The modern eraWith minor modifications, the public health pattern created by the medieval urban community continued in use from the sixteenth to the nineteenth century. With the development of national states in Europe, central governments took action increasingly but sporadically; on the whole, public health problems were handled by the local community. During this period, however, basic scientific knowledge was being acquired on which the structure of modern public health would eventually be erected. The great scientific outburst of this period began to make possible the more precise recognition of diseases and a better understanding of their nature. At the same time, ideological form was given to the possibility and importance of applying scientific knowledge to the health needs of the community. Concurrently, a quantitative approach to health problems developed out of the political and economic needs of the modern state. To increase national power and wealth, a large population was considered necessary. It was in relation to this concern that political arithmetic, that is, the collection and analysis of quantitative data bearing on national life, developed. The founder of this approach was William Petty, a seventeenth-century physician and economist; but the first solid contribution to vital statistics was made by his friend John Graunt, whose classic book Natural and Political Observations Upon the Bills of Mortality appeared in 1662. The application of statistical analysis to community health problems was to prove extraordinarily fruitful for the development of public health.The consideration of health problems in connection with the aim of maintaining and augmenting a population that could be economically productive and provide fighting men logically implied a health policy for the entire dominion of a monarch or of a nation. This implication was recognized and began to be developed in England and on the Continent during the seventeenth and eighteenth centuries. While a number of thinkers and men of affairs endeavored to deal with public health on a national scale, it was not until the nineteenth century, with the advent of the new industrial and urban civilization, that the problem of organizing the larger community to protect its health became a matter of national concern and led to concrete results. The earlier efforts reached a high point in the work of Johann Peter Frank, whose career spanned the late eighteenth and early nineteenth centuries, and who is best known as a pioneer in public health administration and social medicine.During the eighteenth century the cultural and economic movements known as the Enlightenment and the industrial revolution provided the seedbeds in which the new ideas, tendencies, and methods that revolutionized public health in the nineteenth century germinated and developed. In Britain, France, the countries of central Europe, and the United States, similar problems were attacked in the name of reason, order, human welfare, economy, and community concern. Among these were alcoholism, infant mortality, epidemics, the care of the insane, the creation or improvement of hospitals and dispensaries, improvement of the physical environment in towns, and the health conditions of specific groups such as soldiers, sailors, scholars, prisoners, miners, metalworkers, and various kinds of artisans. This interest is linked to the development of the health survey. The method was applied to the investigation of regions, communities, institutions, or population groups. Thus, John Howard published his account of the State of the Prisons in 1777 and proposed means to ameliorate social and health conditions which he had found. When applied to regions or communities, these investigations were known as medical topographies. Comprising sanitary surveys, epidemiologic studies, and social investigations, they prepared the way for the more specialized surveys and analyses that were carried out during the nineteenth and twentieth centuries. Today the survey as a tool for studying community health problems is an important component of the public health armamentarium.Public health and sanitary reformModern public health developed out of the sanitary reform movement of the nineteenth century, which began in England, where the impact of the industrial revolution on health was first recognized as a matter of community concern requiring governmental action on a continuing basis. Nevertheless, wherever industrialism developed, whether in France, Germany, or the United States, the consequences were similar and called for similar remedies. The human cost of industrialization and urbanization in terms of ill health and premature death was great, and the sanitary reformers endeavored to reduce it by organizing the community to protect the health of its members. This aim was coupled with a recognition that disease for which the individual could not be held responsible was an important factor in the cost of public assistance and that it would be good economy to undertake community-wide measures for the prevention of disease.In EnglandThe industrial revolution found England without any effective system of local government or any national agency to deal with the health problems which it created or intensified. At the same time urban communities grew and became more congested, and more and more people became aware of the cities novel, powerful, and alarming qualities. It was apparent that endemic or epidemic diseases tended to seek out the poorer districts, but they were not limited to them. This awareness and the consequent desire to reduce or eliminate disease and the destitution which it produced are among the major roots from which the sanitary reform movement sprang.One of the first products of this reform movement was the Report on the Sanitary Condition of the Labouring Population of Gt. Britain, a fundamental document dealing with modern public health which appeared in 1842. Prepared by Edwin Chadwick, lawyer, administrator, and one of the creators of sanitary reforms, the Report showed that communicable diseases were associated with filthy environmental conditions. In Chadwicks view, what was needed was an administrative organ to undertake a preventive program by applying engineering knowledge and techniques in an efficient and consistent manner. He also recognized the need for a physician to see that action was taken when necessary and to keep watch on health conditions in the community.The Public Health Act of 1848, passed by Parliament after six years of agitation, established the General Board of Health. This step was a major landmark in the history of public health, because it created a basis for the further evolution of public health administration in England and led eventually to the establishment of the Ministry of Health in 1919. Moreover, it set an example whose influence was felt far beyond England. The impact of British sanitary reform was nowhere more pervasive than in the United States, where, as in England, one of the basic problems involved in the genesis and development of public health was the need to create an effective administrative mechanism for the supervision and regulation of community health.In AmericaBetween 1800 and 1830, only five major American cities had boards of health. Even as late as 1875 many large urban communities had no health departments. Beginning in the 1830s, however, increasing immigration and urban growth produced situations that required urgent attention. Inadequate provision for housing, water supply, sewerage, and drainage brought into being a whole brood of evils that expressed themselves in the urban slum. Recurrent epidemics of smallpox, typhoid and typhus, cholera, and yellow fever impressed upon the public the urgent need for effective public health organization.In 1866 the New York Metropolitan Board of Health was established, an event which marked a turning point in the development of American public health. This example was soon followed by other states and municipalities in establishing effective health departments: Massachusetts, 1869; California, 1870; District of Columbia, 1871; Minnesota, 1872; Virginia, 1872; Michigan, 1873; Maryland, 1874; Alabama, 1875; Wisconsin, 1876; and Illinois, 1877.As state and local health departments were organized, the idea of a national health agency seemed the logical next step. However, it should be remembered that until practically the end of the nineteenth century the U.S. government had no concern with public health matters. Organization and action for the protection of community health were considered a local responsibility to be carried out by the state or the locality. Thus, the doctrine of state sovereignty continued to hold sway in the health field and handicapped public health action on a national basis for many years. Congress created the National Board of Health in 1879, but it was of little significance and disappeared after 1883. The establishment of a national health agency was not achieved in the United States until 1953, when the Federal Security Administration became the cabinet Department of Health, Education and Welfare, which included the Public Health Service, the Childrens Bureau, and the Food and Drug Administration, as well as other health, welfare, and educational services of the federal government.