Dr William Stewart, surgeon general from 1965 to 1969, died recently (April 2008). His activities focused on reducing health hazards associated with cigarettes and catalyzing the desegregation of hospitals in the south by withholding Medicare funding from those institutions unwilling to change this practice. A pediatrician and activist, he advocated for health services to the poor and national health insurance. This visionary is also remembered for another view of the public health future expressed in a 1967 presentation to the Association of State and Territorial Health Officials: "It's time we close the book on infectious diseases."1
Stewart, generally correct in identifying the public health agenda, was not alone in his assessment of the future role of transmissible diseases. The late Dr Robert Petersdorf, infectious disease expert, former Chair of the University of Washington Department of Medicine, and later President of the Association of American Medical Colleges, wrote in a 1978 New England Journal of Medicine article: "I cannot conceive of a need for more infectious disease experts unless they spend their time culturing each other."2(p631)
In 1979, Healthy People marked a turning point in the strategy for public health in the United States and distinguishing between a first and second public health revolution. The first public health revolution was the struggle against infectious disease in the late 1800s and early 1900s. This revolution was fought in the environment with environmental actions, including sanitation and water purity, and by reducing the vulnerability of individuals through immunization. A second revolution was foreseen as occurring in the new field of action: chronic disease and the associated individual behavioral antecedents.
In hindsight, the premature judgments were not surprising on the demise of infectious disease as a major hazard to human health. In the United States, virtual elimination of a number of transmissible diseases had occurred: cholera, yellow fever, dysentery, smallpox, typhoid, diphtheria, and polio. Tuberculosis, the leading cause of death at the beginning of the 20th century, was greatly reduced in prevalence. In 1890, nearly one of every four dwellings in New York City experienced a tuberculosis-related death. The toll was much higher in poorer neighborhoods, leaving these communities devastated by the disease.
In the latter part of the 20th century, infectious diseases no longer caused the majority of deaths in the United States. National and local data show the same transition to chronic disease. Tobacco, alcohol, illicit drugs, firearms, motor vehicles, diet, activity levels, and sexual behavior became responsible for half of the deaths.
It became clear shortly after the pronouncements of Stewart and Petersdorf that the book on infectious disease is still open-chapters, stories, and characters are being added continually. There is an ongoing second revolution in public health; an insurrection engendered by adverse individual risk behaviors, influenced by environmental factors in our communities. But the first revolution, countering infectious diseases, has reemerged as a public health activity.
New or reemerging diseases of recent importance include severe acute respiratory syndrome, hantavirus, moneypox, West Nile virus, HIV, and the specter of pandemic influenza respiratory syndrome. A series of articles on current infectious disease issues appears in this issue: Hepatitis A, Hepatitis C, tuberculosis, rabies, HIV, and sexually transmitted diseases.
Housing, urbanization, overcrowding, and the availability of quality water have been recognized for their importance to community health. Activities to address environmental health hazards have been a focus of public health efforts from antiquity. In her superb editorial, "Climate Change: Public Health Crisis or Opportunity" appearing in this issue of the Journal of Public Health Management and Practice, Dr Katherine M. Shea broadens our perspective on the relationship of environment to our health, emphasizing the potential major impact of global warming and the responsibility of public health practitioners to act for the benefit of our global and local communities. Indeed, continuing the focus of this editorial on infectious disease, climate change, one of the factors associated with emerging infectious diseases, is expanding the zones of vector-borne diseases including malaria and dengue. Air travel has also facilitated the importation of emerging disease. Malaria is imported into this country each year through air travel and secondary small outbreaks of this disease are regularly occurring in a number of locations in the United States.
Articles in this issue document both the ongoing challenges of preventing emerging infections, Hepatitis C and HIV, and the long-standing disease threats of tuberculosis, rabies, influenza, and sexually transmitted diseases. The future of public health practice will be defined by both the "first revolution" of infectious disease and the "second revolution" of chronic disease. Collective community action, grounded in environmental approaches, will determine our progress.
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