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HISTORY OF AMERICAN PUBLIC HEALTH Jonathon Erlen.
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The evolution of American public health strongly effected the development of medicine and health care. As we examine the growth of this health care specialty it is necessary to combine materials from political, Constitutional, social, and economic history to explain the progress, or lack of progress, in the public health field. Because of the tremendous scope of public health, fully justifying an entire course and not merely 2 lectures, I intend to focus on some of the major public health problems as they were perceived by American society at different points in our history and the attempts by both private and governmental groups to create effective administrative machinery to handle these large‑scale public health problems.
Public health has a 2-fold mission: (1.) the prevention of diseases and health care problems, particularly those which are communicable or of potential epidemic proportions i.e.: polio, AIDS, and car accidents; and (2.) the treatment of these illnesses after the fact i.e.: the Red Cross work here in western Pennsylvania after the recent floods.
Public health has 2 major strands. One is the striving through research to achieve scientific medical advances in understanding the nature and causes of diseases and how to prevent and cure them. The second, and the 1 we will focus on, is the economic, political, and the social policies of society which dictate the application of this knowledge. As I hope to convince you it is this second strand of public health which has had the greatest impact on the evolution of American public health from the colonial period to today.
When we look back on colonial America we find only the rudimentary beginnings of what today we term public health. Colonial America was a rural society with few of the public health problems which would come with 19th and 20th century urbanization. In the small towns there were only spotty efforts to collect garbage and dispose of sewage, 2 major public health concerns which remained of primary importance until the start of the 20th century.
The main public health issue in colonial America was how to deal with the periodic epidemics of various communicable diseases, such as smallpox and yellow fever. As we have seen in earlier lectures, the threat of an approaching epidemic was sufficient to cause widespread panic in colonial communities. The colonial governments adopted 3 specific public health measures to deal with this major health threat: (1.) the isolation of the sick in their own homes or in community funded pest-houses; (2.) the passing of quarantine laws to prevent potential disease-carrying ships from entering ports; and (3.) a limited amount of what was termed disinfection.
These, then, were the types of public health measures taken during the colonial period. There was no permanent public health administrative machinery created either at the local or colonial levels. Quarantine officers, beginning with Dr. Gilbert Guttery in 1712 Charleston, were appointed only during times of emergency. The single most effective public health measure begun during the 17th and 18th centuries was the use of variolation against smallpox, but even this beneficial effort was carried out only sporadically. The first temporary board of health was not created until 1780 in Petersburgh, VA., and no large American city created a board of health until N.Y.C. adopted this approach to its public health problems in 1796.
With the creation of the U.S. with its federal governmental structure following the Revolutionary War there was, for the first time, the opportunity for a nationally organized approach to major public health issues. However, this was not to occur until well into the 20th century. To understand why there was this 1 and a half centuries lack of effective federal involvement in public health we need to look at the Constitution itself. In this document Article X gives all powers not expressly given to the federal government to the state governments. Since public health and medicine are not expressly mentioned in the Constitution this meant all public health matters fell solely under individual state control.
This debate over the Constitutionality of federal intervention in pubic health explains the national government’s relative inaction throughout the 19th century, despite at times desperate public outcries for assistance, such as the calls from Philadelphia in 1800 and N.Y.C. in 1802 for a national quarantine law. The only major federal public health action prior to the Civil War was the 1798 creation of the Marine Hospital Service to help care for ailing merchant seamen. This federal organization, which would eventually become in the 20th century the U.S.P.H. Service, was poorly administered and under financed throughout the 19th century, thus performing little if any public health functions.
There was little effective public health work accomplished prior to the Civil War, though the 3 main factors which were to create modern public health problems were well underway during this period. These 3 trends, which began in large‑scale after 1820, were urbanization, immigration, and industrialization. It was not until the United States began changing from a rural, agrarian society to an urban, industrial society fueled by the masses of European immigrants that public health became a key factor in American health care. Both public health problems and the efforts to reform these health care issues centered on America's emerging cities.
When we look at the early efforts at public health reforms the reasons for their failures become readily apparent. One reason, as we have already mentioned, was the poorly defined governmental responsibility in regards to pubic health matters: was it federal or state or local? A second factor was the widespread political corruption in local and state governments, thus what funds there were for provided for public health work were often diverted into the pockets of political hacks. Thirdly, the concept of any governmental body paying for pubic health-related efforts went against the 19th century American laissez-faire economic system which believed that individual's were solely responsible for their own well-being. Fourth and finally was the low level of medical knowledge regarding the prevention and handling of public health problems.
The major impetus for 19th century public health reforms came from the general public's fear of and reactions to the various epidemics which periodically struck America's rapidly growing cities. While the public came to accept the public health problems of high infant mortality, polluted water, foul‑smelling air, and overcrowding as everyday factors of life, the sudden appearance of an epidemic, which produced tremendous losses both in terms of life and of economic losses, created a strong demand for direct governmental public health responses.
The ships fro, Santo Domingo carried the mosquitoes which serves as the vector for yellow fever, but the local medical community found many other potential causes for this epidemic, as Noah Webster, one of the city’s leading physicians said: malignant distempers; “Infection is a subordinate cause of the propagating of; but is itself an effect of some more general cause, whose force is a hundred fold more powerful and formidable than that of infection.”
The effects of the epidemic on Philadelphia between August and November, 1793, was truly staggering. By Sept. 1, 300 persons had died of yellow fever; between that date and the mid-point of October another 1,400 had perished. On October 11, the worst day of the epidemic, 119 deaths were reported. The result was that the city, for all purposes, closed down. Congress left Philadelphia and temporarily resettled in Germantown PA. President Washington retreated to his home at Mount Vernon, and around 1/3 of the city's populace fled for the supposed security of the countryside or for other towns. Foreign ships refused to dock in Philadelphia’s harbor, thus closing down the city's lucrative shipping commerce.
To meet this drastic health crisis the College of Physicians came out with the following medical advise for the citizenry. The populace told to avoid infected persons, place placards on homes of the sick as a warning, not to over eat or over drink, to avoid exposure to currents of air, especially evening air, put vinegar and camphor on handkerchiefs, not to toll bells, and to have all funerals as private as possible. Rush recommended his patients chew garlic. He also called upon his old favorite remedies, calomel and bloodletting' which he used on all his patients and encouraged his colleagues to do likewise.
There was also a political side to the debate over this 1793 epidemic between the factions who believed that yellow fever came from local causes and those who thought it had arrived from foreign ports. In the 1790's American politics were divided between the Federalists, who opposed the ideas stemming from the French Revolution, and the Jeffersonian Republicans, who sought to foster close ties with France. With the outbreak of yellow fever in 1793 Philadelphia, community doctors divided along political lines. The Federalist physicians blamed the epidemic on French commerce from Santo Domingo and tried to have all commerce with this and other French ports stopped.
From this public clamor emerged early the United States’ first boards of health which attempted to handle these emergency public health situations. In ante-bellum America these boards of health were only temporary administrative organizations, as a combination of political opposition, public apathy, and medical indifference killed any chance to create permanent public health administrative machinery.
Despite the overall low level of public health in pre-Civil War America there were reformers, both physicians and concerned laymen, who pointed out many of the mayor public health problems if their times, as well as potential answers to these increasing health menaces. As early as 1820 Dr. David Hosack of N.Y.C. called for 7 major urban public health reforms: 1) better nutrition; 2) an effective sewage disposal system; 3) improved housing for the poor; 4) use of stone instead of wood in buildings; 5) wider streets; 6) better constructed docks and wharves; 7) and limited burials inside of the city.
The 1840's and '50's saw an increase in public health reforming zeal created by 4 factors. One was the reports of successful public health reforms coming from Great Britain. We could spend an entire class on the British public health movement and its impact on the United States. Great Britain had faced the public health crisis created by sudden urbanization and industrialization a century before the United States.
Under the enlightened leadership of reformers such as Edwin Chadwick, whose 1842 classic, General Report on the Sanitary Conditions of the Labouring Population, became the inspiration for American public health reformers, Parliament in 1848 created the General Board of Health, the first mayor piece of modern public health legislation in the Western world. Reports of British public health successes greatly impressed American public health leaders.Secondly this was a period of heightened crusading fervor in American society, as the public embraced a wide range of worthy causes, such as anti-slavery and temperance, as well as public health.
The Massachusetts Medical Association in 1849 funded the major American public health document published prior to the Civil War, the report by Lemuel Shattuck on the state of Massachusetts’ public health, which was published in 1850. This detailed report discussed the history of and the current public health issues of his time and suggested potential solutions to these issues, basing these views on the economic success of public health reforms, following Shattuck's outline for public health reform.
Despite this temporary setback, public health reform received a major boost from the public uproar surrounding the 1853 yellow fever epidemic which devastated New Orleans, killing over 9,000 citizens. The ineffectiveness of all state quarantine measures, such as Louisiana's, inspired Dr. Wilson Jewell of Philadelphia to have the temporary Philadelphia Board of Health, in 1856, call for the first national public health meeting to discuss this quarantine issue. Jewell opened the 1857 Quarantine Convention with the following statement.
The success of this first national public health meeting lead to an annual gathering of medical and lay public health leaders for the next 3 years. At each of these meetings the initial subject of quarantine was broadened to encompass ever-wider public health concerns, as illustrated by the meeting’s changing names in 1858 it was called the Quarantine and Sanitary Convention, and in 1859 and 1860 the name was changed to the National Quarantine and Sanitary Conventions. The 1861 meeting was scheduled for May, 1861 in Cincinnati, but the Civil War intervened, ending the existence of these national public health conventions. Yet we can say that they were the direct forerunners of the APHA which would be created in 1872.
With the outbreak of the Civil War, public health reformers shifted their attention from the general public health needs of urban America to the unique public health problems created by the war. The reports of the British Sanitary Commission from the Crimean War gave the United States guidelines for appropriate public health activities to undertake during the Civil War. The U.S. Sanitary Commission was responsible for most of the public health activities during this conflict. Even though the war meant the end of the national public health conventions and shifted public interest from major urban public health reform needs, we can find 7 positive points for public health advances emerging from the this conflict.
First, through the efforts of the U.S. Sanitary Commission there were major gains made in providing pure water and better nutrition for the Northern troops, thus saving many lives. Secondly, young army medical officers received training in public health ideas which they would use after the war in the emerging public health movement. Thirdly, a large number of civilians became actively involved in the public health movement through their wartime efforts. Thus the Civil War can be viewed as the beginning of large-scale volunteer health associations i.e.: the American Red Cross founded in 1882 by Clara Barton, who got her start in the health field during the Civil War serving as a nurse. Women's groups organized sanitary fairs and more than 15,000 soldiers' aid societies in the North to help the war causes.
AMERICAN PUBLIC HEALTH IIThe 5 years following the Civil War saw 2 critical breakthroughs in American public health. The first occurred in N.Y.C., probably the site of America’s worse public health abuses. In 1860 N.Y.C. had circa 20,000 people living in underground dark, dank cellars. Efforts to reform these conditions were thrawted by the immensity of the public health problems and the political opposition by the corrupt Tammany Hall political machine which ran N.Y.C.
The second breakthrough occurred in 1869 when the state of Massachusetts created the first actual state board of health. Although Louisiana had a state board of health dating from 1855, it only really was effective in the area in and around New Orleans, whereas the Massachusetts state board of health was the prototype for all future state boards of health. By 1890 there were 28 state boards of health patterned after Massachusetts’ model. Thus by 1870 the appropriate state and local public health administrative machinery had been created and would quickly be copied throughout the United States. What remained was for national level public health organizations to be created, and this would be the success and failure of the 1870's public health efforts.
In many ways the period between 1870 and 1895 was an unlikely era for public health reform, both in terms of new public health problems created in these decades and the public's and the federal government’s continued refusals to confront both old and new public health issues. The United States was becoming more and more an industrial rather than an agrarian society. In the 1880's American industrial output supplanted agricultural goods as this country's main export, and circa 1890 the United States replaced Great Britain as the world's leading industrial nation.
The urban population increased explosively, from 23 million in 1850 to 106 million by 1920, an increases of 357%. This tremendous growth came from 2 sources: immigration from abroad, and the influx of rural population into the cities seeking jobs, as between 1880 and 1920 figures showed 15 million people moving into cities from the country. This influx of humanity made American cities the most crowded in the world i.e.: in 1894 N.Y.C. there were 986.4 persons/acre as compared to 759.7 persons/acre in Bombay, India at that time. Infant mortality in N.Y.C. was 65% higher in 1870 than it had been in 1810. By 1900 infant mortality had reached as high as 317/1000 in sections of some American cities.
Even engineering progress created new public health dangers, as the development of balloon frame steel girder buildings with elevators made high-rise slums available in American cities. Within big cities horse-drawn transportation created a major public health nuisances for city streets and air. On the average a horse discharged gallons of urine and circa 20 pounds of fetal matter/day. Multiply this times 100,000 and you get the conditions in the mid to later 1880's in America’s cities.
The 1870's, from an historical standpoint, seemed the most unlikely decade for the major public health reforms which were implemented. The United States was undergoing the end of the political Reconstruction period following the Civil War, thus the nation was still adjusting to the post‑war political climate. Between 1873 and 1878 the United States also endured its first modern economic depression, throwing the country into financial panic.
Even with all these negative factors the 1870's saw more public health reform impetus than any decade in the 19th century. The first positive action took place in 1870 when Congress finally reorganized the Marine Hospital Service for the first time since its creation in 1798. During that interval the Marine Hospital Service had spent $3 million to build and operate 31 hospitals, but because of incompetence and local bickering, only 9 hospitals were still functioning in 1870. The reorganization act of 1870 created a supervising Surgeon-General to oversee all operations and to assure that the Marine Hospital Service would now function as a national rather than a local government agency.
An even more auspicious event occurred in 1872 with the founding of the APHA. Under the leadership of Dr. Steven Smith, who we mentioned earlier as the chief supporter of the Metropolitan Health Bill in 1866 N.Y.C., the APHA held its first meeting in 1872. From the beginning this association combined the public health skills and interests of a wide group of talents, including physicians, sanitary engineers, and other interested lay people. The main goal of the APHA at that time was to encourage the creation of state and local boards of health. By the end of this decade this focus had changed to encompass the creation o£ a national public health organization within the federal government.
The final event foreshadowing the creation of a federal public health agency was the massive yellow fever epidemic which struck all the large Southern cities in 1878. With steamboats now making regular runs to Cuba and the West Indies, where yellow feverwas always present, it appears to us today that it was only a matter of time before this disease was brought into a Southern port. On May 21, 1878, the ship Emily B. Sounder arrived at a Louisiana quarantine station. This station failed to detain this ship, despite the fact that there was at least 1 known case of yellow fever aboard. The resulting epidemic was 1 of the worst in American history.
Congress had passed the Bromberg Bill -the National Quarantine Act ‑ in 1878, but this watered-down measure still maintained the power of state quarantine laws over federal intervention and provided no funds to implement any quarantine activities, thus it was an empty gesture to the South which had sought much stronger legislation. The APHA was also pressuring Congress for actions to create a federal public health agency. Under all these pressures Congress finally relented and created the National Board of Health in 1879.
Looking back on the failure of the National Board of Health we can see 5 reasons for its demise. First and foremost was the fact that Congress never really wanted the National Board of Health to succeed, but had created this extremely weak government agency only to placate public pressures following the 1878 yellow fever epidemic. Secondly, the National Board of Health was undermined politically by the work of the surgeon‑general of the Marine Health Service who hoped to get the National Board of Health’s authority transferred to his own federal agency - a goal that he succeeded in accomplishing.
With the hope of a centralized federal public health agency at least temporarily ended, the American public health movement fell back to advancing on the state, not the national level. The major advances of the 1880's were made in the laboratories rather than in the federal or state legislatures. It was during the 1880's that European scientists were able to isolate the disease-producing organisms that caused such major communicable diseases as typhoid fever, diphtheria, tetanus, tuberculosis, and cholera, among others.
America’s first course in bacteriology was taught in 1884, and in 1886 the Massachusetts State Board of Health opened the Lawrence Experiment Station under the leadership of William T. Sedgwick. This important public health educational and research institution became the center for the training of sanitary engineers and for studying new techniques in water purification and sewage disposal. In 1888 Providence, R.I. began operating America’s first diagnostic laboratory, under the guidance of Charles Chapin.
The concept of the diagnostic laboratories spearheaded America’s new scientific approach to public health which would continue into the 20th century. Diagnostic laboratories were created in every large American city during the 1890's and the early 1900's with 3 primary functions: 1) the diagnosis of potential communicable diseases ‑the direct forerunner of today's Communicable Disease Control Center in Atlanta; 2) research into methods of disease transmission; 3) and providing serums and antitoxins to end the danger of massive epidemics which had been so prevalent in 19th century America.
With the growing acceptance of the germ theory of disease causation in the 1890's and the emergence of the diagnostic laboratories as the focal point of public health activities, the American public health movement underwent several major changes. The main emphasis, which during much of the 19th century had been on cleaning up the environment, now shifted to direct control of communicable diseases. This new emphasis placed a growing amount of authority in the public health movement with the physicians involved with public health work, and the interested lay public which before had played a direct role in public health activities were being forced into a new approach to helping with the public health field, namely, the creation of voluntary health associations.
Returning to the national picture, the period between 1895 to 1920, as I have mentioned in earlier lectures, was termed the Progressive Era. During this quarter of a century the United States finally began to accept its emerging urban rather than agrarian focus and to come to grips with some of the problems created by wide‑spread urbanization. This included public health issues. We can see a number of major success in public health reforms undertaken during this period, with many being at the local or state levels. I want to mention only a few of these public health reforms to indicate the breath of scope of the public health movement during the Progressive Era.
Yet during this 25 year period the main public health focus centered on the federal government’s willingness to finally accept some measure of responsibility for the country's public health activities. A number of pioneering public health related bills were passed by Congress which laid the groundwork for the federal government’s current role in public health work. In 1893 Congress finally passed an effective maritime quarantine act, thus overcoming states rights opposition in this critical matter. Those of you who have read The Jungle or The Octopus by Upton Sinclair, or other writings by the leading muckraker journalists of that era understand some of the terrible problems which existed in America’s food and drug industries.
It was also during the Progressive Era that the federal government restructured its administrative machinery to deal with public health matters. In 1902 Congress placed most of the existing federal public health responsibilities under the Marine Hospital Service and renamed this agency the Public Health and Marine Hospital Service. While this was a step in the right direction, public health leaders in the APHA and the AMA wanted a stronger, independent cabinet level public health federal agency. This lead to a struggle during the following decade between those favoring a new, stronger public health agency and the old leadership of the Marine Hospital Service who sought to retain their authority over public health activities.
Opposing the Owens Bill were Walter Wyman, surgeon-general of the Public Health and Marine Hospital Service, and the advocates of a states rights approach to public health administration, such as John L. Bates from the National League for Medical Freedom. The opponents of the Owens Bill claimed that it was unconstitutional, threatened the principle of states rights, and would allow the AMA to created a medical monopoly. The opposition forces mounted an extensive and expensive newspaper campaign which succeeded in defeating the Owens Bill by having it tabled in committee.
The story of the evolution of American public health for the remainder of the 20th century up to today is one of the federal government assuming ever increasing responsibility and authority for public health activities at all levels. Interestingly enough the past sixty plus years has also seen a narrowing of the scope of public health activities caused by the growing power of the AMA and the Am. medical community in general, which after W.W.I came to see organized public health efforts to treat sick portions of the public as a economic threat to their livelihood, much as organized medicine had opposed the neighborhood dispensaries earlier in the 20th century.
The 1935 Social Security Act. provided, for the first time, long-range federal grant ‑in aids to state governments. for public health activities, such as maternal and child care, aid to crippled children, and assistance to the blind. The 1939 Reorganization Act transferred the Public Health Service from the Treasury Department to the newly created Federal Security Agency. The 1944 Public Health Service Act consolidated all public health service authority into a single statute. The Public Health Service was transferred in 1953 to the Department of HEW, where it remained until the creation of the Department of Health and Welfare during the Reagan administration.
The federal laws passed since W.W.II pertaining to some aspect of public health are too numerous even to list. Fed. funding has been provided for such diverse public health activities as environmental pollution control, health assistance for particular needy groups in society i.e. Medicare, Medicaid, and research on individual diseases, such as cancer and heart disease. Societal, economic, and political pressures still determine, to a great extent, the scope of current public health actions undertaken by the federal government i.e.: the 1973 energy crisis undercut pollution control 1aws end our current concern over reliance on overseas energy is forcing us to face a new potentially dangerous public health issue at home, namely the use of nuclear energy and the current attack on the tobacco industry.
