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What Is Public Health?

Then and Now


Wednesday, January 23, 2013

Last weekend, I took my kids down to Alice Keck Park Memorial Gardens for a peaceful afternoon in the fresh air and warm sun. I was pondering the topic for this column – What is public health? – as I watched them slurp from the water fountain and munch on fresh apples from a local market. As Deputy Health Officer for the Santa Barbara County Public Health Department, my own image of the answer to that question involves bacterial cultures and syphilis statistics. But as I observed the vibrant park around me, the omnipresence of public health’s accomplishments over the last century appeared everywhere I looked.

Public health is the air we breathe. It is the water we drink. It is the rosy cheeks of my four-year-old son, born into a community no longer tormented by the ravishing terrors of polio, tuberculosis, and small pox. Public health is, above all else, the comforting background hum of a 133-year-old machine running tirelessly to provide protection, wellness, and health to the members of our community. In the inaugural issue of what will be a regular column in The Santa Barbara Independent, I’d like to highlight the local history of public health in our community, from its inception in 1880 to the vital role it plays in keeping our population healthy today.

Charity Thoman
Click to enlarge photo

Charity Thoman

Our story starts in 1857, when slavery was alive in the South and Lincoln was still a country lawyer somewhere in Illinois. Santa Barbara County appointed its first “County Physician,” who functioned primarily as the “Welfare Officer” in caring for the indigent and poor. During this era, which predated our country’s formal social welfare system by more than 100 years, the county physician was the sole provider of government healthcare. In 1880, the Santa Barbara City Council established the first Board of Health, headed by the city’s mayor. Of the five board members, four were physicians. The Board’s responsibilities – quarantine of infectious persons, birth and death certificates, basic trash collection and sanitation – would become the premise of the future County Public Health Department.

By 1913, a formal County Health System had been established. The leading causes of death at that time, in descending order, were tuberculosis, pneumonia, influenza, heart disease, and diarrhea. (In 2012, the list looked very different: heart disease, cancer, chronic obstructive pulmonary disease, stroke, and accidents.) The observation that 100 years ago infectious disease was the leading cause of death, and today it doesn’t even appear in the top five, is a testament to the accomplishments of public health over the last century. To be even clearer, it was public health’s calculated, strategic methodology which knocked infectious diseases off the top of the charts, where they had held court for the last 2,000 years (or longer).

Let us take my favorite communicable disease, tuberculosis, as an example of strategic methodology for eradication of a disease. In the mid 1900s, every local health jurisdiction across the country established the job of Tuberculosis Controller, and charged that physician with tracking, testing, and treating every single case of TB. Not just the contagious patients were under scrutiny, but every single contact to that case. Since TB is spread through the air, and quickly passes from one person to the next, the legal authority to quarantine contagious persons was handed to the TB Controllers. These physicians were also given the legal authority to force patients to take their TB medication and submit to regular examination. This strategic approach of quarantine, mandatory treatment, and extensive testing of contacts lead to a rapid decline in tuberculosis over the past 50 years. And this strategy is still in practice by our department today, as we have around 25 TB cases each year in Santa Barbara County.

Despite this tremendous progress in the area of tuberculosis, I would argue (and I would be right) that the single greatest accomplishment of public health in the last century was the development and administration of vaccines. From ancient Egyptian times, when carvings depicted crippled children, to the worldwide epidemics of the 20th century, polio held a terrifying grip on the world. Its frightening epidemics peaked during the warm summer months, spreading sinisterly through families. Tasteless and odorless, polio brought death and devastation to parents helpless to stop the virus. In 1952, the United States saw the worst polio epidemic in our nation’s history. Although 23 children in Santa Barbara County died from polio the following year – let that sink in – victory was right around the corner. How would this 5,000-year-old monster be defeated? By the enormous mobilization of public health officials and medical philanthropists worldwide, after the introduction of the Salk Polio Vaccine in 1955. Our current-day immunization program continues to be the leader for vaccine awareness and promotion, a cornerstone of public health.

Although many things in public health have changed since 1857, one thing has not: We still have our County Physician, now known as the Health Officer, overseeing 482 public health employees who strive, every day, to keep our community healthy and safe.

For me, being a physician in public health is a daily adventure involving fascinating diseases and on-the-spot problem solving. Just wait till you hear what we’re up to. Through this column, I hope to bring a taste of that daily intrigue – sometimes provocative, sometimes grotesque – into your life as well.

Charity Thoman, M.D., is a deputy health officer in Santa Barbara County's Public Health Department.

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