Public health has never come easy.
Whether raising funds to set up a laboratory to produce diptheria vaccine in New York or the appointment of medical officers by the government slightly earlier in Great Britain, campaigners had had a tough time of it, though finally they succeeded.
The impact of the laboratory on New York death rates was phenomenal: they fell from 296 per 100,000 in 1875 to just 2.2 by 1912. In the UK public health improved considerably.
But all those gains are under threat consequent on the blows rained on the system by the business lobby, charges Richard Swift.
Writing in the New Internationalist, he notes all the bulwarks of public health - air quality, the purity of drinking water, food safety, road safety, proper drainage and the inspection of work dangers - are in danger of collapsing.
Hartmut Sehwarzbach / Still Pictures
The US itself has seen a drop of 25 per cent in money for public health. In many countries budgets for environmental compliance by a range of industries have been gutted. In the former Soviet Union a crumbling system of public health and environmental protection has seen life expectancy plummet for both men and women. In countries as diverse as Bolivia and Britain such core public services as water provision have been privatized. In far too many places the basic building blocks of public health are being degraded - either through neglect or wilful destruction. A perilous industrialism, once made bearable by public-health controls, today threatens to turn malignant.
Overspent budgets, user fees and an obsession with cost controls, shortages of personnel, patients lying for days on stretchers in hospital corridors, long waiting lists for life-or-death procedures - in short a system badly overburdened.
Debt repayment, keeping the supply of exported foodstuffs and minerals flowing, the national security obsessions of the state, all come before the provision of basic health needs. In India public health has been downloaded from the federal to state governments who lack the resources and sometimes the will to fill the gap. By the 1991-92 budget year health expenditure was only 0.04 per cent of the national budget, just a tenth of the previous decade's. The following year it was slashed by a further 20 per cent but the state governments only increased their budgets by 5 per cent in order to compensate. State governments ignored a painstakingly established surveillance system and were ill-prepared for the outbreak of plague that swept through the ramshackle slums of Surat in Maharashtra State during the mid-1990s.
Both India and its neighbour Pakistan spend a fortune on military preparations including millions on developing nuclear capacity.
Dangers to public health are everywhere. Some are old, such as plague and the renewal of once-thought-defeated diseases like tuberculosis - that classic disease of poverty.
Africa is reeling under an AIDS pandemic that is wiping out a whole generation, while antibiotic-resistant forms of malaria, tuberculosis and several other infectious killers are taking a savage toll.
There are other problems, not even imaginable until recently. Last October the 120,000 citizens of Punta Arenas, a Chilean town on the southern tip of Latin America, received a very unusual public-health warning. They and the Argentinean citizens of Ushuaia just across the border were warned to stay indoors between the hours of 11 am and 3 pm - out of the blistering rays of a southern sun peeking through an ever-expanding hole in the ozone layer. The ozone filter over the South Pole has become so weakened by a mixture of manufactured chemicals - chloroflouro-carbons, bromine atoms, nitrogen oxides and chlorine - that severe skin damage could occur in just seven minutes. Epidemics of skin cancers, widespread fertility and hormonal dysfunctions, a plethora of immune system breakdowns - all are connected in one way or another to our petro-chemical model of development.
Today the shift, at least in the industrial world but also increasingly in the South, is towards the prevention of chronic rather than infectious diseases. It is predicted that the main causes of human mortality, even in a South still plagued by infectious disease, will soon become cancers, heart disease, strokes, Alzheimer's, diabetes, schizophrenia and many more. Causes can no longer be seen as strictly local but are increasingly global - tied to a toxic development model dominated by corporate hazard merchants who profit, either directly or indirectly, from ill health and our harassed style of work and consumption.
Many people understandably look to the obvious and often impressive achievements of modern medicine when it comes to illness. And there is no denying these achievements - the rollback of smallpox, polio and leprosy for a start. The medical specialist in particular has achieved virtual superstar status with intricate transplant operations, laser surgery and now talk of genetic manipulations to save lives. But there have also been rebound effects as microbes of such diseases as tuberculosis and malaria and a plethora of other infections have developed immunity to widely used - and misused - antibiotics. Medical science has been painstakingly slow in finding 'cures' for the main chronic killers.
Today life-expectancy rates that rose pretty consistently throughout the last century are starting to stall, particularly in places with high levels of social and economic inequality like the US, Britain and Germany. A littleunderstood fact is that the main improvement in the health quality of people's lives, and in the prolongation of those lives, is not due to modern medicine at all. It is due to the patient work of public-health activists in their successful struggle to overcome the conditions in which infectious and other disease thrived: slums, bad ventilation, dodgy water, minimal sewerage, child labour, dangerous work, ignorance about sexually-transmitted diseases. Proper health statistics and a system of food inspection also improved matters. Most of these gains occurred before antibiotics were even invented. In Britain, for example, for example deaths from tuberculosis fell 86 per cent before the age of antibiotics and only nine per cent thereafter.
But with the shift in the burden of disease from the infectious to the chronic, the focus of public health has had to shift as well.
To draw attention to dangerous business practice, the World Health Organization has coined the brave and politically risky notion of 'hazard merchants.'
We need a public-health movement for the 21st century. Unfortunately we also need to go back and secure the causes fought for by the original public-health pioneers. Things like safe water and proper sewerage are a public trust, not simply another business opportunity.
The cost-cutting temptations of bottom-line logic are a poor substitute for vigilant public servants with adequate resources to do the job. But beyond that we need a public-health movement that unites equity and environment in a common democratic agenda empowering the people at large, stresses Swift.