Introduction

The birth of Public Health took place at the end of the 18^th century and the beginning of the 19^th century, in Germany, by Johann Peter Frank and his doctoral thesis, in which he scientifically analyzed the relationship between poverty and disease. It is the starting point of Public Hygiene, when he proposed the welfare of the population by means that would make it possible for people to enjoy with happiness and for long periods the advantages that social life can offer them. Previously, there was no discipline that contemplated the different components that affected collective health, only social practices aimed at combating the greatest public health danger: epidemics¹.

Already in the 19^th century, in England, the center of the Industrial Revolution, Public Health was established as a sanitary practice. However, it was in France, with the changes introduced by the French Revolution, that the first chair of Public Hygiene was created, as well as the first scientific journal of the specialty and the first professional society.

In the 20^th century, after the work of Pasteur and Koch in bacteriology and microbiology and the work of Pettenkofen in nutrition, clothing and aeration, in addition to the changes brought about by the Second World War, Public Health developed with epidemiological aspects and the separation of curative and preventive medicine. The construction of the welfare state in Germany and England contributed to this, with the appearance of national health services and the creation of the World Health Organization.

Public health in Peru

In Peru, in the 1930s, environmental sanitation was deficient throughout the country, in spite of the urban sanitation policy implemented by Augusto B. Leguía.

In 1937, the Minister of Public Health, Constantino Carvallo, spoke about the high general mortality in the country caused by infectious diseases, highlighting tuberculosis as the main cause. All this despite the fact that the Political Constitution of 1933 stated that the State was in charge of public health and private health care, and that its primary duty was the defense of the physical, mental and moral health of children, which was the responsibility of the Ministry of Development and Public Works.

It was not until October 5, 1935 that the Ministry of Public Health, Labor and Social Welfare was created, and 8 months later the mandatory social insurance. The National Institute of Hygiene and Public Health was created in 1936, replacing the National Institute of Vaccine and Serotherapy.

However, health conditions in the country did not improve, as Dr. Miguel Angel Delgado stated in a presentation at the First Peruvian Medical Convention in June 1947, where he pointed out the major health problems of the country: towns without drinking water, sewage, pavement, electricity and lack of control in the handling of food, slaughterhouses and garbage disposal.

More serious were the living and health conditions of the indigenous population of the highlands and jungle, mostly illiterate and poor, as documented by Maxime H. Kuczynsky-Godard in the medical-social surveys published between 1941 and 1945. These surveys described unhealthy conditions, infant mortality, tuberculosis, malaria and hookworm disease, as well as alcoholism as the main factors.

Two years earlier, in 1945, a commission had been formed to present a plan for the organization and progressive technification of the Minis-try of Public Health and Social Assistance. This commission, chaired by Minister Oscar Trelles, presented the plan to the government with ten considerations, among which were the functions of hygiene and sanitation, the perfection of preventive and curative medicine, the orientation of health and assistance activities towards social groups, and the organization of the structure of the ministry and its relationship with periph eral agencies and coordination with all official and private institutions related to public health. This plan was approved and led to the creation, within its structure, of the General Directorate of Public Health at the highest level². It can be said that it was at that time that Public Health took on the role of differentiating activities of a sanitary and preventive nature from those of an assistential and curative nature.

However, contradictorily, one of the first actions of the ministry was the construction of 40 hospitals with a total of 7,000 hospital beds, i.e., priority was given to curative activities.

Years later, in 1957, another reorganization formed a General Directorate of Health to re-place the General Directorate of Public Health, thus eliminating the separation between preventive and assistance. This was maintained for years, causing a hospital emphasis with a concentration of financial resources and high technology, which increased the social prestige of hospital personnel compared to that of the health centers that had the preventive tasks.

It was the cooperation programs of U.S. agencies and the Rockefeller Foundation that supported preventive medicine, as well as training programs for medical professionals and postgraduate studies in public health. One example was the eradication of malignant malaria in 1959. With USAID support, the Public Health Training Center was launched under the direction of Dr. Mario León Ugarte, entity that later became the Peruvian School of Public Health. In the sixties, under the impulse of Carlos Paz Soldán and Alberto Hurtado, the subject of Preventive Medicine was introduced in the medical training plan of the Faculty of San Fernando.

It was not until the 1979 Constitution that the right to health was clearly established as the primary responsibility of the State, guaranteeing the right of everyone 'to the protection of integral health and the duty to participate in the promotion and defense of their health, that of their families and the community'. The conceptual framework of the World Health Organization considers health as the enjoyment of the highest level of physical, mental and social wellbeing in its promotional, preventive, restorative and rehabilitative aspects.

Public health and women's health

In 1974, the first United Nations International Conference on Population took place in Bucharest, which reached a consensus that States should include family planning in population policies. At that time, reproductive health was understood as 'maternal and child health', i.e., care during pregnancy, childbirth and puerperium, and the reduction of maternal death.

In 1975, the first World Conference on Women was held, which discussed women's right to health and safe and healthy motherhood, as well as the right to access family planning. All this as a consequence of the fact that a decade earlier human sexuality and human rights had been redefined due to the sexual revolution brought about by the discovery of the contraceptive pill, which allowed sex without reproduction. Modern contraception allowed many women the possibility of education, training, and paid and professional work. However, the Vatican's opposition to the use of the pill represented a problem for governments to approve its use not only as a contraceptive but also in birth control, in those countries with high population growth and population density beyond their resources.

It was finally at the third International Conference on Population and Development, held in 1994 in Cairo, that reproductive health became a right that allows women self-determination over their bodies, sexuality and reproduction³. This was ratified at the IV World Conference on Women in 1995, where sexual and reproductive rights were declared as inherent to human rights. Like wise, the countries committed themselves to respect the conditions of equity and equality between men and women⁴. This occurred almost 200 years after a heroine of the French Revolution, Olympe de Gauges, wrote the Declaration of the Rights of Women and Citizenship, in 1791, as a plea against female discrimination⁵.

In Peru, maternal health care began professionally with the first birthing school and its attached hospital, the Casa de Maternidad de Lima, in 1826, by decree of General Santa Cruz. Its first director was the French obstetrician Pauline Cadeau de Fessel, wife of a surgeon who came to work in the country. Her Elementary childbirth course, in its chapter on childbirth practice, describes in detail the anomalous deliveries -shoulder presentation, placental retentions, hemorrhages and uterine inertia-, with rules to control these contingencies, before which the best doctors in Lima had no resources. It was she who paved the way for obstetrics in Peru.

Then, in 1985, by a law signed by Nicolás de Piérola, the chair of clinical gynecology was created in the Faculty of Medicine of the Universidad Nacional Mayor de San Marcos under the direction of Dr. Constantino T. Carvallo, considered the Father of Gynecology. It was his son, Dr. Constantino J. Carvallo who, in 1947, with a group of distinguished physicians dedicated to gynecology and obstetrics, founded the Peruvian Society of Obstetrics and Gynecology. The first cesarean section was performed by Dr. Alberto Barton, in 1900. It is worth mentioning that Dr. Barton was the discoverer of Bartonella bacilliformis. In 1922, part of the old Santa Ana Hospital became the Maternity Hospital of Lima, in charge of the Public Charity, which in 1962 handed it over to the Ministry of Health.

In those years, the former San Bartolomé Military Hospital was transformed into the San Bartolomé Maternal-Children's Hospital, under the direction of Dr. Abraham Ludmir, who was the initiator of prenatal care and organized, in 1962, the first medical residency program in the specialty of gynecology and obstetrics at the Universidad Nacional Mayor de San Marcos⁶. Five years later, in 1967, at the Cayetano Heredia General Hospital, Dr. Manuel Gonzales del Riego started the second program with the Universidad Peruana Cayetano Heredia. Both schools, under the model of the American school, have prepared over the years hundreds of specialists who work throughout the national territory, creating new specialization programs that have allowed remarkable improvements in specialty care.

Public health and family planning

In the public sphere, after Peru's participation in the World Population Conference in Bucharest, the government, under the presidency of General Francisco Morales Bermudez, issued in 1976 by Supreme Decree the Population Policy Guidelines, which was the first official population policy document in our country. Family planning and maternal and child health were highlighted in this document. Objective 2 of the document states 'To achieve a significant reduction in morbidity and mortality, especially of mothers and children, which will allow to increase the quality of life and life expectancy of the entire population'. It also indicates the programming of actions in the areas of education and promotion of responsible parenthood understood as the 'conscious and free choice of couples in determining the dimension of families'. This document was the work of a priest and economist, Juan Julio Wicht.

Although the guidelines really remained a declaration and not an execution, it gave rise to the operation of several non-governmental organizations (NGOs) in the area of research and delivery of family planning services. These included the Marcelino Institute, founded in 1967 in Barrios Altos by Drs. Esteban Kesserú and Alfredo Larrañaga, with support from Fernando Graña and Schering Pharmaceuticals, which not only conducted research in hormonal contraception but also provided family planning services. The Peruvian Association for Family Protection (APPF), initiated by Drs. Carlos Alfaro and Miguel Ramos, with support from USAID, provided services in poor neighborhoods.

In 1978, the Association of Pharmaceutical Laboratories of Peru (ALAFARPE) began its social outreach programs to the community through 3 centers located in José Carlos Mariátegui, Jardín and Delicias de Villa, later incorporating Virgen de Lourdes, all located in the southern cone of the city of Lima. It was an initiative of Dr. Alfredo Brazzoduro, Manager of Roche Laboratories, and its director was Dr. Alfredo Guzmán. It provided maternal and child care and educational talks. Shortly after starting its work, it received support from the Pathfinder Fund to include family planning in the premises and with the new strategy that was applied for the first time in Peru, the community distribution of contraceptives (DCA)⁷. The Asociación de Trabajo Laico Familiar (ATLF), directed by Dr. Guillermo Tagliabue, was also formed to provide family planning information and services, but only with so-called 'natural' methods⁸. The Universidad Peruana Cayetano Heredia set up family planning services in the Arzobispo Loayza and Cayetano Heredia hospitals for teaching and research purposes. In 1979, the General Directorate of Maternal and Child Health and Population was also promoted in the Ministry of Health, under the leadership of Dr. Luis Sobrevilla, and the Family Planning Regulations Manual was approved in December 1980. These were the first steps taken by the Peruvian State in this field⁹. However, its actions in the field of contraception were minimal; the number of users did not exceed 2%.

In 1980, family planning services were initiated at the Edgardo Rebagliati Hospital, the largest hospital of the Peruvian Social Security Institute (IPSS), now EsSalud. Finally, the National Population Council (CNP) was created. This Council and the Ministry initiated a vast communication program on family planning, immunizations and control of childhood diarrheal diseases. In 1985, the National Population Policy Law was enacted. And in 1986, the first Demographic and Family Health Survey (ENDES) was conducted, which provided estimates on fertility levels and trends, aspects of maternal and child care, and contraceptive prevalence.

However, the medical community and medical organizations did not feel very committed to family planning, let alone rationalize its preventive and public health concept. On the other hand, the Church and conservative groups opposed the State's actions on population and family planning. These groups achieved a victory when the Population Policy Law was enacted, by not considering voluntary surgical contraception (VSC) as a method of family planning, placing it in the same category as abortion. This was reversed in 1996. Nevertheless, in the following government, under the APRA administration, the first steps were taken to institutionalize family planning programs in the public sector. In 1987, the first National Family Planning Program was implemented in the IPSS, under the direction of Dr. Alfredo Guzmán. What was transcendental and gave it a very important boost was to grant it the status of a special program, dependent only on the executive presidency of the institution, which allowed it to enjoy administrative and budgetary autonomy. This was achieved through an agreement between the United States Agency for International Development (USAID) and the IPSS. Family planning clinics were installed in all IPSS facilities nationwide. The success of the program led the Minister of Health, Dr. David Tejada, to convene this team and a group of officials from the portfolio to organize the first National Family Planning Program of the Ministry, with Dr. Hilda Garcia as its director. The two programs established a fruitful coordination and cooperation. USAID and the United Nations Population Fund (UNFPA) provided technical and financial cooperation to both programs.

Public health and sexual and reproductive rights

In the 1990s, the government of Alberto Fujimori gave greater support to the national program, increasingly assuming its financing. The National Population Program 1991-1995 was approved. Such was the importance given to the program by this government that it declared 1994 as the Year of Austerity and Family Planning. In 1992, the normative guide for the Comprehensive Care of Pregnant Adolescents was approved. And in September 1996, after an arduous debate in Congress and with the opposition of the Church and conservative groups, the Population Law was modified by a majority vote to include Voluntary Surgical Contraception (VSC) as a method of family planning. In 1996, the National Sex Education Program was restarted by the Ministry of Education and 34,000 primary and secondary school teachers were trained.

In 1996, in order to meet an unsatisfied demand for limiting rather than spacing reproduction, the Ministry of Health designed a joint strategy with the IPSS for maternal and child care and family planning in all regions of the country, with emphasis on voluntary surgical contraception (AQV). These reproductive health campaigns had a pilot plan in the towns of Sayán and Oyón accompanied by a consulting team, which gave recommendations to improve the campaign. In three years, more than 200,000 AQVs were achieved; however, there were complications and 16 deaths that were widely reported in the national and international media, with the consequent scandal. A group of consultants was convened for a rapid assessment in several regions of the country. The report of the consulting group found that the campaigns had not followed the original recommendations, the information provided to the users was not of adequate quality and content, there were cultural and language barriers with the users, the technical capacity of the providers was not homogeneous, the type of anesthesia was not the recommended one and there was a deficient postoperative follow-up. Several corrective measures were taken, including a 72-hour cooling-off period for the signing of the informed consent form, certification of the facilities and surgical equipment suppliers, and the development of a new program called Quality Management. However, this seriously damaged the program.

In 2001, during the transitional government and the administration of Dr. Eduardo Pretell, emergency oral contraception (EOC) was introduced, which was only available in private pharmacies, and the Ministry of Health was allowed to provide it free of charge. There were voices from the Church and conservative groups that considered EOC to be abortifacient. However, EOC was incorporated into the methods provided by the Ministry.

The next administration had a conservative and fundamentalist character. A witch hunt was launched against those who had participated in the AQV campaign, EOC was questioned and the policy guidelines issued, and the terms reproductive health, gender equity and sexuality were eliminated. They stopped providing funding for the purchase of contraceptives, questioned the IUD and condoms with nonoxynol-9 and pointed out that manual vacuum aspiration (MVA) was used to perform abortions in health facilities. All these claims had to be clarified by international cooperation agencies and the World Health Or ganization. MVA was discussed in a high-level commission that finally recommended its release; the Ministry of Justice was of the same opinion, but conservative groups reacted by filing an injunction in the Supreme Court against the Ministry of Health, despite the fact that several scientific studies showed that MVA was not abortifacient and was safe and effective. This was eventually overcome, but at present there are still attempts to remove it from the national guidelines.

The last battle won in the field of reproductive health was the approval by the Ministry of the therapeutic abortion protocol for those cases in which a pregnancy would affect the life and health of the pregnant woman. This again caused great opposition, despite the fact that clandestine abortions due to unwanted pregnancy are a cause of high morbidity and mortality in our country. The implementation of the protocol has not been easy, since there are also barriers within the health personnel themselves. However, it is provided in three large national hospitals and in at least four regions of the country¹⁰.

As we have seen throughout these lines, public health since its beginnings in the country, almost a century ago, has allowed the improvement of the living conditions of the population, a task that is not yet finished, since we continue to be plagued in many regions by communicable diseases already eradicated in many countries. The conditions of poverty and vulnerability of many population groups, especially in rural Amazonian and scattered areas of our territory, make the task difficult. To this, we must add chronic and degenerative diseases, especially in a growing elderly population. What we can affirm is that public health, in its broadest concept, covers sexual and reproductive rights, which have allowed the development of public programs and services that have improved the health conditions of Peruvian women and the exercise of their rights to live a full and healthy reproductive health and sexuality.