Historical background

Until recently it was a commonly held view that improvements in health were the result of scientific medicine. This view was based on experience of the modern management of sickness by dedicated health workers able to draw on an ever-growing range of diagnostics, medicines and surgical interventions. The demise of epidemics and infectious disease (until the manifestation of AIDS), the dramatic decline in maternal and infant mortality rates and the progressive increase in the proportion of the population living into old age coincided in Britain with the development of the National Health Service (established in 1948). Henceforth, good-quality medical care was available to most people when they needed it at no immediate cost. Clearly there have been advances in scientific medicine with enormous benefit to humankind, but have they alone or even mainly been responsible for the dramatic improvements in mortality rates evident in developed countries in the last 150 years? What lessons can we learn from how these improvements have been brought about?

Public health has been defined as ‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society’ [1]. In Europe and North America, four distinct phases of activity in relation to public health over the last two hundred years can be identified. The first phase began in the industrialised cities of northern Europe in response to the appalling toll of death and disease among working-class people who were living in abject poverty. Large numbers of people had been displaced from the land by landlords seeking to take advantage of the agricultural revolution. They had been attracted to growing cities as a result of the industrial revolution and produced massive changes in population patterns and the physical environment in which people lived [2].