the time that I joined the New York City Department of Health in 1972, George Rosen was a legendary figure in public health. Within the department, he was remembered for his legacy of important innovations in the Bureau of Health Education. At that time, many of the department’s professionals had studied under him at Columbia and greatly admired him as an inspiring teacher. At this stage of his career, he enjoyed an international reputation as a scholar, teacher, and editor. His tenure as editor of the American Journal of Public Health (1957–1973) was marked by great improvements in the journal and an expansion of its scope of coverage. Although my contacts with George Rosen were few, I was always impressed by his warm and welcoming manner and his effortless ability to engage younger public health specialists as respected colleagues. I think that he would be pleased to know that his volume continues to make the exciting history of public health available to younger generations. That audience now includes not only seasoned public health professionals but also an ever-expanding audience of students enrolled in baccalaureate, master’s, and doctoral degree programs in public health.

PUBLIC HEALTH, PAST AND PRESENT

A Shared Social Vision Elizabeth Fee

George Rosen’s A History of Public Health is a classic of public health history. An admirably comprehensive synthesis of the development of public health in Europe and North America, it engages the interest of both beginners and specialists. Rosen takes us on a chronological journey from the Greco-Roman ideas of health based on the balance of the four humors, through the plagues and quarantines of the Middle Ages, to the more modern era of political and industrial revolutions, and the health and sanitary reform movements of the nineteenth and twentieth centuries. Throughout, he displays his mastery of public health, his understanding of the social context as well as the biological determinants of disease, and his knowledge of social history, sociology, and political philosophy. Conceived in grand style and incorporating a wealth of detailed knowledge, the History is animated by the author’s social and scientific optimism and his deep commitment to public health and progressive reform. At the time of its first publication in 1958, Rosen’s History filled an absolute vacuum; no book on the history of public health was at once so comprehensive, so accessible, and so informative. It soon became the standard history of the subject; in many ways, it has served to define the content and boundaries of the field ever since. When we consider the purpose, scope, and vision of Rosen’s text, we can begin to understand why this book has not been superseded in the intervening decades. George Rosen’s History provided the framework and set the agenda for much subsequent research and writing on public health history. Over the past twenty years in particular, historians have paid increasing attention to the history of disease, medicine, and public health. For the most part, they have dealt with specific issues, institutions, personalities, places, and diseases—few have attempted to present a fully comprehensive view across the continents and centuries.1 A flood of monographs and articles on aspects of public health history has extended Rosen’s analysis of specific periods and issues; one purpose of this essay is to provide guidance to this more recent work in the field. Both the notes to this introduction and the new bibliography at the end of the volume thus serve as entry points to the more specialized historical literature. For those new to public health history, Rosen’s book provides an excellent starting point and a necessary context for exploring these more specialized studies, but even those familiar with the recent literature will find that Rosen’s sweeping synthesis remains useful in relating the diverse aspects of the field and in provoking new questions. Some of these more recent scholarly studies challenge Rosen’s interpretations, and others explore and elaborate them through extensive research in the primary sources. The generation of social historians of health that came of age in the 1960s rejected an older tradition of medical history that seemed to celebrate medical science, glorify the role of physicians, and project a positivist view of scientific progress, while appearing to accept uncritically the existing forms of medical care organization and the underlying structures of social inequality. Instead of a decontextualized story of scientific discoveries, Rosen offered a social history in which he tried to demonstrate the social

production of health and disease, to place physicians and public health practitioners within their social context, and to show how their changing ideas and practices related to the larger framework of political and economic conditions. At the same time, he preserved a heroic place in his history for all those struggling to improve health and prevent disease, whether through the development and application of scientific ideas or through social reforms intended to promote the public health. Rosen’s History thus provided both a model of social criticism and an inspirational tale offering the possibility of (albeit reconceptualized) progress. The first of these themes appeals directly to the critical interests of historians, while the second engages the activist impulses of public health practitioners. This presentation of the history of public health is especially oriented to the interests of public health practitioners in the United States, the country where he spent most of his life working in public health and medical history. His early years as a medical student in Germany and his long-standing interest in European history, politics, and culture served to broaden his perspective and provided a comparative, and often critical, view. Rosen’s medical and sociological training, his social and political concerns, and his almost twenty years of practical and administrative experience—all inform his historical analysis and help make his work relevant to the interests of public health students and practitioners. Most share his social concerns, his essentially optimistic belief in progress and social improvement, and his appreciation for science and positive knowledge. Rosen showed how the history of public health can capture the attention of practitioners by playing on themes that relate the past to the present. Like his friend and mentor Henry E. Sigerist, he believed that history was an essential discipline in training health professionals; those working in practical and policy positions needed the perspective that could be provided only through knowledge of the past.2 In his own professional career, Rosen demonstrated the dual interests of the historian and the practitioner. As former editor of the Journal of the History of Medicine and Allied Sciences and Ciba Symposia, he was familiar with a broad spectrum of research on the history of medicine and public health, and he could draw on his own extensive historical writings as well as on the work of other scholars in the field.3 As a public health practitioner, administrator, and educator, and as editor of the American Journal of Public Health, he was also very much involved in the public health issues and controversies of his day and could speak with authority within the public health community. Historians often find it difficult to analyze the period in which they live and work, preferring the distant past to the contentious present and welcoming the perspective provided by time’s passing. George Rosen, however, sought direct connections between the past and the present—he deliberately used the past as an argument, as a guide, and sometimes as a source of moral lessons for action in the present. Since he believed so firmly in progress, he detected (or perhaps created) a rational progression in the past: a progression in the direction of ever-increasing social concern, social responsibility, equity, and fairness—and he was convinced that history provided precedent and support for continued progress in the future.

Looking Backward: A Later Perspective on Rosen’s Politics Rosen’s history ends in the middle of the twentieth century, in the 1950s, and much has changed since then. In the United States, a multiplicity of social protest movements, beginning with the civil rights movement, prompted the expansion of the welfare state through the Great Society programs of the

1960s. The War on Poverty, the Civil Rights Act, and the passage of Medicare and Medicaid are certainly developments of which Rosen would have approved, but the escalation of Vietnam War provoked a large antiwar movement and proved a national as well as an international trauma, marking the end of the United States’ assumptions of invincibility. The rise of the decolonialized states and the Non-Aligned Movement also directly challenged the dominance of the United States and European powers. At home, the massive entry of women into the labor market, the flowering of the women’s movement, and later of the gay movement, challenged assumptions about gender relations, the family, and sexuality. The occupational health movement and environmental movement created the social consciousness that would lead to the establishment of the Occupational Health and Safety Administration and the Environmental Protection Agency of 1970. Economic stagnation, recession, increased global competition, and the oil crisis were, however, followed by political backlash, attacks on unions and on the political and cultural movements of the 1960s. The Nixon administration brought the slashing of domestic social expenditures, including public health programs, as again did the Reagan administration in the 1980s. Internationally, the fall of the Berlin Wall and the collapse of the Soviet Union marked the end of superpower rivalries that had structured international relations since World War II. Free-trade policies, international debt crises, economic globalization and growing inequalities among countries and populations were accompanied by the emergence and reemergence of deadly infectious diseases, as Pascal Imperato has explained in his Foreword to this volume. The wars in Iraq and Afghanistan, fears of terrorism and bioterrorism, eruptions in the Middle East, threats of global warming and climate change, and economic expansion collapsing into recession and unemployment have all contributed to making the world a much more threatening and less predictable place than it appeared at the time when George Rosen was writing. In reviewing the history of these more recent decades, it is difficult to see these changes as simply one more chapter in a history already understood: they appear sufficiently discontinuous as to force a more thorough reconsideration of the meaning and scope of contemporary history, including the history of public health. A progressive, Rosen’s political views had been shaped by the experiences and ideas of the 1930s and 1940s, the trade union victories of the Congress of Industrial Organizations (CIO), and the fight against fascism. Progressives and liberals believed firmly in progress, both social and scientific. History offered evidence that human beings, through will and organization, could change their societies for the better. By extrapolation, the future should offer more—more progress, more justice, more equality, and better health. In the future, the benefits from ever-expanding scientific and technological achievements, instead of accruing to a few, would be shared by all. When Rosen wrote A History of Public Health in the 1950s, the Cold War was entrenched and social conflicts that earlier had been overt and obvious were muffled in apparent consensus. A postwar economic boom, widespread prosperity, the retreat to suburbia, and political repression of left-wing ideas had produced a consumer culture of patriotism mixed with complacency. Much of this complacency stemmed from the very gains of the New Deal and the fact that real wages were rising in an expanding economy. Progress, still a pervasive theme in popular culture, was now generally interpreted to mean the acquisition of personal security and material goods. In this context, social conflicts and contradictions were blanketed in silence, as were the politics of gender and sexuality. To be sure, the politics of class and race were being fought out in the factories, in the courts, and in the schools; the civil rights movement, still at its most optimistic, centered on the ideal of racial integration into the mainstream of American life. But for the most part, social and political life seemed untroubled. Rosen’s assertion of an alternate vision of progress was a courageous political

act as well as a statement of personal conviction. A few decades later, after the upheavals of the 1960s, 1970s, 1980s, and 1990s, our perceptions of the history of the twentieth century have irrevocably changed. The progressives who triumphed over depression, war, and fascism were able to read the twentieth century as a story of progress. A later generation would find this most basic form of political optimism difficult or impossible. Rosen’s very faith in progress and in the continuous steady development of the welfare state, social reform, and public health now gives the final chapters of this book a somewhat old-fashioned air. Today, we tend to be more pessimistic and more cynical. The welfare state is the center of bitter political struggles and can no longer simply be assumed as a measure of social progress and civilization. From immigration to national health insurance, the United States shows deep political divisions and great difficulty moving forward. Other countries around the world are also battling entrenched and, frequently, violent conflicts.

Public Health Issues That Exploded in the 1960s and After Obviously, it would be unfair to criticize Rosen for not addressing issues that exploded in the 1960s and thereafter, nor can we necessarily fault his reading of progress on the basis of our contemporary skepticism or disillusionment. Anyone writing a history of public health today, for example, would have to pay attention to issues of race; we are incapable of thinking and talking about urban health, poverty, and welfare without dealing with race and racism, particularly as we struggle with differing perceptions and evaluations of the Great Society programs of the 1960s. By contrast, Rosen’s reading of progress led him to frame his discussions of the social context of disease in clear economic terms. Rosen insisted on the importance of class as a factor in public health. This unfashionable emphasis was particularly remarkable in the late 1950s, when the United States and other advanced capitalist countries had supposedly become virtually classless societies. Some readers may still find Rosen’s emphasis on class, the impact of class inequalities on health, and the history of occupational health surprising or troubling, as more recent discussions of public health and social policy have often remained blind to the class issues to which Rosen devoted considerable attention. This emphasis on class and on the economic basis of health and illness is, however, all too relevant today, given the falling standard of living of the United States working class, deteriorating occupational health protections, and the return of epidemic tuberculosis and other diseases of poverty, as well as the emergence of devastating new epidemics.4 We still need histories of public health in which class and race in their domestic and international context are together understood as central ways of shaping social experience and as the twin parameters of social policy in the twentieth and twenty-first centuries. Although sensitive to class issues, Rosen has little to say about gender. He incorporates into his history conventional descriptions of maternal and child health programs but ignores many issues that today convulse discussions of public policy, such as abortion, reproductive rights, and gay marriage. From present perspectives, this volume is curiously silent about such matters as birth control, sex education, and the medicalization of women’s health. In the context of the current worldwide pandemic of AIDS, widespread public awareness of sexually transmitted diseases, active contemporary discussions of family violence, battering, and child abuse, and political warfare over abortion rights, it is no longer possible to doubt the relevance to public health of sexuality, sexual behavior, and gender relations. At his best, Rosen provides interpretations that help us understand the shifting contours of public

health in relation to fundamental political and economic changes—mercantilism and cameralism, the Enlightenment, and the philosophic radicalism of the early nineteenth century. In his discussions of the eighteenth and nineteenth centuries, for example, we will see how he draws on elements of Marxist analysis to explore the relationship of public health to the economic and political processes that changed the shape of Europe and North America. At other times, however, when he loses sight of the underlying economic and political processes, his text tends to become a more descriptive listing of efforts and accomplishments—one that is useful, to be sure, but less illuminating and less exciting to read. This is most apparent in Rosen’s final sections on public health in the twentieth century, where his inattention to issues of race and gender is also most troubling. As many readers will note, Rosen pays little attention to the global realities of public health beyond the boundaries he has set by restricting his account to Europe and the United States. There are only a few, fleeting references to Asia, Africa, and South America; these continents appear most frequently as the sources of disease epidemics affecting the more developed world. Rosen gives some indication that he recognizes the need for a larger, more international view of public health problems and interventions, but at the same time, his account is constricted by the implicit conviction —still common today—that all the really important events and activities, at least in modern times, have taken place in Europe and North America. In the preface to his book, he makes explicit reference to an understanding of “development” in which the nations of the Third World are simply lagging several centuries behind their more prosperous neighbors: “For a variety of reasons, a large part of the world—in Asia, in Africa, in the Middle East—stopped developing economically, politically and scientifically around 1400, just about the time that the Western nations entered upon a period of extraordinary growth in these areas. As a result, it is only today that the Asian and African peoples are beginning to effect the far-reaching changes necessary to bridge the gap of centuries.” Like most other historians of the period, Rosen’s perspective on international health seems innocent of any real comprehension of colonialism, imperial wars, or international political economy, and their impact on the health of the world’s populations. Since that time, these subjects have been energetically explored and have generated a considerable literature.5 Drawing attention to the issues not covered or minimally discussed by Rosen should not be interpreted as criticism of him for failing to foresee issues that have emerged as present-day concerns, but to point out the ways in which, as health and social policy are reshaped in response to new understandings, so too must their history be revised to reflect a changing universe of meaning. In reading Rosen’s History from a contemporary perspective, we may observe the subjects he chooses to address and those he omits, notice how his account reflects certain priorities and neglects others, become conscious of the ways in which he guides us and focuses our attention—and at the same time, continue to admire the scope of his accomplishment. With these contemporary concerns and attitudes in mind, we can thus retrace Rosen’s history, observing along the way how he has shaped the history of public health in ways that emphasize the moral, political, and social lessons he wished to convey.

Reading Rosen’s History We begin as Rosen does, following the traditional outline of European and American history, with the ancient civilizations of Greece and Rome. This framework was certainly the standard when George Rosen was writing, and indeed, it continues to be the dominant framework for much of the history of medicine, science, and public health. There are, however, some indications within the body of Rosen’s work that he found the traditional focus on Europe and the United States somewhat

constricting. He thus began his History with a brief discussion of the sanitary ideas and practices of the ancient civilizations of India, Egypt, and Peru, and he ended with comments on the future of international health. In his tantalizingly brief introductory chapter on ancient worldwide sanitary practices, Rosen establishes two important points. The first is that the history of public health cannot ultimately be restricted to European civilizations; although his text will be limited mainly to the history of Europe and North America, that history forms but part of a longer and larger history of health and healing throughout the world. The second is that public health includes broad environmental measures and is not restricted to the prevention of specific diseases; Rosen continually emphasizes the idea that such issues as cleanliness, water supplies, and waste removal are more fundamental to health and disease prevention than a sophisticated scientific knowledge of disease causation and transmission. Turning to the main body of the book, we notice that Rosen devotes the first 40 percent of his text to the history of public health before 1830, the next 20 percent to the nineteenth-century sanitary movement, and the last 40 percent to the bacteriological era and the subsequent developments of the early twentieth century. Some historians would consider this a foreshortened account, but the balance of attention seems appropriate for public health workers, who are likely to be more interested in the relatively recent past than in distant times. The chapters on the ancient and medieval world are primarily intended to provide a context for discussing the later development of public health in Europe. In these sections, Rosen tries to show how particular ideas of disease causation and prevention fit within their specific social, economic, and political contexts and how they satisfied immediate practical needs. He argues, for example, that the Hippocratic text on Airs, Waters, and Places not only represented the first systematic effort to relate environmental factors to disease but also served as a practical guidebook. He explains that the seafaring Greeks needed to understand the relationships of health to climate, soil, water, and nutrition to select the healthiest sites for the establishment of new colonies. Individual Greek physicians, who were essentially wandering craftsmen, also had to understand the geographical distribution of disease; a physician setting up practice in an unfamiliar town could impress potential patients by his familiarity with local diseases and ability to make accurate prognoses. In a similar way, the Romans, as a great military power, produced public health knowledge and practices compatible with their social and military organization. Although they were dependent on the Greeks for much of their medical knowledge, they were supremely successful as engineers and administrators; their aqueducts, providing water to the cities, were the engineering marvel of the ancient world.6 Rosen argues that the Roman public baths made personal hygiene and cleanliness possible for all citizens, and he applauds Roman administrative efficiency in the development of public health services, the provision of public hospitals, and the employment of city physicians. Here, he emphasizes themes that will recur in other contexts throughout his History: the need for public services, especially for the poor, and the importance of administrative efficiency in providing such services.7 Throughout his section on the ancient world, Rosen sets the stage for another key theme—the tension between a broad environmentalist view of disease and one emphasizing the action of specific disease agents. In a global generalization, he argues that the Hippocratic text Airs, Waters, and Places served as the basic epidemiological reference for more than two thousand years and that ideas of disease causation did not radically change until the development of bacteriology and immunology in the late nineteenth century. Although he will later provide a glowing account of the achievements of

bacteriology, Rosen is clearly sympathetic to the broad, environmentalist perspective.8 Rosen’s History moves rapidly to the monasteries and municipalities of the Middle Ages in Western Europe, referring only briefly to the transmission of Greek and Roman learning by Arab scholars and physicians. As in earlier chapters, he compresses a long and complicated historical development into a few pages, deliberately highlighting themes that show the social context of public health and link historical developments to contemporary concerns. He discusses the sanitary problems of medieval cities, quarantines and the isolation of people with communicable diseases, medical and social assistance to the poor, and the founding of hospitals, hospices, and bathhouses. He concludes that, despite a lack of concrete scientific knowledge, medieval cities were generally able to create “a rational system of public hygiene” for dealing with health problems.9 Here, he is again trying to counter the scientism of popular culture by showing how much practically useful work can be accomplished in the absence of specific scientific and technological resources. The Renaissance is associated with the beginnings of modern science and the rise of a new urban middle class, or bourgeoisie, whose wealth was dependent on commerce rather than on land. Their economic activities made possible the development of the national state and, with intellectuals who were often encouraged and directed by royal patronage, helped create a new secular culture, a new science, and the technologies essential for building weapons of war, increasing wealth, and consolidating power.10 Rosen argues that the bourgeoisie’s growing interest in numerical calculations prompted the gathering of statistical information, first produced in Italian cities during the fourteenth century. Their scientific and quantitative interests also encouraged new approaches to the body: Andreas Vesalius brought a new level of critical observation and precise description to human anatomy, and William Harvey’s discovery of the circulation of the blood demonstrated elements of a more functional, experimental, and quantitative approach to physiology. Close clinical observation brought recognizable descriptions of such diseases as whooping cough, typhus fever, and scarlet fever, and studies of disease transmission resulted in what Rosen terms “the first consistent theory of contagious disease,” by Girolamo Fracastoro.11 In addition to stressing the new importance of scientific observation in the Renaissance, Rosen emphasizes the relationship between new (or newly observed) diseases and the social context in which they developed and were transmitted. Typhus fever traveled with armies and was nourished by constant military campaigns.12 Scurvy, earlier observed in medieval cities under siege, now became an occupational disease of sailors, sent on voyages of exploration in ships lacking fresh fruits and vegetables.13 Rickets, a disease born of economic depression, poverty, and malnutrition, was nurtured in dark, overcrowded urban settlements. Deep mines produced the occupational hazards and diseases of mine workers, as recognized by Paracelsus and as discussed comprehensively for the first time in Bernardino Ramazzini’s treatise on the diseases of workers.14 Rosen also examines how military explorations, trade, and travel generated epidemics by exposing nonimmune populations to new diseases. Around the time of the Columbian voyages, syphilis arrived in Naples and spread from Italy to the rest of Europe.15 Smallpox, which had smoldered endemically in Europe, proved devastating to Native American populations in the New World. Europeans also brought malaria to the Americas, probably carrying new strains of the parasite from Africa, India, and the Far East. The increasing integration of the world through trade meant the internationalization of disease organisms, which served, all too often, as aids to the armies of conquest.

In examining the early modern period from 1500 to 1750, Rosen shows how new theories of the state and the political and economic doctrines of mercantilism—the new system being built around trade and commerce—integrally involved public health. These theories assumed that no distinction need be made between the welfare of the state and the welfare of society; the interests of the state in building national power and wealth required a large and healthy population. This approach supported public health, albeit of a notably authoritarian form, in the concept of “medical police.” The state, wanting to increase the size of the population and the productivity of labor, now began to apply statistical methods to calculations of mortality, life expectancy, and fertility.16 Statistics thus became more than a matter of curiosity to mathematicians or aristocrats interested in improving their gambling odds; they represented the “book-keeping of the state” or, as William Petty called it, “political arithmetic.” The rulers of the absolutist German states had essentially unlimited powers over their populations. While admiring the spirit of enlightenment and humanitarianism that pervades the monumental work of Johann Peter Frank in the late eighteenth century, Rosen notes that Frank’s concept of the “medical police” was based on the political agenda of the absolutist state, which, by the early nineteenth century, was “already outmoded and reactionary.”17 He thus refuses to present Frank as simply a “pioneer” of public health and insists that we read his work in the context of the political struggles between an older concept of the authoritarian state and the more democratic ideals of the French revolution. While rejecting authoritarian power, Rosen also deplores the inefficiency of systems run with purely local controls. He describes without admiration the English system of fragmented, local public health authorities, which lacked any administrative structure linking them to the central government. He praises several sweeping health policy proposals for the provision of national health and medical care—proposals that he admits were, at the time, purely theoretical. For Rosen’s purposes, these Utopian proposals provide intellectual precedents within Western culture for the idea that the state should take responsibility for the population’s health and welfare. Rosen presents the Age of Enlightenment (from 1750 to 1830) as pivotal in the evolution of public health. The French philosophers of the Enlightenment had challenged tradition and authority as sources of knowledge and asserted the primacy of reason. In the Enlightenment dream of reason—the belief in the supreme social value of intelligence, the idea that, through reason, man could design and even guarantee social progress, the conviction that education and free institutions could lead to human perfectibility—Rosen found the ultimate justification for even the most mundane efforts to reform social institutions and improve social conditions. From this perspective, the purpose of public health was to translate the ideals of the Enlightenment into practice. Rosen saw the French as intellectuals, the British as administrators: whereas the French philosophers argued the power of human reason and the possibility of progress, the more pragmatic English tried to translate these ideals into legislation and social policy.18 In England, Rosen argues, the urban middle class developed a distinctive ethos, based on the values of order, efficiency, and social discipline—but also on the conviction that social conditions m