Signatories of the 1924 Pan American Sanitary Code
During the 1800s, health officials in some southern ports in the USA set off gunpowder and burned pots of sulphur during yellow fever season to purify the air. Ships, their crews, passengers, and their cargo were subject to long quarantines and fumigation. “These measures”, notes Marcos Cueto in his history of the Pan American Health Organization (PAHO), “were generally annoying, useless, and even harmful”. They were also bad for business since they “seriously affected trade, and led to shortages of supplies and higher prices for necessities”, Cueto writes.
The PAHO story underscores just how the concerns of trade and commerce have driven advances in public health. In the 1880s, public-health boards were ad-hoc commissions convened to deal with outbreaks after they had begun; their membership often included clergy, as well as public officials and medical personnel. Interventions focused narrowly on the ports and were far from evidence-based. Quarantine regulations varied not only from country to country, but from port to port. The crews of steamships plying American waters might need to have as many as 25 different health documents on hand.
The 19th-century expansion of maritime trade and immigration, together with the need to prevent the introduction of infectious diseases into the general population, were, according to Cueto, “strong motives for redesigning international public health in the Americas”. The Washington Sanitary Convention of 1905 not only said that “each government shall immediately notify the others of the first appearance in its territory of confirmed cases of plague, cholera, and yellow fever”, but also stated that merchandise did not transmit diseases and that detention of cargo, crew, and passengers should be as brief as possible and in line with scientific knowledge.
With time, however, it became clear that the best way to fight epidemics was not with quarantines at the dockside, but by improving the hygiene of the port cities and surrounding areas. Eventually, public-health initiatives began to address diseases not subject to quarantine. With these changes, Cueto argues, came a change in attitude that public health had “intrinsic value, ie, that it did not have to be justified by its economic benefits”. As a result, the landmark Pan American Sanitary Code, drawn up in 1924, in addition to provisions on quarantine and fumigation also called for “the recognition of health as a right of all countries and of all people”.
By the mid-20th century, PAHO's leadership promoted public health by emphasising the link between health and prosperity. During the 1960s and 1970s, Abraham Horwitz, a Chilean and PAHO's first Latin American director, argued that health interventions could only accomplish so much. Health also depended on better housing, education, and nutrition, which only development could bring. “The lack of resources causes high rates of disease, while the high rates of disease make it impossible to produce the resources needed to improve health conditions for the population and the economy in general”, he wrote.
The link between commerce, trade, and public health remains evident in the 21st century. Increases in trade and travel—underscored by the worldwide spread of HIV/AIDS and such outbreaks as severe acute respiratory syndrome and avian influenza—are forcing public-health officials to rethink old strategies. At the same time, the leading causes of death in the Americas are now the non-communicable diseases. Today, more than three-quarters of the deaths in the Americas are related to chronic diseases that were long considered diseases of affluence. In its Health in the Americas 2007 report, PAHO notes that “At least 80% of premature heart disease, stroke, and type 2 diabetes, and 40% of cancer in the Americas could be prevented through healthy diet, regular physical activity, and avoidance of tobacco products.” In an odd twist, the prosperity that has resulted from improvements in trade, commerce, and advances in health has itself become a problem for public health.