The history of health protection
Health protection is essentially about infectious diseases and environmental hazards, on an individual, group and population level. This includes identifying, mitigating and preventing the impacts of communicable diseases and environmental threats to health, as well as implementing continued surveillance and management measures, particularly for infectious disease outbreaks.
Infectious diseases
Quarantine is a centuries old public health response to infectious diseases which aims to limit the spread of infection by controlling the movement of the infected body. The first known English quarantine regulations were introduced in 1663[i] for the confinement of crew and passengers on ships who were suspected to be infected with plague. When the Great Plague of London hit in 1665, orders of quarantine were enforced in the form of public ‘penthouses’ – designed to house and isolate infected victims from the general population. However, it wasn’t until years later, in 1721, that the Quarantine Act was passed by Parliament following a series of outbreaks of diseases resulting again from travelling ships.
The Spanish Flu, a global influenza outbreak in 1918 which has been quoted as being the deadliest global pandemic in history, was a significant lesson in health protection. Around 250,000 people in Britain died as a result of the virus, with a large proportion being young and healthy adults, and around a quarter of the population were affected[ii].
When the second wave struck in October 1918, healthcare was provided by local authorities, overseen by the Local Government Board. Arthur Newsholme, Chief Medical Officer, had prepared a strategy for dealing with a resurgence of the disease, including measures such as preventing large gatherings of people or overcrowding on public transport. Unfortunately, due to a lack of support because of the ongoing war effort, these measures were cancelled with Newsholme stating an individual duty to ‘carry on’[iii]. The virus continued to spread rapidly through the population as a result, claiming many more thousands of victims and infecting countless more.
However, James Niven, the Medical Officer of Health for Manchester, issued a public advisory in June 1918 closing schools and recommending the isolation of infected people to try and control the outbreak. Influenza incidence was highest in children and young people, suggesting school closures were influential in epidemic waves in the UK and a study estimated that the transmission rate was reduced by approximately 40% during school holidays.[iv] These successful public health interventions are thought to be the first in Britain aimed at stopping the disease.
Another, more recent example of the importance of health protection measures is the SARS-CoV-2 pandemic. The World Health Organisation (WHO) declared Covid-19 to be a pandemic on 11 March 2020[v] and on 23 March 2020 the UK Prime Minister announced the first national lockdown, ordering people to stay at home[vi].
Although the disease was well established before measures were introduced, a variety of mitigating measures were introduced throughout the course of the pandemic. Localised and national lockdowns with varying restrictive measures depending on case numbers and hospitalisation rates were introduced and a surveillance system in the form of NHS Test and Trace was rolled out to monitor the spread of the virus. NHS Test and Trace was heavily supported by Directors of Public Health (DsPH) across the country and drew upon their extensive knowledge of local infection rates and partnerships within their communities. A mass immunisation programme against the disease began in December 2020 – the first in the world outside of clinical trials and, as of August 2023, over 151 million doses of the vaccine have been administered.[vii]
Throughout the crisis, DsPH shaped the response on both a regional and local level, guiding their respective emergency structures and committees to react to the evolving situation. They also played a pivotal role in engaging with local communities, facilitating vaccine take up and much needed social support.
Vaccines and immunisation programmes have revolutionised health protection, saving millions of lives each year – more than any other medical intervention in history.[viii] ADPH’s resource on the history of immunisation explores the importance of vaccines and their role in public health.
Environmental hazards
Environmental hazards including physical, chemical, biological and radiological factors are also capable of causing harm and, as with infectious diseases, need to be contained using health protection measures.
The Salisbury poisonings in 2018 involving the Novichok nerve agent was a major public health incident due to the potency of the chemical used. Tracy Daszkiewicz, DPH for Salisbury at the time, played a key role in the multidisciplinary response that followed – collaborating with Public Health England and security agencies, whilst reassuring the public as more information came to light. Other less publicised events, such as the Armley asbestos disaster, have also highlighted the threat to public health from external agents. Throughout the late 19th century and until the factories closure in 1959, around 1000 houses were contaminated with asbestos dust from a neighbouring factory. A report into the subsequent deaths was commissioned and was undertaken by Leeds City Council. Over 300 deaths have been linked to the contamination.[ix]
Environmental health officers (EHO) play an important role in public health, monitoring and enforcing health and hygiene legislation, as well as investigating outbreaks of food poisoning and infectious diseases and tracking and tracing contacts. Smaller, localised outbreaks such as salmonella poisoning fall under the remit of an EHO.
EHO and related organisations, such as the Food Standards Agency, also manage responses to national crises, for instance the outbreak of Bovine spongiform encephalopathy (BSE) in the 1980/90s. BSE spread rapidly throughout cattle in the UK and led to 178 human fatalities through the consumption of infected meat and the subsequent development of Creutzfeldt-Jakob disease (vCJD).[x]
Despite initial denial from Government over the link between BSE and vCJD, in 1996 the link between the bovine disease and human equivalent was acknowledged. Strict animal husbandry measures were introduced to regain control of this public health crisis and prevent it from reoccurring.[xi] Infected cattle had to be culled, and during the outbreak 4.4 million cattle were slaughtered. Cattle feed could no longer be supplemented with meat-and-bone-meal, which used the remains of other animals as a source of protein and allowed the infection of healthy cattle with infected material.[xii] An export ban on UK cattle, their meat and products was also placed in 1996, which was not lifted by the European Commission until 2006.[xiii]
Lessons learnt from how Governments and the public health community have responded to threats from both infectious disease and environmental hazards can be used to prepare for and inform future health protection events. Combining preventative measures with surveillance and real-time monitoring protects individual and population health and maintains effective public health standards.
[i] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3559034/
[ii] https://www.redcross.org.uk/stories/health-and-social-care/health/coronavirus-how-the-red-cross-helped-in-the-spanish-flu-pandemic
[iii] https://history.blog.gov.uk/2018/09/13/the-flu-that-wasnt-spanish/
[iv] https://royalsocietypublishing.org/doi/10.1098/rspb.2013.1345#d28818150e1
[v] https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020
[vi] https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020
[vii] https://coronavirus.data.gov.uk/details/vaccinations
[viii] https://www.who.int/news-room/spotlight/history-of-vaccination/a-brief-history-of-vaccination
[ix] https://publications.parliament.uk/pa/cm199293/cmhansrd/1992-07-08/Debate-15.html
[x] https://www.food.gov.uk/safety-hygiene/bovine-spongiform-encephalopathy-bse
[xi] https://navigator.health.org.uk/theme/bse-outbreak-initial-government-response
[xii] https://www.nhs.uk/conditions/creutzfeldt-jakob-disease-cjd/prevention/
[xiii] https://ec.europa.eu/commission/presscorner/detail/en/IP_06_278