From ‘Leprosy’ to ‘Space Exploration’: The Next Chapter in Public Health

What is public health?  If you go about seeking an answer—be it from the Institute of Medicine, this blog, or the website dedicated to that very question—you may well find yourself asking, “OK, what isn’t public health?”

The purview of public health spans many domains: from seatbelts to smoking, health care to housing, bacteria to bike helmets, pandemics to poverty, depression to diabetes, nutrition to noise pollution, vaccines to violence, and countless others.

With all that, when does something officially become a “public health problem?” 

There’s no definitive answer. But I recently found an interesting resource that gives a pretty good, and undeniably official, indication.

The U.S. Code contains all the federal laws of the United States—around 200,000 pages of them.  Often, when Congress passes legislation, it is amending one of the 51 Titles of the U.S. Code.

Title 42 is entitled “The Public Health and Welfare.” The Title 42 table of contents, which lists its 159 chapters, serves as an illustrative timeline of what have been considered public health problems over the course of our nation’s history.

Title 42 starts out simple enough. Chapter 1 officially establishes the U.S. Public Health Service, building upon the existing infrastructure of the U.S. Marine Hospital Service—often considered the first government public health institution in America.  Chapter 2 highlights the issues of communicable disease, from which the discipline of public health emerged, and strategies to address them through public sanitation and quarantine.  The supplementation of Chapter 3 (entitled “Leprosy”) with Chapter 3A  (“Cancer”) in the 1930s provides an early indication of the transition from communicable diseases to the chronic illneses that would come to define public health in the second half of the 20th century.   

Moving forward, we see concern for the health of specific groups: Chapter 5 is “Maternity and Infancy Welfare and Hygiene.” Chapter 7 creates Social Security in 1935; it would eventually be amended, in 1965, to provide health insurance for the elderly (Medicare) and for people with low incomes and disabilities (Medicaid). 

In the 1960s, Chapter 33 provided the first explicit mention of mental health. And Chapters 42 (“Narcotic Addiction Rehabilitation”) and 60 (on alcohol abuse prevention) suggest that substance abuse was finally being recognized as a public health problem—not just a social problem.

In the 1970s, we see a number of new chapters on energy-related issues—the subtext being that the health of our population will be endangered if we keep desecrating the environment (as evidenced by Chapter  97, “The Acid Precipitation Program and Carbon Dioxide Study”).

Toward the very bottom of Title 42’s table of contents is Chapter 157:  “Quality, Affordable Health Care for All Americans.” This is the legal home of the Affordable Care Act, the sweeping health-care legislation that detractors like to call “Obamacare.”

While the ACA brings us to the present, and would be a fitting end to our legislative public health history tour, it has already been surpassed. The final chapter—at the moment—is 159 (“Space Exploration, Technology, and Science”).  

Whatever the next frontiers of public health—be them focused on Mars or Marlboros—chances are they’ll have a place somewhere in Title 42 of the U.S. Code.

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