Living Longer and Better

Texans Track 20th Century Public Health Advances

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Cover Story -- January 2000

By Johanna Franke
Associate Editor

It protects the food we eat, the water we drink, and the air we breathe. It ensures the buildings in which we live, work, and learn are safe. It defends us from disease and disasters and teaches us preventive practices.

It's known by many names: community health, collective health, and even, mistakenly, poverty health. No matter what we call it, 20th century public health changed the way we live.

Individual versus society

Though most Texans aren't sure what public health is, a 1996 survey conducted by The University of Texas at Austin for the Texas Department of Health (TDH) shows they know it's important. Survey participants were unclear about the activities of public health professionals, and they associated public health with clinics and services for the poor.

In actuality, public health programs prevent epidemics, protect against environmental hazards, prevent injuries, promote and encourage healthy behavior, help communities recover from disasters, and assure the quality and accessibility of health care services.

The phrase "public health" was created in the early 19th century to designate the actions governments and societies (as opposed to private individuals) should take to preserve and protect the people's health (1). At the beginning of the 20th century, these actions included improving sanitation, purifying foods and drugs, and controlling communicable diseases. As scientists worked feverishly to piece together which bacteria caused what disease and how that disease was transmitted from person to person, quarantine officers spent their time isolating members of the community to control death rates from tuberculosis, cholera, diphtheria, and other infectious diseases.

Public health took on a more individual focus during World War I. Despite using lowered health standards for induction, the armed services still rejected 34% of the potential recruits because of physical and mental disabilities (2). After studying data from these medical examinations, public health experts realized that while communicable diseases had been controlled, other preventable health problems had been ignored. Public health programs began focusing on the health resources for each citizen, which is where organized medicine entered the picture. Physicians began teaching their patients how to lead healthy lives through prevention on an individual level.

"Increasing understanding of how we individuals in our behavior affect our own health has become a very important area," said Thomas Hyslop, MD, director of the Harris County Health Department. "It's not just the government doing things for you -- it's what you can do for yourself."

But this attention to the individual, along with improvements in technology, has pulled public health off the community track, says State Commissioner of Health William R. Archer III, MD. "Public health got lured into a mission of being the gap filler for the private sector for health, and we lost our way in the real mission of protecting whole populations," he said.

Much of the funding for health goes toward individual health care, Dr Archer says. "Just about 2% of health dollars goes to essential public health programs. Individual health care gets 98% of the dollars, and we're not even meeting all the needs for individual care," he said. "The nature of public health is if you keep something from happening, people forget what you're doing to keep it from happening, so they lose their interest in funding preventive measures."

And advances in technology have little to do with advances in the health status of the public. According to TDH, 25 of the 30 years of life expectancy gained during the 20th century can be attributed to public health efforts, while medical advances can take credit for only 5 of those years.

Public health's greatest hits

Texas public health experts have some thoughts about the 20th century public health efforts that contributed the most to today's greater life expectancy. Controlling infectious disease through immunizations, food and water purification, and sewage treatment topped all of the experts' lists.

"The biggest thing that changed the course of public health in the 1900s is the advent of immunizations," said David R. Smith, MD, president of Texas Tech University Health Sciences Center in Lubbock. During Dr Smith's tenure as state health commissioner, TDH created the highly successful Shots Across Texas campaign, which helped increase immunization rates in Texas from 40% to 71%, with assistance from the Texas Medical Association and the TMA Alliance. "We've only really wiped out one bug," Dr Smith added. "We're on the verge of eradicating polio, but smallpox has been our only true success story. Despite all of the science, we've still got a ways to go."

Vector control, the victory over Big Tobacco, and distribution of bicycle helmets round out Dr Smith's list of the 20th century's greatest public health advances.

Safe food and water, sanitation, and immunizations "are among the top" public health achievements, followed by the recognition of nutritional requirements, says TMA Council on Public Health member Alecia A. Hathaway, MD, MPH, of Fort Worth.

Dr Archer's top pick goes "back to the basics. Clean water and wastewater and solid waste removal are really important things that we take for granted." As for an important public health advance in Texas, Dr Archer is proud of the work TDH has done to protect Texans from rabies.

In the policy arena, Drs Hathaway and Archer say Texas' greatest public health achievement occurred during the 1999 session of the Texas Legislature with the passage of legislation addressing local public health infrastructure. Dr Archer says Texas is the first state to pass such a bill, and called its adoption "an amazing accomplishment that took 6 years."

The law, House Bill 1444, was sponsored by Rep Dianne Delisi (R-Temple) and grants cities and counties funds for essential public health services to:

  • Monitor public health status and mobilize community partnerships to identify, investigate, and solve community health problems and hazards;
  • Inform, educate, and empower the public about health issues;
  • Develop policies and plans that support individual and community efforts to improve health;
  • Enforce laws and rules that protect public health and safety;
  • Link individuals who need community and personal health services to appropriate professionals;
  • Ensure a competent workforce to provide essential public health services; and
  • Evaluate the effectiveness, accessibility, and quality of personal and population-based health services in a community.

TMA worked with TDH and Representative Delisi's office to develop the legislation, and TMA members and lobbyists spent much of the session educating lawmakers on the importance of local public health efforts.

"TMA played a big role in the passage of House Bill 1444," Dr Hathaway said. "Just getting the legislature to recognize that public health at the local level is critical was a huge advance."

The promise of partnership

The partnership between public health and medicine that made House Bill 1444 a success also helped to defeat Big Tobacco, Dr Smith says. "It took a combined effort of public health and medicine, which is a harbinger of what has to happen in the future," he said. "Public health and medicine have been in their own separate arenas, but we're beginning to see the power of bringing the two together."

With growing problems such as drug-resistant microbes, the disparity of health care outcomes in minority communities, and the effects of unhealthy behaviors, the power of the public health and medicine partnership will be needed in the 21st century.


  1. Krieger N, Birn AE. A vision of social justice as the foundation of public health: commemorating 150 years of the spirit of 1848. Am J Public Health. 1998;88:1603-1605.
  2. Green LW, Ottoson JM. Community Health. 7th ed. St Louis, Mo: Mosby-Year Book, Inc; 1994:19-24.


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