"Airs, Waters, Places" and Other Hippocratic Writings: Inferences for Control of Foodborne and Waterborne Disease.
Contemporary interest in the relationship between the environment and human health was an original preoccupation of Western science and medicine, Ancient Greek philosophers and medical thinkers seeking rational explanations for disease studied and discussed the relationship between health and environment. By the fifth century B.C., they had come to recognize that evil spirits did not invade the body and cause disease and that magical incantations or potions were not curative. Preeminent among these thinkers were the members of the Asclepiad medical community on the island of Cos, the most noteworthy of whom was Hippocrates (460-370 B.C.), "the father of medicine" (see photo on page 10).
The Hippocratic Writings
A collection of about 60 eponymous "writings of Hippocrates," the work of a number of authors, has come down to us. The Hippocratic writers viewed humans as situated in and subject to the order of nature and as composed of natural substances. They assimilated to their doctrine the teachings of pre-Socratic philosophers like Empedocles (circa 493-433 B.C.), who posited the existence of four basic elements: air, water, fire, and earth. This assimilation is reflected in the Hippocratic doctrine of the four humors--blood, phlegm, yellow bile, and black bile--which had to be in harmony for good health (1). Under the normal functioning of the human organism, a balance of substances or proper mixture was maintained in the body, and the body and its organs were sound and whole.
The Hippocratic writers saw diseases as processes whose causes could' be rationally understood as observable disturbances of normal functioning (1,2). This concept is not greatly different from a typical modern definition of disease as "any deviation from, impairment of, or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of one or more signs or symptoms" (3).
The Hippocratic physician understood that diseases had discernible origins and stages of development, crisis, and resolution. It was the physician's role to understand the signs and stages and to assist the patient in struggling against the disease so that a natural resolution could be achieved. This role usually meant ensuring that the patient adopted an appropriate regimen, or combination of diet and exercise. The Hippocratics tried to distinguish the diet appropriate for people in good health from that appropriate for people who were ill. They characterized diseases and conditions according to the perceived excess or deficiency of a humor, and treatment involved counterbalancing the excess or deficiency. For example, a patient suffering from a fever that appeared to induce dryness was to be put on a liquid diet consisting of barley gruel and drinks of wine or water and honey .
To the Hippocratic writers, the environment was an important factor in people's health and well being. Infection resulted when environmental influences involving air, water, food, or other aspects of life and health--whether seasonal or otherwise--destabilized people's "humoral equilibrium." Changes in the seasons and other natural influences, as well as characteristics of climate and location, could and did give rise to diseases.
The seasons, like the bodily humors, were thought to correspond to the four elements. Thus, winter, the cold, wet season corresponded to the element water; spring, the season of rebirth, was associated with the element air; summer, a hot, dry season in ancient Greece, was related to fire; and autumn, the season when leaves turned brown and the weather gloomy, represented the element earth. To these seasons and elements corresponded the respective humors phlegm, blood, yellow bile, and black bile, as well as characteristic patterns of humoral excess or deficiency
The author of the Hippocratic treatise "Airs, Waters, Places" associates seasons, prevailing winds, and the quality of the air and water with the physical condition of people and the occurrence of disease . He advises the physician coming upon a city that is new to him to take note of the environmental factors that determine the kinds of diseases endemic to that location. He characterizes the properties of water, soil, and human behaviors and relates them to epidemiology and the maintenance of human health. In his opening chapter, for example, he advises the physician to consider what effects each season of the year can produce because each season and each change of season differ from the others. As the year passes, physicians will be able to tell what epidemic diseases will arise in the summer and what in the winter, and they will be able to distinguish seasonal diseases from those arising out of an individual's mode of life [6,7]. Today the principles advocated in this early description of environmental influences on epidemiology and disease are routinely applied.
Epidemiology today uses the principles of risk assessment (hazard identification, dose/response assessment, exposure assessment, and risk characterization) to estimate health risks and develop an appropriate scientific response to protect public health . The modern use of sophisticated quantitative methodologies and epidemiological determinants has, nevertheless, validated the Hippocratic observations that seasonal variations influence the incidence of disease.
The clinical spectrum of foodborne disease, with limited exceptions, supports the seasonal concept. In industrial countries with temperate climates, it is a commonplace that respiratory infections, colds, and influenza are associated with the winter months. Most food-associated cases occur in the warm months [9,10]. In the United States, outbreaks of foodborne illness are reported most frequently during the warm months, from May through September. Salmonella is most frequently cited as the causative organism . Even in the tropics, where foodborne infections appear endemic, many of the acute diarrheal episodes are distributed seasonally, with the highest frequency during the early rains or at the beginning or height of the monsoon.
Relevance of Water to Disease Causation
The Hippocratic author also noted the influence of waters on human health, distinguishing those conducive to good health from those that caused illness . Among the examples cited are problems faced by inhabitants of marshy areas. Those who drink the water, whether during the summer or during the winter, "have always large, stiff spleens, and hard, thin, hot stomachs, while their shoulders, collarbones and faces are emaciate" .
In later ages, these specific symptoms were to be associated not with bad water but with "bad air"-malaria . The author notes, in addition, that during the summer, numerous dropsies occur, resulting from epidemics of prolonged dysentery, diarrhea, and quartan fever. He continues with a discussion of the circumstances and sources of good and bad water, finding particularly unhealthful the waters from snowmelt and runoff .
We know today that a variety of environmental conditions, as well as rains that wash contaminants (bacteria, parasites, viruses, and protozoa) into water sources, can cause the occurrence and severity of outbreaks to vary, depending on the degree of contamination and the distribution of the population at risk. The incidence of disease is greatest in heavily crowded areas .
The problems associated with polluted drinking water have existed for centuries. The gravity of the problem varies around the globe. Today, in developing countries, water-related diseases are major causes of morbidity and mortality among both infants and adults. Indeed, waterborne contamination is the single largest killer of infants and the principal cause of illness in adults. In areas of developing countries where waterborne diseases are endemic, malnutrition associated with weaning, secondary hypochlorhydria, and increased exposure to contaminated water heighten incidence among the immunocompromised young, particularly those two to four years of age . This phenomenon is especially to be observed in the epidemiology of cholera, but it is reasonable to assume that other waterborne or food-borne pathogens operate on similar principles. More than a third of the world's population, in the poorest countries, have no access to safe water. In some countries, potable water constitutes 10 percent or less of th e water supply. The industrialized world takes "clean" drinking water for granted, although there is still a serious contamination threat even in the most advanced countries .
Water remains the primary vehicle of infection for cholera, especially in developing countries. Even when a food source is associated with the disease, contaminated water plays a significant role in most reported outbreaks. The United Nations considered the problem of clean drinking water so acute during the 1980s that it declared the decade the "Drinking Water and Sanitation Decade." Despite the increased attention and funding that have been devoted to the problem, nearly two billion people do not have access to safe drinking water. The problem remains acute throughout the world.
Even in advanced industrialized societies like the United States, waterborne transmission of disease is a serious public health challenge. The pathogen most often implicated has been identified as Giardia lamblia. A review of reports from the Centers for Disease Control and Prevention (CDC) indicated that from 1986 through 1988, nine outbreaks of waterborne giardiasis resulted in 1,169 cases .
Cryptosporidium has been identified in surface water from reservoirs, rivers, lakes, ponds, and streams, including water intended for swimming and drinking. Outbreaks have been reported in several states and throughout the world, with the two largest reported from Carrolton, Georgia, in 1987 and Milwaukee, Wisconsin, in 1993. The Georgia outbreak affected an estimated 13,000 people who had consumed water from a public water supply that met federal standards, and the Wisconsin outbreak affected 403,000 people (17,18). The major symptom of cryptosporidiosis is diarrhea, which is more profuse in immunocompromised people, including those afflicted with AIDS, than in people with normally functioning immune systems. When the immune system is compromised, cryptosporidiosis infections tend to persist for long periods of time and to result in death .
Foodborne Disease Implications
In accordance with their dietetic approach to medicine, the Hippocratic writers recognized that food, as well as air and water, could be a source of disease. Raw foods could be harmful and might have to be mixed with other ingredients and "compounded" or cooked before being consumed. Medicine arose with the perception that the sick and the well required different diets, differently prepared. According to the author of "Ancient Medicine," neither medicine nor the culinary arts would have been discovered had humans in their primitive, natural state enjoyed good health, and had they not become ill at times from eating "crude" foods (19,20):
Not even the mode of nourishment enjoyed at the present time by men in health would have been discovered, had a man been satisfied with the same food and drink as satisfy an ox, a horse, and every animal save man, for example the products of the earth-fruits, wood and grass .
The author speculates that in the beginning men lived as animals did, and suffered when eating raw foods "uncompounded and possessing great powers". This view is supported by the findings of modern historians of medicine who have noted that the disease hazards affecting hunter-gatherer peoples are similar to those affecting wild animals--infections and parasites .
Only the strongest survived under those primitive conditions. For this reason, ancient people looked for food that agreed with their constitution. They learned how to make wheat flour, bake bread, and cook many other things. They found that food they boiled or baked, combining "strong and uncompounded with weaker components" was more adaptable to the human constitution, whereas the raw or strong foods could cause pain, disease, and death. This discovery of the cooking and preparation of foods was one of the foundations of medicine, which was looked upon as a way to improve one's health, whether one was already sick or well. The sick were fed liquids, and the healthy ate solid foods. But whether one was well or ill, "it is the strongest foods that hurt a man most and most obviously" .
The Hippocratic writers tended to suspect water or air, rather than food, as the vehicle for epidemic disease. They viewed diet and nutrition largely as a personal matter or as an aspect of a people's way of life. In any outbreak of illness, however, they followed a time-honored epidemiological principle by seeking the common denominator:
Diseases arise, in some cases from regimen, in other cases from the air by the inspiration of which we live. The distinction between the two should be made in the following way. Whenever many men are attacked by one disease at the same time, the cause should be assigned to that which is most common, and which we all use most. This it is which we breathe in .
Despite the emphasis on air and water, it was recognized that food could be a reservoir of disease. One Hippocratic author recorded that "In Aenus those who continually ate beans during a famine, both men and women, became weak in the legs and continued so. And those who ate vetch had knee ailments" .
Today, we are more conscious of the hazards posed by unprocessed foods but are often as incapable as the ancients of controlling environmental reservoirs of pathogens. Our defenses lie in the arts of food processing and preservation and, when those arts fail us, in clinical medicine.
We understand that the ubiquitous distribution of microbial pathogens in the environment is a constant dilemma in the epidemiology of foodborne disease. The occurrence of pathogens in live, apparently normal food animals is directly associated with the occurrence of those same pathogens on raw meat and poultry The asymptomatic carriage by animals in husbandry habitats is part of the chain of infection that defies easy control measures. In addition, Salmonella serotypes survive in cattle feces for approximately three years, contributing to a constantly contaminated farm environment . It is realistic to assume that the widespread persistence in nature of other bacterial genera precludes their elimination at the farm level . Thus, foodborne diseases present a complex problem that defies any single solution and demands sophisticated and integrated control systems throughout the entire chain of production . While certain pathogens with which the medical and public health communities have traditionally been concerned (Salmonella spp., Staphylococcus aureus, and Clostridium perfringen's) continue to pose problems, new concerns have been aroused by Listeria, Yersinia, Campylobacter, Escherichia coli O157:H7 and Vibrio spp. In addition, animal pathogens that can be transmitted to humans (zoonoses) through meat, milk, or eggs have drawn the attention of the media and government officials charged with enforcing food safety regulations !
A successful food safety program depends on the control of foodborne pathogens during each phase of production, distribution, and consumption--from the farm to the fork, as it were. Some potential sources of transmission, however, defy traditional methods of prevention. For example, 30 percent to 50 percent of the human population are carriers of Staphylococcus aureus in the nose or throat, and the same organism is the predominant cause of skin infections on the hands, arms, and face . The organism is also a frequent cause of mastitis in dairy cows. As a result, staphylococcal intoxication persists as one of the most common types of foodborne disease, with meat and meat products being the most frequently implicated foods .
Clostridium perfringens intoxications are most often associated with the consumption of meat and poultry. The organism commonly occurs in animal feces and in the soil. One major study found 60 percent of poultry and 80 percent of veal carcasses to be contaminated by C. perfringens . The ubiquity of the organism and its heat resistance make it a leading cause of foodborne disease.
The widespread distribution of Salmonella in animal reservoirs make this genus responsible for human disease on a global basis. Salmonellosis in humans generally results from contamination of foods of animal origin followed by inadequate cooking or subsequent recontamination after cooking . The ubiquity of the organism and the widespread failure of prevention ensure that no change in the rate of Salmonella infection should be anticipated in the near future.
Role of Customs and Laws
To the Hippocratic writers, environmental influences combined with the laws and customs of societies were important determinants of people's physical constitution. In countries where the seasons changed, for example, the frequent shocks to the mind made people more spirited and less sociable. Even the type of political regime was determinative. The author of "Airs, Waters, Places" considered those who lived under monarchy to be more slavish and less competitive than those who were independent. While climate affected physique and character, he asserted, health, well-being, and vigor could be improved by appropriate laws affecting their regimen:
The inhabitants of hollow regions, that are meadowy, stifling, with more hot than cool winds, where the water used is hot, will be neither tall nor well-made ... bravery and endurance [similar to that of people in rugged, mountainous regions] are not by nature part of their character, but the imposition of law can produce them artificially ,
The Greek interest in the relationship between politics and the character and physiognomy of the individual is one that cannot engage us here, but the public health role of ancient governments--of which the most visible remaining symbols are the Roman sewers and aqueducts--is noteworthy .
Modern governments carry out policies and programs, based on scientific advances in the fields of microbiology and nutrition, that are aimed at enhancing public health. In the United States, at the federal level, such programs are implemented by the U.S. Environmental Protection Agency (U.S. EPA), which is responsible for clean air and water, and by the U.S. Department of Agriculture (USDA) and the Department of Health and Human Services (HHS), which provide research, regulatory, and public information programs for food safety and wholesomeness. Examples of preventive and informational programs aimed at improving food safety and nutrition are the hazard analysis critical control point (HACCP) programs of the Food Safety Inspection Service and the Food and Drug Administration (FDA), and the USDA-HHS dietary guidelines .
A persistent question is whether any significant reduction in the incidence or prevalence of disease can be realized without completely modified control or prevention policy. There is no guarantee that government policies and programs will decrease microbial threats to the food chain. The HACCP method, however, is a logical and systematic approach to hazard prevention and control that should be applied by everyone who produces food. It demands that sanitary and hygienic precautions be taken at every stage of food production and processing, whether at slaughtering or processing plants, in restaurants or institutions, or in the home kitchen. The last stage is as critical as those preceding it. Even if food producers and processors apply HACCP principles, food safety knowledge must reach individuals and be put into practice in their homes if measurable progress is to be achieved. The simple act of a diaper change can have serious implications for foodborne disease transmission. A well-documented outbreak of gia rdiasis in a Minnesota farming community exemplifies the problem. After changing the diaper of a child with giardiasis, a person prepared a salad which became the vehicle in a foodborne disease outbreak .
The Hippocratic writings distinctly articulate some basic principles of environmental epidemiology and preventive medicine. These principles include
* identifying environmental factors in disease outbreaks and in the overall health of the population,
* distinguishing between endemic and epidemic disease,
* recording the times and places of cases and outbreaks, and
* identifying common vehicles of foodborne infection.
Insofar as these concepts take into account the environment and other external influences on human health, they parallel those applied in the modern world to control and prevent disease.
The 19th century provided new insights into the cause of infectious disease, but the environmental and behavioral links to non-communicable diseases like cancer and heart disease have come to light only in recent decades. Both government and private agencies have initiated preventive public health programs, including scientific research and information campaigns, to deal with these diseases. Nevertheless, in our day as in Hippocrates', the individual practitioner and the patient still struggle to maintain or restore health by following appropriate regimens.
Consider the advice given early in "Airs, Waters, Places":
[The physician must consider] the mode of life also of the inhabitants that is pleasing to them, whether they are heavy drinkers ... and inactive, or athletic, industrious, eating much and drinking little (7).
Compare these recommendations with present-day medical advice. Although much progress has been made over the centuries, many obvious prescriptions remain the same. Ultimately the individual must assume some responsibility for health improvement.
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(2.) Conrad, L.I., M. Neve, V. Nutton, R. Porter, and A. Wear (1995), The Western Medical Tradition, 800 B.C. to A.D. 1800, New York: Cambridge University Press.
(3.) U.S. Department of Health and Human Services, Food and Drug Administration (1998), "Regulations on Statements Made for Dietary Supplements Concerning the Effect of the Product on the Structure or Function of the Body: Proposed Rule," Federal Register, 63(82):23623.
(4.) Hippocrates (1978), "Regimen in Acute Diseases," In Hippocratic Writings, Ed. G.E.R. Lloyd, J. Chadwick, I.M. Lowie, W.N. Mann, and E.T. Withington, New York: Penguin Books, pp. 186-205.
(5.) Last, J.M. (1992), "Scope and Methods of Prevention," In Public Health and Preventive Medicine, J.M. Last and R.B. Wallace, eds., Norwalk, Conn.: Appleton and Lange, Ch. 1, pp. 3-7.
(6.) Hippocrates (1988), "Airs, Waters, Places," In The Challenge of Epidemiology, Ed. C. Buck, A. Llopis, E. Najera, and M. Terris, Scientific Publication No. 505, Washington, D.C.: World Health Organization, pp. 18-19.
(7.) Hippocrates (1995), "Airs, Waters, Places," In Hippocrates I, Trans. W.H.S. Jones, Cambridge, Mass.: Harvard University Press, pp. 65-137.
(8.) Gochfeld, M. (1992), "Environmental Risk Assessment," In Public Health and Preventive Medicine, Ed. J.M. Last and R.B. Wallace, Norwalk, Conn.: Appleton and Lange, pp. 322-341.
(9.) Blaser, M.J., N.W. Leuchterfeld, L.B. Reller, and W.L.L. Wang (1982), "Campylobacter jejuni Infections in Denver," Western Journal of Medicine, 136:287-290.
(10.) Tee, W., B. Dwyer, and J. Kaldor (1986), "Epidemiology of Campylobacter Diarrhea," Medical Journal of Australia, 145:499-503.
(11.) Bean, N., F.J. Angulo, J.S. Goulding, and C. Lao (1996), Surveillance for Foodborne-Disease Outbreaks--United States, 1988-1992, Atlanta, Ga.: Centers for Disease Control and Prevention.
(12.) Patrick, A. (1967), "Disease in Antiquity: Ancient Greece and Rome," In Diseases in Antiquity: A Survey of the Diseases, Injuries, and Surgery of Early Populations, Ed. D.R. Brothwell and A.T. Sanidison, Springfield, Ill.: Thomas, pp. 238-246.
(13.) Benenson, A.S. (1991), "Cholera," In Bacterial Infections of Humans, Ed. A.S. Evans and P.S. Brachman, New York: Plenum Medical, pp. 207-225.
(14.) Nalin, D.R., and J.G. Morris, Jr. (1991), "Cholera and Other Vibrioses," In Hunter's Tropical Medicine, Ed. G.T. Strickland, Philadelphia, Pa.: W.B. Saunders Co., pp. 366-374.
(15.) Hu, H., and N.K. Kim (1993), "Drinking Water Pollution and Human Health," In Critical Condition: Human Health and the Environment, Ed. E. Chivian, A. Haines, H. Hu, and M. McCally, Cambridge, Mass.: Massachusetts Institute of Technology Press, pp. 31-48.
(16.) Fayer, R. (1994), "Foodborne and Waterborne Zoonotic Protozoa," In Foodborne Disease Handbook, Vol. 2, Ed. Y.H. Hui, D.O. Cliver, J.R. Gorham, and K.D. Murrell, New York: Dekker, pp. 331-362.
(17.) Levine, W.C., and C.F. Craum (1990), "Waterborne Disease Outbreaks, 1986-1988," Morbidity and Mortality Weekly Report, 39(55-1):1-13.
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(19.) Jouanna, J. (1999), "Hippocrates and the Birth of the Human Sciences," In Hippocrates, Trans. M.B. DeBevoise, Baltimore, Md.: Johns Hopkins University Press, pp. 210-242.
(20.) Jouanna, J. (1998), "The Birth of Western Medical Art," In Western Medical Thought from Antiquity to the Middle Ages, Ed. M.D. Grmek, Cambridge, Mass.: Harvard University Press, pp. 22-71.
(21.) Hippocrates (1995), "Ancient Medicine," In Hippocrates I, Trans. W.H.S. Jones, Cambridge, Mass.: Harvard University Press, pp. 12-64.
(22.) McKeown, T. (1988), The Origins of Human Disease, Oxford, U.K.: Blackwell.
(23.) Hippocrates (1998), "Nature of Man," In Hippocrates IV, Trans. W.H.S. Jones, Cambridge, Mass.: Harvard, pp. 25-29.
(24.) Hippocrates (1994), "Epidemics 2," In Hippocrates VII, Ed., trans. W.D. Smith, Cambridge, Mass.: Harvard University Press, pp. 18-91.
(25.) Controlling Salmonella in Livestock and Poultry Feeds (1990), Ottawa, Canada: Bulletin Agriculture Canada/Canadian Feed Industry Association, pp. 1-20.
(26.) "Preharvest Pathogen Reduction" (1993), In Proceedings of the World Congress on Meat and Poultry Inspection, College Station, Tex.: U.S. Department of Agriculture/FSIS, pp. 2.01-2.06.
(27.) Eklund, M., M.S. Bergdoll, J.M. Goepfert, and R. Labbe (1984), "Food Poisoning by Gram-Positive Toxigenic Bacteria," In Proceedings of the Second National Conference for Food Protection, Washington, D.C.: Food and Drug Administration, pp. 107-116.
(28.) Genigeorgis, C. (1987), "The Risk of Transmission of Zoonotic and Human Diseases by Meat and Meat Products," In Elimination of Pathogenic Organisms from Meat and Poultry, Ed. F.J.M. Smulders, New York: Elsevier.
(29.) Doyle, M.P., G.K. Morris, G.N. Stelma, N.J. Stern, and R.M. Twedt (1984), "Gram-Negative Bacteria, as Potential, Foodborne Disease Agents," In Proceedings of the Second National Conference for Food Protection, Washington, D.C.: U.S. Food and Drug Administration, pp. 117-131.
(30.) Cartwright F.F., and M.D. Biddiss (1972), Disease and History, New York: Crowell.
(31.) Nutrition and Your Health: Dietary Guidelines for Americans (1995), Washington, D.C.: U.S. Department of Agriculture, Department of Health and Human Services.
(32.) Barnard, R.J., and G.J. Jackson (1984), "Giardia lamblia, the Transfer of Human Infection by Food," In Giardia and Giardiasis: Biology, Pathogenesis and Epidemiology, Ed. S.L. Erlandsen and E.A. Meyer, New York: Plenum Press, pp. 365-378.
"Airs, Waters, Places" and Other Hippocratic Writings: Inferences for Control of Foodborne and Waterborne Disease
* Contemporary interest in the relationship between the environment and human health was an original preoccupation of Western science and medicine.
* Preeminent among Ancient Greek medical philosophers were members of the Asclepiad community on the island of Cos, the most noteworthy of whom was Hippocrates (460-370 B.C.).
* A collection of about 60 eponymous "writings of Hippocrates," the work of a number of authors, has come down to us.
* The Hippocratic writers believed diseases were processes whose causes could be rationally understood as observable disturbances of normal functioning.
* This concept is not greatly different from FDA's definition of disease as "any deviation from, impairment of, or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of one or more signs or symptoms."
* The Hippocratic writings also articulated some basic principles of environmental epidemiology and preventive medicine. These principles include
-- identifying environmental factors in disease outbreaks and in the overall health of the population,
-- distinguishing between endemic and epidemic disease,
-- recording the times and places of cases and outbreaks, and
-- identifying common vehicles of foodborne infection.
* The author of the Hippocratic treatise "Airs, Waters, Places" associates the physical condition of people with
-- prevailing winds,
-- air quality, and
-- water quality (runoff and snowmelt were considered particularly unhealthful).
* Today, sophisticated quantitative methodologies have validated the Hippocratic observation that seasonal variations influence disease incidence.
* We also know that rain and snowmelt can wash contaminants (bacteria, parasites, viruses, and protozoa) into water sources increasing the likelihood of disease.
* The author of another Hippocratic treatise, "Ancient Medicine," acknowledges the dangers of raw foods.
* This author speculates that in the beginning human beings lived as animals did-and suffered from eating raw foods "uncompounded and possessing great powers."
* This view is supported by the findings of modern historians who have noted that the disease hazards affecting hunter-gatherer peoples are similar to those affecting wild animals--infections and parasites.
* The Hippocratic writers also recognized the public health role of ancient governments--of which the most visible remaining symbols are the Roman sewers and aqueducts.
* Similarly modern governments carry out policies and programs, based on scientific advances in microbiology and nutrition, that are aimed at enhancing public health.
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|Author:||Williams, Charles E.|
|Publication:||Journal of Environmental Health|
|Date:||Jun 1, 2000|
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