Syndemic Prevention Network: Monograph -- The Era of Relative Clarity

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Perceiving Dynamic Conditions

The Era of Relative Clarity

It is easy to imagine the intense, well-deserved optimism that John Snow must have felt as the incidence of cholera cases dropped so sharply in the wake of his action. In the century that followed, many physicians, epidemiologists, and biomedical researchers shared that same satisfying feeling. An array of discoveries and technological advances fueled the belief that each item on the long list of human diseases would succumb, one after the other, to the relentless progress of science. Progress, however, was never exactly uniform and there were many misguided notions and frustrated aspirations. But overall, the public and professional ethos from the late-19^th to the mid-20^th century was one of steady progress and relative clarity (Hudson, 1983; Mullan, 1989; Winslow, 1943).

Much of that clarity sprang from a deep-seated faith in the power of medical specialization (Rosenberg, 1989). The advent of bacteriology, back in the late 19^th century, changed both medicine and public health, leading to an understanding of germs as vectors of infectious disease and solidifying the study of tightly controlled experiments as the sine qua non of health science (Brandt and Gardner, 2000). These developments helped shape the essential character of the field, with its operational emphasis on beginning with a clear case definition, its obsession with understanding the causal mechanisms of both disease and of program/policy interventions, and its organizational tendency to proliferate new areas of specialization as necessary. These emphases led to many well-documented successes (e.g., the development of vaccines, water filtration systems, and milk pasteurization) which, in turn, justifiably reinforced the idea that a single-minded focus was tremendously useful and productive. The turn of the 20^th century, notes historian Paul Starr, “now seems to have been a golden age for public health, when its achievements followed one another in dizzying succession and its future possibilities seemed limitless” (Starr, 1982:197).

That optimism prevailed well into the 1960s, when the promise of penicillin and other “miracle” drugs led the U.S. Surgeon General, among others, to predict an imminent triumph over all infectious diseases. “The time has come to close the book on infectious diseases. We have basically wiped out the infection in the United States,” said Dr. William Stewart in 1967 (Surowiecki, 2001:46).²⁰

As we know, however, headlines in the subsequent decades brought news of drug-resistant tuberculosis, escalating rates of chronic disease, troubling displays of violence and environmental damage, and the appearance of HIV/AIDS along with dozens of other baffling threats to the public’s health. The original model of disease specialization that seemed so successful earlier in the century was not shown to be wrong, only too limited a concept for organizing and sustaining initial gains, especially amidst profound shifts in the physical and social environment. An era of creative thinking then ensued out of which came the broader concept of health promotion (O'Donnell, 1986a, 1986b, 1989).

After its initial articulation, which most scholars assign to Canada’s Lalonde Report in 1974 (Canada Department of National Health and Welfare and Lalonde, 1974), the full scope of what health promotion entailed took shape only incrementally. The basic philosophy evolved inexorably from a diagnostic, to an environmental, to what is now an ecological or systems approach (Green, 1980; Green and Kreuter, 1991, 1999, 2004).

Many saw health promotion as a positively framed inversion of disease prevention. Instead of concentrating on deficits and disease, now the focus was on assets, empowerment, and health (Antonovsky, 1984; Brown, 1985; Kretzmann and McKnight, 1993; Wallerstein, 1992). Others conceded that there was more to it, but could only see health promotion’s lofty goals like safe schools, healthy children, racial justice, sense of community, and the end of poverty. Several writers observed profound political and ethical implications differentiating health promotion from disease prevention, implying the need to complement a focus on behavioral change with an emphasis on social change and principles of an open society (Freudenberg, 1978; Minkler, 1978, 1989). But despite the intuitive sensibility of health promotion, it lacked a clear formalism to match the perceived pragmatism and quantifiable credibility held by epidemiology and clinical preventive medicine.

Epidemiologic methods continued to enjoy institutional favor. They proved invaluable in identifying and illuminating many narrowly bounded problems of disease, such as toxic shock syndrome (Centers for Disease Control and Prevention, 1997) and Legionnarie’s disease (Fields, Benson, Besser, 2002). At the same time, health promotion showed that health was not only an end, but also a means to achieving greater quality of life (World Health Organization, 1998). But neither approach offered an organizing framework for the field capable of supporting the increasingly diverse health protection enterprise. Rather, when pursued in parallel, these separate problem solving strategies were generating problems of their own and further fragmenting the field.

20. This quotation, widely attributed to Surgeon General Stewart, is in fact a matter of some historical controversy. John Parascandola, official historian for the U.S. Public Health Service, has been unable to determine the exact circumstances in which the remark was made. Even Dr. Stewart himself does not recall having said it. But neither does he refute the possibility, saying only that he may have said something to that effect. Nevertheless, the continual reappearance of this statement suggests that the sentiment behind the supposed quote was (and is) widely accepted. Or, at least it is widely thought to be a plausible thing for the Surgeon General to have said. So plausible, in fact, that Stewart himself accepts the premise. The popular acceptance of this notion is perhaps the more relevant point anyway. According to Parascandola, “there is no question that in the period of the late 1960s, and beyond, there was a great optimism about our success against infectious disease” (personal communication, November 11, 2001).

Page last reviewed: January 30, 2008
Page last modified: January 30, 2008