The Historical Relationship Between Medicine and Public Health

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Historically, the relationship between medicine and public health in the United

States can be characterized as having proceeded in three phases:
■ an early supportive relationship prior to the early 20th century
■ a period of professionalization and practice transformation spurred by
the emergence of bacteriology
■ an acceleration of functional separation in the post-World War II era
As the committee reviewed these phases, the perceptions of the focus
group participants became easier to understand. Their tacit assumption of an
interrelationship between medicine and public health is a vestige of a common
framework the sectors once shared in addressing health and illness. Their
inability to describe a cross-sectoral relationship in practical terms reflects the
extent to which medicine and public health had become isolated—in training
and in practice—by the time they embarked on their careers. While the factors
accounting for this isolation are complex, the analysis that follows suggests that
it has four underlying causes: (1) the progressive loss of any perceived need for
the two sectors to work together; (2) the lack of adequate incentives or structural foundations to support cross-sectoral relationships; (3) recurring tensions
deriving from overlapping interests; and (4) the development of striking cultural differences.

THE EARLY CONNECTION BETWEEN MEDICINE AND PUBLIC HEALTH

Although societies throughout the world have approached health problems
from two distinct vantage points—public health and medicine—these perspectives have not been conceptualized independently. In Greek mythology, for
example, the close relationship between healing and health was epitomized by
two sisters: Panacea and Hygeia. In the fourth century B.C., Hippocrates
espoused a framework that related medical and public health perspectives in
practice. In approaching the individual patient, he urged physicians to pay
attention to the environmental, social, and behavioral context in which illness
occurs: the airs “peculiar to each particular region,” the “properties of the
waters” the inhabitants drink and use, and “the mode of life of the inhabitants,

whether they are heavy drinkers, taking lunch, and inactive, or athletic, industrious, eating much and drinking little.”78
In the United States, this type of comprehensive framework—encompassing prevention and treatment as well as a broad range of determinants of
health—served as a common ground for leaders in medicine and public health
from the mid-19th to the early 20th centuries. During this period, the nation’s
most pressing health problems were infectious diseases. Tuberculosis was
“captain of the men of death.” Influenza, pneumonia, streptococcal infections,
and other airborne diseases struck the population with great force, mainly
during the winter months. Infants died routinely as a result of acute communicable respiratory and diarrheal diseases. Measles and chickenpox were a
“natural” part of childhood. It was not unusual for women giving birth to
succumb to perinatal infections. Smallpox epidemics, with their considerable
mortality, struck communities from time to time. Typhoid fever occurred on a
small scale, spread within and between families, and occasionally erupted in
outbreaks. Cholera epidemics created alarm and were a major cause of death in
American ports.
With infectious diseases rampant, there was general agreement that an
effective strategy required societal preventive action as well as medical care.
Little could be done for patients once they were infected. Moreover, communicable diseases affected everyone—both the wealthy and the workforce—threatening not only people’s health but also the economy. Although early public
health workers lacked any knowledge of specific etiologic agents, they were
able to relate infectious diseases to conditions associated with urbanization
and industrialization. Citizen sanitary associations organized efforts to clean
up squalid living conditions in the cities.57 Health departments and boards of
health were established to conduct and enforce sanitary measures, and to
maintain birth and death records, which were needed to track disease.
Together, these voluntary and governmental public health efforts were successful in addressing many of the important risk factors for transmission of
communicable disease: overcrowding, poor nutrition, inadequate sewerage
systems, uncollected garbage, and contaminated water and food.
At this time, with the public health movement focused on sanitary engineering, environmental hygiene, and quarantine—activities unrelated to the
direct care of patients—the strategies of public health and medicine were distinct. Nonetheless, leaders in the two sectors overlapped considerably, and
many physicians were actively involved in public health efforts. For example:
■ John H. Griscom, a physician at the New York Dispensary and the New
York Hospital, served as City Inspector of New York. In 1842, he conducted one of the first surveys of conditions in tenement housing and
basement schools. He also advocated the construction of better homes
and appealed for the study of occupational health, arguing that
improved health and longer life expectancy among the productive population made a sound public health investment.
■ Nathan Smith Davis, one of the founders of the American Medical Association (AMA) in 1847, was instrumental in proposing and getting 

approval for the construction of a sewerage system and a general hospital in Chicago. He also spearheaded the formation of a local medical
society and a society for the care of the poor.
■ Stephen Smith, a surgeon in the Civil War, was a founding member of the
American Public Health Association (APHA) in 1872. He was also a
leading member of the New York Sanitary Association, the New York Citizens Association and the Special Council of Hygiene and Public Health,
for which he directed a major sanitary survey of New York City, which led
to the establishment of the Metropolitan Board of Health.
■ Henry Bowditch, one of the founders of APHA, served as president of the
AMA in 1877. He helped establish the Massachusetts Board of Health in
1869, and served on the National Board of Health in 1879. A paper he
wrote in 1874, “Preventive Medicine and the Physician of the Future,”
condemned the “error and stupidity which does not believe in the duty
of studying the physical causes of disease and at least in endeavoring to
crush out these originators of pestilence and death.”23
The key reason that leaders in medicine and public health had such a close
relationship during this period was that neither sector could address the infectious disease problem alone; each was in need of something that only the other
could provide. Physicians supported public health measures because they
could do relatively little on their own. Clinicians could comfort patients and
inform them about their prognosis, but medical interventions were relatively
ineffective in curing or preventing infectious diseases. Caring about public
health was also a status symbol for physicians. It marked the “distinguished
practitioner who was above the commercial competition of merely dealing in
drugs, bleeding, and purging.”57
A close relationship with the medical sector also was of benefit to public
health. The influence of physicians with policymakers and the public was of
substantial value in efforts to institute sanitary reforms and establish health
boards. Equally important, clinicians’ contact with patients was a useful
resource in targeting public health interventions. This was highlighted in an
1852 report of The New York Academy of Medicine, which stated that no one is
as “well qualified for the examination and correction of public sources of diseases, in the cellars, the garrets, the courts and cul-de-sacs, and the hollows” as
medical practitioners, “whose business it is now to treat, in these very localities,
the diseases produced by them”.

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