HISTORY OF AMERICAN PUBLIC HEALTH Jonathon Erlen

1
HISTORY OF AMERICAN PUBLIC HEALTH Jonathon Erlen
2
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.
3
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.
4
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.
5
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.
6
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.
7
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.
8
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.
9
This debate over the Constitutionality of federal
intervention in pubic health explains the
national governments 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.

10
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.
11
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.
12
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.
13
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 citys
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.
14
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 Philadelphias harbor,
thus closing down the city's lucrative shipping
commerce.
15
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.
16
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.
17
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.
18
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.
19
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.
20
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.
21
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.
22
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.
23
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 meetings 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.
24
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.
25
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.
26
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
Americas 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.
27
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.
28
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
governments 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.
29
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.
30
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 Americas cities.
31
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.
32
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.
33
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.
34
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 fever was 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.
35
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.
36
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 Healths
authority transferred to his own federal agency -
a goal that he succeeded in accomplishing.
37
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.
38
Americas 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 Americas first
diagnostic laboratory, under the guidance of
Charles Chapin.
39
The concept of the diagnostic laboratories
spearheaded Americas 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.
40
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.
41
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.
42
Yet during this 25 year period the main public
health focus centered on the federal governments
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 governments
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 Americas food and drug industries.
43
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.
44
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.
45
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.
46
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.
47
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.