Comment

A Vision of Social Justice as theFoundation of Public Health:Commemorating 150 Years of the Spiritof 1848Nancy Krieger, PhD, and Anne-Emnanuelle Birn, ScD

Social justice is the foundation of publichealth. This powerful proposition-still con-tested-first emerged around 150 years agoduring the formative years ofpublic health asboth a modem movement and a profession. Itis an assertion that reminds us that publichealth is indeed a public matter, that societalpattems of disease and death, of health andwell-being, of bodily integrity and disintegra-tion, intimately reflect the workings of thebody politic for good and for ill. It is a state-ment that asks us, pointedly, to rememberthat worldwide dramatic declines-and con-tinued inequalities-in mortality and morbid-ity signal as much the victories and defeats ofsocial movements to create a just, fair, caring,and inclusive world as they do the achieve-ments and unresolved challenges of scientificresearch and technology. To declare thatsocial justice is the foundation of publichealth is to call upon and nurture that invinci-ble human spirit that led so many of us toenter the field of public health in the firstplace: a spirit that has a compelling desire tomake the world a better place, free of misery,inequity, and preventable suffering, a worldin which we all can live, love, work, play, ail,and die with our dignity intact and ourhumanity cherished.

Why commemorate the 150th anniver-sary of 1848? Because knowing the pathsour field has traversed and identifying whichdreams of the early public health visionarieshave been fulfilled and which have not canhelp us understand our current situation, putcontemporary conflicts in perspective, builda collective identity, and substantivelyinform options for future endeavors. Histori-cal imagination is midwife to transformation:learning from those who have gone beforeand appreciating what we can now see thatthey could not encourages us to think criti-cally in our own era. In so doing, we mayresist the hubristic belief that, as publichealth professionals, we have all the answers

or can by ourselves improve the public'shealth without efforts to ensure social andeconomic justice.

Why 1848? Because in 1848 popularuprisings and movements around the worldwere championing social justice and politicaland economic democracy, including thesocialist and trade union movements inEurope, the anti-slavery and women's rightsmovements in the United States, and move-ments resisting imperialism in India andMexico, as well as nationalist and suffragistmovements (Table 1). 1848 was the year inwhich the Communist Manifesto' was pub-lished and became a landmark text coalesc-ing the era's visions for social change. Thisperiod also marks a burgeoning of publichealth activity, from studies of workers'health in France to public health legislationin Britain to recognition of the political basisfor health inequities in Prussia. Some ofthese efforts were highly influential, somedelivered mixed results, and still othersfailed, but all derived from a spirit of social,political, and public health activism that arefoundational to public health and froht whichwe can-and must-learn.

Consider, for instance, the case of the1848 Public Health Act in Great Britain.This act authorized a newly created GeneralBoard of Health to establish local boards todeal with water supply, sewerage, and con-trol of offensive trades, as well as to institute

Nancy Krieger is with the Department of Healthand Social Behavior, Harvard School of PublicHealth, Boston, Mass. Anne-Emantuelle Birn iswith the Robert J. Milano Graduate School ofManagement and Urban Policy, New School forSocial Research, New York, NY.

Requests for reprints should be sent to NancyKrieger, PhD, Department of Health and SocialBehavior, Harvard School of Public Health, 677Huntington Ave, Boston, MA 02115 (e-mail:nkrieger@hsph.harvard.edu).

American Journal of Public Health 1603

Comment

surveys and investigations of sanitary condi-tions in particular districts.2-5 The impetusfor this act lay not simply in the growingfilth of rapidly industrializing and ever moredensely populated cities but in the responsesof an emerging capitalist state to a labormovement that was demanding improvedworking conditions, better pay, and decenthousing; a Chartist movement calling forpolitical democracy; and socialist move-ments calling for an end to economicexploitation and for an economy based oncooperation and economic democracy ratherthan competition and greed.24

Edwin Chadwick, architect of the 1848Public Health Act, was also author ofBritain's draconian poor law of 1834. Heheld fiercely to the view that filth and theimmorality of the poor-not economic poli-cies-were principal causes of disease.9 ButWilliam Farr and other new public healthprofessionals and advocates vigorously dis-puted Chadwick's view, arguing that povertywas not only a direct cause of disease, forexample, via starvation, but also a criticaldeterminant of family discord and alcoholabuse.3'7">'2 Improved sanitation certainlyimproved health24" 3; neglecting other path-ways by which poverty and poor workingconditions harmed health, however, had acost. These disputes of 1848 reflect a set ofdebates, still ongoing, about what and who isresponsible for inequality, disease, and suf-fering and what steps should be taken, bywhom, to improve the public's health.4'5"4

Alternatively, recall how the abolitionistmovement in the United States spurred rein-terpretations of racial disparities in health,which were no longer seen as a sign ofinnate inferiority, but rather as a consequenceof social inequality. In the 1840s and 1850sthe first generation of credentialed AfricanAmerican physicians-exemplified by DrJames McCune Smith and Dr John S.Rock15-18-empirically challenged the long-standing credo embraced, even promulgated,by prominent physicians and other scientificauthorities that poorer health among BlackAmericans than among White Americanswas but one more sign of White racial supe-riority.' 22 To make their case, abolitionistphysicians marshaled data to show that justas poverty produced ill health among WhiteAmericans, so too did slavery, conjoinedwith poverty, produce racial inequalities inhealth.15-'8 Sadly, these insights were mutedin the aftermath of the Civil War and the sub-sequent rise of social Darwinism.23-26 In the1930s and again since the 1960s, publichealth researchers have challenged naive,fallacious, and dangerous race doctrines andare now reviving the idea, based on contem-porary understanding of population genetics

and social determinants of health, thatracial/ethnic inequalities in health reflect theembodiment of lifelong histories of eco-nomic and social deprivation, includingexperiences of racial discrimination.2734

A gaze in the direction of internationalhealth and tropical medicine reveals furthercomplexities entwined with colonialism andimperialism. The decimation of indigenouspopulations in the New World wrought bymilitary conquest and the consequent spreadof smallpox and other diseases in the 16thcentury was succeeded in subsequent cen-turies by ever more death, disruption, anddisease.3938 Driving this misery were power-ful economic interests, intent on extractingraw materials, increasing agricultural produc-tivity, and displacing populations to replenishthe labor supply.39'40 Ecological alterations-

such as the construction of canals, cesspools,and irrigation ditches-exacerbated malariaand cholera by causing floods, creatingbreeding sites for mosquitoes, and sullyingwater supplies.41" In the face of these myr-iad problems, colonial public health mea-sures served more as colonialism's hand-maiden than as its corrective. Not only werepublic health measures parceled out selec-tively but they were robed ideologically,geared more toward protecting imperialarmies and settlers than indigenous popula-tionS.3639 4Q,45 Mid-19th century public healthmeasures in British India, for example, weremuch more concerned with ensuring that theBritish military were prepared against thepossibility of another 1857 Indian mutinythan with extending the reach of sanitaryinfrastructure.46 Likewise, early 20th-century

November 1998, Vol. 88, No. 111604 American Joumal of Public Health

TABLE 1-Selected Notable Events In and Around 1848

1840-1847Louis Rend Villerme publishes the first major study of workers' health in France, A

Description of the Physical and Moral State of Workers Employed in Cotton, Linen, andSilk Mills (1840). In England, Edwin Chadwick publishes Report on the Sanitary Conditionof the Labouring Population in Great Britain (1842). First child labor laws in Britain and theUnited States (1842). End of the Second Seminole War (1842). Prison reform movementin the United States initiated by Dorothea Dix (1843). Frederick Engels publishes TheCondition of the Working Class in England (1844). John Griscom publishes The SanitaryCondition of the Laboring Population of New York With Suggestions for Its Improvement(1845). Irish Famine occurs despite high agricultural output and protests against Britishagricultural and trade policies (1845-1848). Start of US-Mexican war (1846). FrederickDouglass founds The North Star, an anti-slavery newspaper (1847). Southwood Smithpublishes An Address to the Working Classes of the United Kingdom on Their Duty in thePresent State of the Sanitary Question (1847).

1848Worldwide cholera epidemic.Uprisings in Berlin, Paris, Vienna, Palermo, Milan, Naples, Parma, Rome, Warsaw,

Prague, and Budapest. Start of the Second Sikh war against the British in India.In the midst of the 1848 revolution in Germany, Rudolf Virchow founds the medical

journal Medical Reform (Medicinische Reform) and writes his classic "Report on theTyphus Epidemic in Upper Silesia," in which he concludes that preserving health andpreventing disease requires "full and unlimited democracy" and radical measures ratherthan "mere palliatives."

Revolution in France, abdication of Louis Philippe, worker uprising in Paris, andfounding of the Second Republic, which creates a public health advisory committeeattached to the Ministry of Agriculture and Commerce and establishes a network of localpublic health councils.

First Public Health Act in Britain, which creates a General Board of Health, empoweredto establish local boards of health to deal with the water supply, sewerage, and control of"offensive trades," as well as to conduct surveys of sanitary conditions.

The newly formed American Medical Association sets up a Public Hygiene Committeeto address public health issues.

First Women's Rights Convention in the United States, Seneca Falls, NY.Henry Thoreau publishes Civil Disobedience to protest paying taxes to support the

United States' war against Mexico.Karl Marx and Frederick Engels publish The Communist Manifesto.

1849-1854Elizabeth Blackwell sets up the New York Dispensary for Poor Women and Children

(1849). Lemuel Shattuck publishes Report of the Sanitary Commission of Massachusetts(1850). Founding of the London Epidemiological Society (1850). Indian Wars in theSouthwest and Far West of the United States (1849-1892). Compromise of 1850 retainsslavery in the United States and the Fugitive Slave Act is passed (1850). Harriet BeecherStowe publishes Uncle Tom's Cabin (1852). Sojourner Truth delivers her "Ain't I a Woman"speech at the fourth Seneca Falls convention (1853). John Snow removes the handle ofthe Broad Street pump to stop the cholera epidemic in London (1854).

control of yellow fever, hookworm, andother diseases in Latin America proved a suc-cess more for free commerce and US scien-tific models than for local public health.47'48

These brief examples caution us toremember that the field of public health infact has many strands, repressive as well asprogressive. Recognition of these conflictinglegacies can illuminate contemporarydebates about public health research andaction and also help uncover ideologies andpolicies that contribute to or even expandsocial inequalities in health. At a time whenvirtually every nation is questioning the roleof the state in fostering human welfare andwhen the very notion of public health associal good is being challenged by profit-driven agendas,514'49-51 it is useful to recallthat the phrase "public health" was coined inthe early 19th century to distinguish actionsgovernments and societies as opposed toprivate individuals should take to preserveand protect the people's health.2'52 We maydo well in our own time to embrace the con-cept of "collective health," coined by LatinAmerican public health professionals toemphasize the notion of shared health out-comes determined in the polis, if manifestedin individual bodies.5355

To acknowledge, then, the importanceof 1848 for the field of public health, thenew Spirit of 1848 Caucus has organized anevening extravaganza on November 17,1998, at the 126th Annual Meeting of theAmerican Public Health Association (session2302.1). The evening will combine music,poetry, dramatizations, and photography,along with 3 academic presentations, to stim-ulate reflection on and commitment to publichealth activism. Participants will representmore than 20 American Public Health Asso-ciation caucuses, sections, committees, andaffiliated organizations. We invite you toattend, to learn, to reflect, and above all tocelebrate our field's dedication, past and pre-sent, to the belief that social justice should bethe foundation of public health. D

AcknowledgmentsThanks to Ted Brown, Ed Morman, and CeciliaZapata for their helpful comments.

References1. Marx K, Engels F. The Communist Manifesto:A Modern Edition. Introduction by E Hobs-bawm. London, England: Verso; 1998.

2. Rosen G. A History ofPublic Health. Introduc-tion by E Fee; biographical essay and new bib-liography by ET Morman. Expanded ed. Balti-more, Md: Johns Hopkins University Press;1993. (Original published 1958.)

3. Hamlin C. Public Health and Social Justice inthe Age of Chadwick: Britain 1800-1854.Cambridge, England: Cambridge UniversityPress; 1998.

4. Hamlin C, Sheard S. Revolutions in publichealth: 1848, and 1998? BMJ. 1998;317:587-591.

5. Calman K. The 1848 Public Health Act and itsrelevance to improving public health in Eng-land now. BMJ. 1998;317:596-598.

6. Szreter S. Economic growth, disruption, depri-vation, disease, and death: on the importance ofthe politics of public health for development.Popul Dev Rev. 1997;23:693-728.

7. Engels F. The Condition of the Working Classin England. OW Henderson, WH Chalones,trans. Stanford, Calif: Stanford UniversityPress; 1958. (Original published 1845.)

8. Hobsbawm EJ. The Age of Revolution1789-1848. New York, NY: Vintage Books;1996. (Original published 1962.)

9. Chadwick E. Report on the Sanitary Conditionof the Labouring Population of Great Britain.MW Flinn, ed. Edinburgh, Scotland: Edin-burgh University Press; 1965. (Original pub-lished 1842.)

10. Hamlin C. Could you starve to death in Eng-land in 1839? The Chadwick-Farr controversyand the loss of the "social" in public health. AmJPublic Health. 1995;85:856-866.

11. Eyler JM. Victorian Social Medicine: TheIdeas and Methods of William Farr. Baltimore,Md: Johns Hopkins University Press; 1979.

12. Alison WP. Observations on the EpidemicFever of 1843 in Scotland: And its ConnectionWith the Destitute Condition ofthe Poor. Edin-burgh, Scotland: W. Blackwood; 1844.

13. Szreter S. The importance of social interven-tion in Britain's mortality decline ca1850-1914: a reinterpretation of the role ofpublic health. Soc Hist Med. 1988;1:1-38.

14. Sram I, Ashton J. Millenium report to SirEdwin Chadwick. BMJ. 1998;317:592-596.

15. Smith JM. On the fourteenth query of ThomasJefferson's notes on Virginia. The Anglo-African Magazine. 1859;1:225-238.

16. Levesque GA. Boston's Black Brahmin: Dr.John S. Rock. Civil War History. 1980;54:326-346.

17. Morais HM. The History ofthe Negro in Medi-cine. 2nd ed. New York, NY: InternationalLibrary ofNegro Life and History; 1968.

18. Krieger N. Shades of difference: theoreticalunderpinnings of the medical controversy onblack-white differences, 1830-1870. Int JHealth Serv. 1987;7:258-279.

19. Augstein HF, ed. Race: The Origins ofan Idea,1760-1850. Bristol, England: ThoemmesPress; 1996. University of Bristol, Key IssuesNo. 14.

20. Gould SJ. The Mismeasure ofMan. New York,NY: WWNorton; 1981.

21. Cartwright SA. The diseases and physicalpeculiarities of the Negro race. New OrleansMedSurgJ. 1850;7:691-715.

22. Nott JC, Gliddon G, eds. Indigenous Races ofthe Earth; or New Chapters of EthnologicalEnquiry. Philadelphia, Pa: JB Lippincott & Co;1857.

23. HaIler JS Jr. Outcasts From Evolution: Scien-tific Attitudes of Racial Inferiority. Urbana, Ill:University of Illinois Press; 1971.

Comment

24. Gamble VN, ed. Germs Have No Color Lines:Blacks and American Medicine, 1900-1940.New York, NY: Garland Publishing; 1989.

25. Kevles DJ. In the Name ofEugenics: Geneticsand the Uses ofHuman Heredity. New York,NY: Alfred E. Knopf; 1985.

26. Zinn H. A People's History of the UnitedStates, 1492-Present. Rev, updated ed. NewYork, NY: First HarperPerennial; 1995.

27. Tibbitts C. The socio-economic background ofNegro health status. J Negro Educ. 1937;6:413-428.

28. Lewontin R. Human Diversity. New York, NY:Scientific American Books; 1982.

29. Cavalli-Sforza LL, Menozzi P, Piazza A. TheHistory and Geography ofHuman Genes.Princeton, NJ: Princeton University Press;1996.

30. The Meaning of Race in Science-Considera-tions for Cancer Research. Report of the Presi-dent's Cancer Panel (April 9, 1997). Bethesda,Md: National Institutes of Health, NationalCancer Institute; 1998.

31. Cooper RS, David R. The biological concept ofrace and its application to public health andepidemiology. J Health Polit Policy Law.1986; 11:97-116.

32. Krieger N, Rowley D, Hermann AA, Avery B,Phillips MT. Racism, sexism, and social class:implications for studies of health, disease, andwell-being. Am J Prev Med. 1993;9(suppl 2):82-122.

33. Williams DR. Race and health: basic questions,emerging directions. Ann Epidemiol. 1997;7:322-333.

34. Lillie-Blanton M, LaVeist T. Race/ethnicity, thesocial environment, and health. Soc Sci Med.1996;43:83-92.

35. Crosby AW Jr. The Columbian Exchange: Bio-logical and Cultural Consequences of 1492.Westport, Conn: Greenwood Press; 1972.

36. Kunitz SJ. Disease and Social Diversity: TheEuropean Impact on the Health of Non-Europeans. New York, NY: Oxford UniversityPress; 1994.

37. McNeill W. Plagues and Peoples. New York,NY: Anchor Books; 1976.

38. Cook N, Lovell WG. Secret Judgments ofGod:Old World Disease in Spanish Colonial Amer-ica. Norman: University of Oklahoma Press;1992.

39. MacLeod R, Lewis M, eds. Disease, Medicine,and Empire: Perspectives on Western Medicineand the Experience of European Expansion.London, England: Routledge; 1988.

40. Arnold D, ed. Imperial Medicine and Indige-nous Societies. Manchester, England: Man-chester University Press; 1988.

41. Crosby AW Jr. Ecological Imperialism: TheBiological Expansion of Europe, 900-1900.Cambridge, England: Cambridge UniversityPress; 1986.

42. Cooper DB. Epidemic Disease in Mexico City,1716-1813: An Administrative, Social, andMedical Study. Austin: University of TexasPress; 1965.

43. Alchon SA. Native Society and Disease inColonial Ecuador. Cambridge, England: Cam-bridge University Press; 1991.

44. Lyons M. The Colonial Disease: A Social His-tory of Sleeping Sickness in Northern Zaire,1900-1940. Cambridge, England: CambridgeUniversity Press; 1992.

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45. Curtin PD. Death by Migration: Europe'sEncounter With the Tropical World in the Nine-teenth Century. Cambridge, England: Cam-bridge University Press; 1989.

46. Harrison M. Public Health in British India:Anglo-Indian Preventive Medicine, 1859-1914.Cambridge, England: Cambridge UniversityPress; 1994.

47. Birn AE, Sol6rzano A. Public health policyparadoxes: science and politics in the Rocke-feller Foundation's hookworm campaign inMexico in the 1920s. Soc Sci Med. In press.

48. Miranda Canal N, Quevedo Velez E, Hemrn-dez Alvarez M. Historia Social de la Cienciaen Colombia. Vol 8. La Institucionalizaci6n dela Medicina en Colombia. Bogota, Colombia:Instituto Colombiano para el Desarrollo de laCiencia y la Tecnologia Francisco Jose de Cal-das, Colciencias; 1993.

49. Navarro V. The Politics ofHealth Policy: TheU.S. Reforms, 1980-1994. Cambridge, Mass:Blackwell Publishers; 1994.

50. Laurell AC. La Reforma Contra la Salud y laSeguridad Social. Mexico, DF: Ediciones Era;1997.

51. Bijlmakers LA, Bassett MT, Sanders DM.Health and Structural Adjustment in Rural andUrban Zimbabwe. Uppsala, Sweden: NordiskaAfrikainstitutet; 1996.

52. Coleman W. Death is a Social Disease: PublicHealth and Political Economy in Early Indus-trial France. Madison: University of Wiscon-sin Press; 1982.

53. Laurell AC. Social analysis of collective healthin Latin America. Soc Sci Med. 1989;28:1183-1191.

54. The Crisis ofPublic Health: Reflections for theDebate. Washington, DC: Pan AmericanHealth Organization; 1992. Pan AmericanHealth Organization Scientific Publication No.540.

55. Donnangelo MCF. A pesquisa na area da sauidecoletiva no Brasil-a decada de 70. In: Ensinoda Saude Publica, Medicina Preventiva eSocial no Brasil. Rio de Janeiro, Brazil: Asso-ciacao Brasileira de P6s-Graduacao em SaiideColetiva; 1983:17-35.

For Further ReadingGENERAL HISTORY

Duffy J. The Sanitarians: A History ofAmericanPublic Health. Urbana: University of IllinoisPress; 1990.

Porter D, ed. The History ofPublic Health and theModern State. Amsterdam, the Netherlands;Rodopi BV; 1994. Clio Medica 26/The Well-come Institute Series in the History of Medicine.

MORE DETAILED HISTORYApple RD, ed. Women, Health, and Medicine in

America: A Historical Handbook. New York,NY: Garland Publishing; 1990.

Cassedy JH. American Medicine and StatisticalThinking, 1800-1860. Cambridge, Mass: Har-vard University Press; 1984.

Fee E, Acheson RM, eds. A History ofEducation inPublic Health: Health That Mocks the Doctor sRules. Oxford, England: Oxford UniversityPress; 1991.

Hardy A. The Epidemic Streets: Infectious Diseaseand the Rise of Preventive Medicine,1856-1900. Oxford, England: Oxford Univer-sity Press; 1993.

La Berge AF. Mission and Method: The Early Nine-teenth-Century French Public Health Move-ment. Cambridge, England: Cambridge Uni-versity Press; 1992.

Pelling M. Cholera, Fever and English Medicine,1825-1865. Oxford, England: Oxford Univer-sity Press; 1978.

Rosenberg CE. The Cholera Years: The UnitedStates in 1832, 1849, and 1866. Chicago, Ill:University of Chicago Press; 1987.

Rosenkrantz BG. Public Health and the State:Changing Views in Massachusetts, 1842-1936.Cambridge, Mass: Harvard University Press;1972.

Stanton W. The Leopard's Spots: Scientific AttitudesTowards Race in America; 1815-1859. Chicago,Ill: University ofChicago Press; 1960.

Wohl A. Endangered Lives: Public Health in Victo-rian Britain. Cambridge, Mass: Harvard Uni-versity Press; 1983.

ORIGINAL TEXTSGriscom JH. The Sanitary Condition of the Labor-

ing Population ofNew York With Suggestionsfor its Improvement. New York, NY: Harper &Bros; 1845.

Rather LJ, ed. Rudolf Virchow: Collected Essays onPublic Health and Epidemiology, Vol 1. Can-ton, Mass. Science History Publications; 1988.

Simon J. English Sanitary Institutions. 2nd ed. Lon-don, England: John Mufray; 1897.

Commnlent: The Past and Future of National ComprehensiveTobacco Control Legislation

In June 1998, the US Congress came asclose as it ever has to passing comprehensivenational tobacco control legislation. Whatwere the provisions of the proposed bills?Why did they fail? And most important,where does the public health community gofrom here?

Tobacco Industry and StatesReach InitialAgreement

This account begins in April 1997,when the tobacco industry began seriousnegotiations with the state attomeys generalwho had collectively sued the tobacco indus-try to recoup Medicaid funds spent on treat-ing tobacco-related diseases. The result wasa comprehensive national settlement. Thetobacco companies agreed to make signifi-cant public health concessions, includingadvertising and marketing restrictions, com-prehensive restrictions on youth access to

tobacco products, tougher health warnings, a$500-million-per-year public education cam-paign, funding for state and local tobaccocontrol programs, smoking cessation assis-tance, regulations against environmentaltobacco smoke, recognition of the authorityof the Food and Drug Administration (FDA)over tobacco products, and substantial penal-ties if tobacco use among children did notdecrease to specified levels.

In addition, the tobacco industry agreedto drop court challenges to FDA regulationover tobacco products and to cease trying tosubvert the Environmental ProtectionAgency's risk assessment of secondhandsmoke. Finally, $365 billion was earmarkedfor state and federal public health programsand related activities. Much of this fundingwas to come from a per-pack increase in theprice of cigarettes.

In return, the state attorneys generalagreed to settle their individual state lawsuitsand all pending private class action suits.

They further agreed to limits on future law-suits, protection for the tobacco industryagainst prospective class action suits andpunitive damages, and an annual cap on theamount the industry was forced to pay inpunitive damages.

Congress Responds to CallforStronger Measures

The agreement was announced on June20, 1997. The outcry from certain tobaccocontrol advocates was immediate andintense. Their major points of contentionwere the limits placed on FDA jurisdiction,the inadequacy of the expected payments bythe industry, and the terms related to futurelitigation against the tobacco companies.

After 3 months of review, PresidentClinton allowed that while the agreementwas an important step forward, stronger pro-visions were needed. He outlined a set of

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