IRA IRA

V.V*
HISCOCK

of Public Health,
Department
University
~~~~~Yale

CHANGING CONCEPTS IN PUBLIC HEALTH*

"God grant us the serenity to accept the things we cannot change, the courage to
change the things we can, and the wisdom to know the difference."**

Progress towards the objectives of world health and peace depends upon
many factors, especially upon the understanding and wishes of the people.
That public health is people is suggested in the title of a popular book.t
What each person may know and do as an individual will influence much of
the future of a local area and a state and a nation. Much will depend on the
continuing ability of communities to send to the governing and advisory
bodies of official and voluntary organizations people whose vision encompasses the health needs of the area as a whole, rather than being restricted
to a group of agencies or to one particular agency. This principle, advanced
by the first Director-General of the World Health Organization, Dr. Brock
Chisholm, applies to the situation in the United States as well as to the
future of the W.H.O. in which we are all likewise interested. This is no
time for "empire building" nor for complacency.
Also necessary for progress in the improvement of health is the greater
development of the skills of direction and co-ordination to ensure maximum
economy and effectiveness of services. It is time for community agencies to
pursue with increased vigor the establishment of long-term goals in terms of
human needs, opportunities, and interrelationships. These factors deserve
priority in emphasis over temporary, short-term goals, backed by skillful
money raising campaigns, some of which have understandable emotional
appeal. This means also that we shall do well to keep in mind the interdependence of the economic and social factors in our society. There is no
doubt that gains in public health are greatly influenced by advances in other
fields.
Constructive programs for public health should be dynamic and adaptable
to changing needs which are influenced by conditions, duties, and occasions
in a state or nation. Concepts of working together for increased effectiveness are taking many forms, depending upon the problems, on the ideas of
people concerned, and on many other factors. The survey in various mani* Based on an address presented at the Second Annual Pennsylvania Health Conference, State College, Pennsylvania, August 17, 1953.
** From the door of a hospital for the care of chronic illness.
t Ginsberg, E. L.: Public health is people. New York, Commonwealth Fund, 1950.

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festations, especially the community self-survey, is one illustration. It has

become common practice among persons of apparent good health to visit
their doctors periodically for a check-up. Similarly, in several places, for
example Cincinnati and Columbus in Ohio, the "patient" (the community)
has gone back to the doctor. The "doctor" in Columbus is a committee of
200 persons created for the purpose of evaluating public health services in
Columbus and Franklin County. The Citizens Committee states that "reevaluation is necessary because times greatly change needs. For example,
infectious diseases are much less a menace than they were a few years ago.
While they now are on the decline, the average length of life is extended.
Chronic diseases and the diseases of old age have become of greater importance. We need to know how well we help with such evaluations and
with research, whether we are continuing to meet the older problems of
public health and whether we are taking steps to meet the newer problems."
This marked change in the types of illness which are principal causes of
death and incapacity requires reflection, study, and work in rehabilitation.
The change also stimulates processes for joint appraisal and co-operative
action. Meanwhile, the erection of a great clinical center within the structure of the National Institutes of Health will provide a new kind of
approach toward the conquering of human illnesses and incapacity.
It is gratifying to see how much progress has been made beyond the socalled "basic six" services of three decades ago in the State of Pennsylvania
and some of its local communities, including Philadelphia and Pittsburgh,
where useful health councils and health center programs have been established. Public health activities in Pennsylvania at one time left much to be
desired. Five years ago a comprehensive study was conducted by the
American Public Health Association at the request of leaders in the state.
This enlightening report, entitled Keystones of public health for Pennsylvania, was introduced by an encouraging statement and eight proposals
which are now receiving continuing attention:
Pennsylvania can enter a new era in public health. It will differ from the old by
being more sound in its concepts, surer in its program, and a more intimate part of
the life of the people of the Commonwealth. Though the program may be somewhat
less spectacular than in the past, health workers and citizens of the new era will
unite in a determined effort to:
1. Return the administration of public health to the local community;
2. Increase efficiency;
3. Complete the task of controlling tuberculosis;
4. Eradicate the commoner major communicable diseases;
5. Bring all modern resources of science to bear against rheumatic fever;
6. Reduce materially the ravages of cancer;

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7. Attack and vigorously apply active preventive measures to the serious, ever
present, and currently increasing problem of mental illness;
8. Insure the maximum application of preventive measures to safeguard the health
of mothers and children, of industrial workers, and of the older citizens of the
Commonwealth.

The accomplishment of these goals entails new and increasing responsibilities for the physician, still the key person in any community program,
and for professional workers and taxpayers. This statement is true for all
localities in these changing times.
Pennsylvania, like many other states, has great strengths and resources
for its public health.* Illustrations of what a good local public health
department can do, in this period of changing conditions, are being presented in many ways through various channels in the citizen effort to bring
community health services up to modern standards. A nation-wide effort
is going forward also to secure the provision of full-time, properly staffed
and equipped local health units for the forty millions residing in several
states now lacking such essential services.
Relatively little change is observed nationally in a half-dozen concepts
and principles which are continuously retested and still retained:
1. The qualities of the director and of the associated individuals, within the
structure of a health agency, are more significant than the pattern of any organization

chart;
2. Qualities of leadership may be found in individuals belonging to a variety of
cultural, economic, industrial, political, racial, religious, and other social groups;
3. Those who accept appointments to serve on boards and committees of community
advisory and appraisal services do so largely because of a friendship for others accepting similar responsibilities (including the person who extended the invitation) and
because of an opportunity to perform a civic duty; rarely is an interest in personal
and public health the primary motive for such action;
4. Principles of sharing of tasks, of working together for a common purpose, are as
old as neighborhoods, although methods differ (e.g., barn "raisings," exchanging work,
sitting up with a sick neighbor);
5. People responsible for allocation of funds, within budgets, vote appropriations for
services directed by persons whom they "like," and those who show reasonable returns
for expenditures of time, energy, and money; an additional factor being the extent of
emotional appeal;
6. Application of the Golden Rule is always appropriate.
* Definition of public health as given to medical and public health students at Yale
in 1953: Public health is the science and the art of preventing disease, prolonging life,
and promoting physical and mental health and efficiency through organized community
efforts for the sanitation of the environment, the control of community infections, the
education of the individual in principles of personal hygiene, the organization of medical
and nursing service for the early diagnosis and treatment of disease and the development of the social machinery which will ensure to every individual in the community
a standard of living adequate for the maintenance of health. By C.-E. A. Winslow.
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Again, on the national scene, the joining of national forces on the part of
several agencies in nursing, and almost simultaneously on the part of three
agencies in mental health, and more recently in New York by two agencies
in blindness did not happen by accident, but by deliberate and objective
steps. Now, also, the National Association for Mental Health intends to go
into "large-scale" financing of research on mental illness, having previously been content to encourage research and to help initiate it through
consultation with government bodies, universities, hospitals, and other
research centers. Fortunately, a commission will attempt to pull together
the findings of the scattered research projects now being carried on, to
determine the critical spots where new research is most urgently needed,
and to recommend the allocation of funds by the National Association to
new or continuing projects.
Individual national agencies devoted to arthritis, cancer, cerebral palsy,
diabetes, heart diseases, multiple sclerosis, poliomyelitis, and tuberculosis,
for example, devote a large segment of their budgets to research, complementing efforts of governmental agencies. Before long, will there not be
needed a more concerted joint educational effort for information and interpretation of results for the people who reside in our local communities and
upon whom the financial and moral support of many services, in addition
to their utilization, is so dependent? The agencies listed above are called
popularly "health agencies," but even a superficial review of the complexity,
of the ramifications, and of the results of invasion in a family of illness due
to these causes indicates that the agencies of primary concern might be
classed in the welfare group.
Many other questions arise for exploration and review of developments.
For example, do federal budget curtailments indicate a trend toward shifting responsibility for financing health services from federal to state and local
sources? Again, does the slowness in the development of full-time local
health services in many areas suggest that a different program is necessary?
Are there better patterns of service for metropolitan areas? Is more to be
studied regarding co-operative programs of health and hospital and home
care agencies through increased regionalization efforts? What of the future
of policies and responsibilities of state and local health departments in meeting such problems as the use and distribution of a scarce commodity of
apparently limited value like gamma globulin? What is the most effective
plan for school health service? Furthermore, does the response to civil
defense challenges indicate symptoms of changing concepts? Note, for
example, observations of a Committee on National Emergency Services of
the National Social Welfare Assembly and Community Chests and Councils
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of America in July 1953: "The National defense emergency has merged

with the regular economy to become the new normality for the nation and
for social welfare. It is the continuing way of life for the forseeable future."
Have health agencies any responsibilities in relation to housing, including
desires for new approaches in the housing of the aged? Although an
increasing number of people are interested in prevention, the question of
whether houses are built to live in more than to look on remains unsettled
in many quarters! Many architects now are allowed and even encouraged to
consider function in addition to structure. Mackintosh of London reminds us
(see References) that members of housing committees should have knowledge of modern housing standards besides good will, and should consider
how construction and equipment impinge upon the health and well-being of
the families that live in houses built for them. He recognizes that housing is
one of the four pillars of the application of medicine to man in his environment, and that the well-designed house provides opportunities for healthy
living.
Are the institutions concerned with medical, dental, nursing, and other
professional education prepared to assume their share of the opportunity
and responsibility, whether or not there are changing concepts of public
health? This is a basic question.
While the introduction of merit systems and better salaries, both on the
state and local level, is becoming more common, fortunately for those interested in positions in public health, the eleven accredited schools of public
health in North America preparing people for these positions are hampered
by inadequate budgets and are seriously overcrowded. In addition to these
ever-present problems, new conceptions of public health create other complexities and challenges. Just as years ago a specialist in the diagnosis and
treatment of typhoid fever found it expedient to devote more attention to
other diseases, now there are signs of new specialists in chronic illness, in
skin, and in general public health activities from the ranks of venereal
disease control experts.
As an example of another practical question worthy of continuing study
by a group of specialists in different flelds, we may consider various aspects
of improvement in the soundness of the nation's financial system due to
developments in medicine and public health. Are workers ill less frequently
and therefore able to produce more goods? Is there better school attendance
because children are in better health? What are the many factors related to
recent vacancies in tuberculosis sanatorium beds in several states, and will
these vacancies continue? Also, what is the effect on requirements for hospital beds and clinic care for acute diseases in contrast with what would
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have been the situation were it not for the sulfonamides and antibiotics
developed since 1935? What, if any, associated problems have developed?
For instance, insurance policy holders are living longer, paying more
premiums, and investing more money.
A quick glimpse of the recent past reminds us that in 1911, when the first
full-time county health unit was established in Yakima, Washington, health
administration was viewed in terms of a health officer, a nurse, and a sanitarian. Environmental sanitation and acute communicable disease control
(still major lines of defense) were the primary activities of health departments. Expectation of life at birth in the general population was slightly
over 50 years as compared with slightly under 70 at present, and with
especially striking gains for the industrial population. At that time diphtheria, for example, flourished in New Haven and in the Territory of
Hawaii, localities where there now have been no deaths from this dread
disease for several years. Then, in these communities, a high proportion of
mothers were attended at delivery by untrained midwives or by anyone who
happened to be around, and deaths of mothers and infants were high in
contrast to the present, when practically all births occur in hospitals
attended by skilled physicians assisted by nurses and other trained personnel. Incidentally, in Great Britain and some other areas, where trained
midwives are employed, deaths of mothers in childbirth are rare and infant
mortality low, indicating that at least a partial shift back to the home for
many cases of maternity and of illness might not be disastrous. The application of science to medicine and public health in the last fifty years has done
more than ease suffering and prolong life; it has affected the age distribution with a relative increase of chronic diseases which are a consequence of
the debilitations of the aging process.
A key to chronic disease control is early diagnosis and treatment. The
opening of the new Clinical Center to expedite the attack, means, in the
words of Surgeon General Leonard Scheele, "that we must not only press
the search for new knowledge, but we must also use what we do know
more intensively, more effectively.-Hundreds of thousands of people who
will die of cancer or heart disease, or who will be permanently disabled by
arthritis or neurological disorders, or mental disease, could be aided if their
illness were detected in the early stages when present methods of treatment
are most successful." But the Surgeon General agrees with others in the
field of public health that attention must be continued for broadening knowledge of the infectious diseases, particularly of the virus infections. And,
furthermore, "we have long since recognized the inseparability of science
and the society in which it functions. We cannot separate a rheumatic
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child's illness from his growing mind and body, from his immediate need
for schooling, his family's potential need for social service. Nor can we
separate the cancer patient's disease from his age, his potential unemployability, or his pension. We cannot separate the crippled workmen's paralysis from his chances for rehabilitation and return to employment and
independence."
These are days when plans are being increasingly developed with
participation of all concerned, based on desires and needs, scientifically
tested, and carried out according to sound principles in an atmosphere of
constructive human relations. Even in some of the elements of the "basic
six,"* assumed to be well covered, new questions arise such as: the importance of reciprocal measures for milk control by states; development of
better criteria and standards for sanitation; key points of an accelerated
attack on tuberculosis; better housing for the aged and infirm; control of
home accidents; the caloric diets of high nutritive quality; and the effects of
changes in nurses' case loads and objectives. Sometimes it is difficult to
determine wisely the activities for emphasis and to abandon old projects in
order to establish more promising new ones, especially in the face of conflicting pressures and protective attitudes. It is encouraging to observe the
example of representatives of the great food industry, however, in meeting
with those of health departments to arrange plans for more complete and
uniform safeguarding of food consumed by the American people in the
home, the hospital, the industrial establishment, the schools, churches, and
elsewhere.
We can adjust readily to rapid changes demanded as a result of research
which provides better techniques and methods-tools with which to combat
problems that threaten the health of our people. Sometimes the changes in
regard to health are better understood and appreciated than so-called
public changes. Many of us could use a more extensive knowledge of the
basic social sciences, including economics and political science that might
help us to understand better the people with whom we work. More and
more we are beginning to recognize the importance of public changes, and
are also utilizing better the possibilities for a unified attack by all members of the health team, including private physicians, dentists, and hos* "Desirable minimum functions" of local health departments-vital statistics and
records, sanitation, communicable disease control, laboratory services, maternal and
child health, and health education. Accident prevention, chronic diseases, the hygiene of
housing, occupational health, school health services, mental health, medical rehabilitation, and hospital and medical care administration, besides more attention to nursing,
nutrition and dental health, are other areas of service and responsibility which have
been incorporated into the programs of an increasing number of local health
departments.

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pital administrators. Simultaneously, we find increased interest in research

and in the application of results. The medical, dental, and public health
schools are stimulating examples of research centers.
There is an important psychological approach also to developing principles of community organization, (as illustrated by studies of topical fluoride
demonstration programs), and by developments in local and state health and
hospital councils. As emphasized by Leavell (see References) and others,
"The health team cannot be a closed circle of in-facing initiates with backs
to the outside world; rather, it must be an open circle ready to welcome new
workers and able to expand as new areas of useful cooperation are
discovered."
Having in mind then the significance of the total approach with a
knowledge of the individual, the family, and the community, besides the
significance of the mandates of the people, we may find comfort in Edmund
W. Sinnott's Two Roads to Truth, with a basis for unity under the great
tradition. (Viking Press 1953) Sinnott reminds us that man is a creature
of both mind and spirit, and destined to be the battleground between them.
"He cannot abdicate the responsibilities which reason places on him, for
they are what make him man. He will not sacrifice the claims of his spirit,
for their authority comes from something deeper still. He is thus bound to
be the seat of lifelong tension between these two contenders for his allegiance. Today he finds it difficult to reconcile the two. In the years to come
he may gain wisdom enough to do so. . . . We should not regret these
differences between the disciplines of reason and of spirit, but rather rejoice
in them. They are the two halves that make man whole. From tension
between them character is born .... Reason and spirit are the pillars that
support our great tradition .... Between them they hold up the hopes of
man today as he strives to fulfill his splendid destiny."
REFERENCES

American Medical Association: Principles of medical ethics. Chicago, 1949, p. 23.

American Public Health Association, Roscoe P. Kandle, et al.,
(a) Keystones of public health for Pennsylvania, 1948.
(b) The local health department-services and responsibilities. Am. J. Pub.
Health, 1950, 40, 67-72.
(c) A guide for the residency training of public health physicians (mimeographed), October, 1952.
(d) The state health department-services and responsibilities, 1953 revision.
American Academy of Political and Social Science. Annals. Mental Health in the
United States, March, 1953.
Banks, A. Leslie: Social aspects of disease. Baltimore, Williams and Wilkins Company, 1953.
Bowlby, J.: Maternal care and mental health. Geneva, World Health Organization,
1951.
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Burn, J. L.: Team work in teaching the public about health. Biology and Human
Affairs, 1953, 18, June.
Canada, Ottawa, Five Year Report, National Health Program, 1948-1953.
Ciocco, Antonio, Densen, Paul M., Horvitz, David G.: On the association between
health and social problems in the population. Milbank Memorial Fund Quarterly,
1953, 31.
Hiscock, Ira V.: Measuring public health. Am. J. Pub. Health, 1953, 43, 846-852.
Hiscock, Ira V.: Public health developments in 1952, Municipal Year Book, International City Managers' Association, Chicago, 1953.
Hiscock, William McC.: Fields of public health yet untilled. Master of Arts Thesis in
Government, Wesleyan University, 1952, (unpublished).
Journal of Social Issues. Community change: An action program in Puerto Rico,
1953, 9.
Kleinschmidt, H. E. and Zimand, Savel: Public health education. New York, The
Macmillan Company, 1953; See also Raymond Patterson and Beryl Roberts,
Community health education in action. St. Louis, C. V. Mosby, 1951 and Health
educators at work, Chapel Hill, University of North Carolina Press, 1953.
Leavell, Hugh R.: New occasions teach new duties. Pub. Health Rep., Wash., 1953,
68, 687-692.
Mackintosh, J. M.: Trends of opinion about the public health, 1901-51. London, New
York, Toronto, Oxford University Press, 1953. See also Mackintosh, J. M. Housing and family life. London, Cassell and Company Ltd., 1952.
National Safety Council: Accident facts. Chicago, 1953.
National Society for the Prevention of Blindness: Study of procedures used for
screening for visual defects. New York, 1952.
Rhode Island. Report of the Governor's Commission. Old age in Rhode Island. Provi-dence, 1953.
Stebbins, Ernest L.: Concepts of public health administration, California Health,
August 31, 1953.
United States. President's Commission on the Health Needs of the Nation. Building
America's health. Washington, D. C., U. S. Government Printing Office, 1953.
Williams, Huntington: Osler and Welch, founders of modern American public health.
Baltimore Health News, 1953, 30, No. 8.

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