If the COVID-19 pandemic has achieved anything over the past 12 months it is to have thrust public health into the limelight that it has not experienced for many years. To our Victorian predecessors it was the pre-eminent perspective on what medicine had to offer the human condition, since much of what was available to the physicians of the day was at best ineffective and at worst no more than quackery. Leaches and periodic bleeding; untested herbal remedies, pills and potions; and brutal surgical intervention often followed by sepsis and death could not compete with safe water and sanitation, slum improvement and improvements in nutrition in reducing infant death rates and improving longevity.1
In the intervening years between the mid-19th century, with its recurrent epidemics of cholera, typhoid and a plethora of water- and food-borne threats to health, and today's familiarity with the miracles of science-based pharmacology and safe, life-changing operations, we have come such a long way that we risk losing sight of the milestones of the journey. When the novel coronavirus tipped up last year, the major emphasis of the response was to dust off plans that spoke of hospital beds, intensive care and ventilation with the barely disguised fear that if things got bad the health service might fall over; soon the pursuit of salvation in the form of effective vaccines dominated efforts to seek out the virus and suppress it through time-honoured public health methods of tracking and tracing those affected and preventing further transmission.
One hundred and fifty thousand deaths later, we are beginning to pick over the entrails of the disaster to see where we went wrong. When PhD students and historians publish their findings, it is likely that the spotlight will come to rest on, among other things, the neglect of hygiene as a fundamental plank of the public health response to epidemics. The corollary of this neglect has been the dominance of therapeutic thinking over that of prevention and health maintenance. This has its roots in the ancient Greeks and the rival beliefs of the worshippers of the goddess Hygieia for whom the good life was an entitlement for a life lived wisely and those of Aesculapius who took a more sceptical view of the weaknesses of the flesh.
While the public health pioneers of the 1840s, including the first Medical Officers of Health, focussed heavily on environmental measures to improve the sanitary conditions of the slum dwellers in the industrial towns, the hygiene movement that followed honed in on those behaviours that mediated between the environment and human biology.2 Safe water, food, air and sex were all fair game to the hygienists, together with the living and working environment drawing on emerging knowledge from the laboratories of Ehrlich, Koch, Virchow and the Pasteurs, and Florence Nightingale's observations in the Crimea. Their tools were soap and water, architecture, town planning, ventilation and condoms. Their immense contributions to public health predated the dawn of the therapeutic era by several decades.
Faced with the pandemic of HIV/AIDS in the 1980s and a prudish government, Chief Medical Officer, Sir Donald Acheson, was able to use cinema public service announcements from World War II aimed at preventing sexually transmitted infections in the armed forces to persuade ministers to adopt a more explicit approach to prevention.
Much of the legacy of the hygiene movement was eclipsed in the post-war years as pharmaceutical advances rode high. As a medical student in the 1960s, this was epitomised by the contrasting practice of the senior, ex-army surgeon at a teaching hospital in the north-east in comparison to his new school academic colleague. While the former was fastidious about every aspect of ward hygiene down to conducting forensic examination of the ablutions every Saturday morning, the professor was more relaxed about aseptic technique to the extent of routinely prescribing antibiotics as a prophylactic for wound infections; their wound infection rates were dramatically different and belied the value of modern medicines, recklessly used. Neglect of best practice began to be seen in the rates of hospital-acquired infection which became a cause celebre in the early years of the new millennium leading to dramatic intervention to reverse a disastrous trend which was accompanied by emerging antibiotic resistance.
The implications of these trends can be seen writ large in the handling of the COVID-19 pandemic where the traditional shoe leather testing and tracing work of local public health teams was subordinated to hospital concerns, even while hospital-acquired COVID, infection was becoming a major issue.3 The neglect of adequate supplies of personal protective equipment, the disparaging of effective environmental and face covering measures by other countries to prevent virus spread, and a general unwillingness to adopt an open learning approach to the crisis eventually led to the United Kingdom having arguably the worst health outcome of most developed countries.
Interestingly, once mask wearing became quite widely adopted by the British public, this seems to have had an impact in preventing the normal transmission of the influenza virus in the winter of 2020/2021 lending weight to the cultural practice of face coverings to prevent the respiratory viral spread which is well established in Asian areas.
It remains to be seen whether changes in public behaviour as a result of the threat of COVID-19 will endure in a country that failed to find enduring benefit from the personal hygiene practices brought by the Romans 2000 years ago such that until recently a significant minority of the public failed to wash its hands after visiting the lavatory. The lessons must also be learnt for the way we educate our health professionals and organise our health services. Long the Cinderella of health curricula, we must take this opportunity to ensure that public health is treated as seriously as the other major disciplines. It is also apparent that those countries that have healthcare systems rooted in prevention and primary care, such as Norway and Finland, Cuba and China, coming from different political traditions, have fared especially well in meeting the challenge.
Declarations
Competing Interests
None declared.
Funding
None declared.
Ethics approval
Not applicable.
Guarantor
JA.
Contributorship
Sole authorship.
Acknowledgements
None.
Provenance
Not commissioned; editorial review.
References
- 1.Ashton J. Practising Public Health: An eyewitness Account, Oxford: Oxford University Press, 2019. [Google Scholar]
- 2.Fraser WM. Duncan of Liverpool: An Account of the Work of Dr W.H.Duncan, Medical Officer of Health of Liverpool 1847–63, London: Hamish Hamilton, 1947. [Google Scholar]
- 3.Ashton J. Blinded By Corona: How the Pandemic Ruined Britain’s Health and Wealth, London: Gibson Square Press, 2020. [Google Scholar]