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OCR for page 56
A History of the
Public Health System
In Chapter 1, the committee found that the current public health system
must play a critical role in handling major threats to the public health, but
that this system is currently in disarray. Chapter 2 explained the committee's
ideal for the public health system-how it should be arranged for handling
current and future threats to health. In this chapter the history of the existing
public health system is briefly described. This history is intended to provide
some perspective on how protection of citizens from health threats came to
be a public responsibility and on how the public health system came to be in
its current state.
HISTORY
During the past 150 years, two factors have shaped the modern public
health system: first, the growth of scientific knowledge about sources and
means of controlling disease; second, the growth of public acceptance of
disease control as both a possibility and a public responsibility. In earlier
centuries, when little was known about the causes of disease, society tended
to regard illness with a degree of resignation, and few public actions were
taken. As understanding of sources of contagion and means of controlling
disease became more refined, more effective interventions against health
threats were developed. Public organizations and agencies were formed to
employ newly discovered interventions against health threats. As scientific
knowledge grew, public authorities expanded to take on new tasks, including
sanitation, immunization, regulation, health education, and personal health
care. (shave, 1984; Fee, 1987)
56
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A HISTORY OF THE PUBLIC HEALTH SYSTEM
57
The link between science, the development of interventions, and organi-
zation of public authorities to employ interventions was increased public
understanding of and social commitment to enhancing health. The growth of
a public system for protecting health depended both on scientific discovery
and social action. Understanding of disease made public measures to allevi-
ate pain and suffering possible, and social values about the worthiness of this
goal made public measures feasible. The history of the public health system
is a history of bringing knowledge and values together in the public arena to
shape an approach to health problems.
BEFORE THE EIGHTEENTH CENTURY
Throughout recorded history, epidemics such as the plague, cholera, and
smallpox evoked sporadic public efforts to protect citizens in the face of a
dread disease. Although epidemic disease was often considered a sign of
poor moral and spiritual condition, to be mediated through prayer and piety,
some public effort was made to contain the epidemic spread of specific
disease through isolation of the ill and quarantine of travelers. In the late
seventeenth century, several European cities appointed public authorities to
adopt and enforce isolation and quarantine measures (and to report and
record deaths from the plague). (Goudsblom, 1986)
THE EIGHTEENTH CENTURY
By the eighteenth century, isolation of the ill and quarantine of the
exposed became common measures for containing specified contagious dis-
eases. Several American port cities adopted rules for trade quarantine and
isolation of the sick. In 1701 Massachusetts passed laws for isolation of
smallpox patients and for ship quarantine as needed. (After 1721, inocula-
tion with material from smallpox scabs was also accepted as an effective
means of containing this disease once the threat of an epidemic was de-
clared.) By the end of the eighteenth century, several cities, including
Boston, Philadelphia, New York, and Baltimore, had established perma-
nent councils to enforce quarantine and isolation rules. (Hanlon and Pickett,
1984) These eighteenth-century initiatives reflected new ideas about both
the cause and meaning of disease. Diseases were seen less as natural effects
of the human condition and more as potentially controllable through public
action.
Also in the eighteenth century, cities began to establish voluntary general
hospitals for the physically ill and public institutions for the care of the
mentally ill. Finally, physically and mentally ill dependents were cared for by
their neighbors in local communities. This practice was made official in
England with the adoption of the 1601 Poor Law and continued in the
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58
THE FUTURE OF PUBLIC HEALTH
American colonies. (Grob, 1966; Starr, 1982) By the eighteenth century,
several communities had reached a size that demanded more formal ar-
rangements for care of their ill than Poor Law practices. The first American
voluntary hospitals were established in Philadelphia in 1752 and in New
York in 1771. The first public mental hospital was established in Wil-
liamsburg, Virginia in 1773. (Turner, 1977)
THE NINETEEN rH CENTURY: THE GREAT SANITARY AWAKENING
The nineteenth century marked a great advance in public health. "The
great sanitary awakening" (Winslow, 1923) the identification of filth as
both a cause of disease and a vehicle of transmission and the ensuing
embrace of cleanliness was a central component of nineteenth-century
social reforms. Sanitation changed the way society thought about health.
Illness came to be seen as an indicator of poor social and environmental
conditions, as well as poor moral and spiritual conditions. Cleanliness was
embraced as a path both to physical and moral health. Cleanliness, piety,
and isolation were seen to be compatible and mutually reinforcing measures
to help the public resist disease. At the same time, mental institutions
became oriented toward "moral treatment" and cure.
Sanitation also changed the way society thought about public respon-
sibility for citizen's health. Protecting health became a social responsibility.
Disease control continued to focus on epidemics, but the manner of control-
ling turned from quarantine and isolation of the individual to cleaning up
and improving the common environment. And disease control shifted from
reacting to intermittent outbreaks to continuing measures for prevention.
With sanitation, public health became a societal goal and protecting health
became a public activity.
The Sanitary Problem
With increasing urbanization of the population in the nineteenth century,
filthy environmental conditions became common in working class areas, and
the spread of disease became rampant. In London, for example, smallpox,
cholera, typhoid, and tuberculosis reached unprecedented levels. It was
estimated that as many as 1 person in 10 died of smallpox. More than half the
working class died before their fifth birthday. Meanwhile, "In the summers
of 1858 and 1859 the Thames stank so badly as to rise 'to the height of an
historic event . . . for months together the topic almost monopolized the
public prints'." (Winslow, 1923) London was not alone in this dilemma. In
New York, as late as 1865, "the filth and garbage accumulate in the streets to
the depth sometimes of two or three feet." In a 2-week survey of tenements
in the sixteenth ward of New York, inspectors found more than 1,200 cases of
smallpox and more than 2,000 cases of typhus. (Winslow, 1923) In Massa
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A HISTORY OF THE PUBLIC HEALTH SYSTEM
59
chusetts in 1850, deaths from tuberculosis were 300 per 100,000 population,
and infant mortality was about 200 per 1,000 live births. (Hanlon and
Pickett, 1984)
Earlier measures of isolation and quarantine during specific disease out-
breaks were clearly inadequate in an urban society. It was simply impossible
to isolate crowded slum dwellers or quarantine citizens who could not afford
to stop working. (Wohl, 1983) It also became clear that diseases were not just
imported from other shores, but were internally generated. "The belief that
epidemic disease posed only occasional threats to an otherwise healthy
social order was shaken by the industrial transformation of the nineteenth
century." (Fee, 1987) Industrialization, with its overburdened workforce
and crowded dwellings, produced both a population more susceptible to
disease and conditions in which disease was more easily transmitted. (Wohl,
1983) Urbanization, and the resulting concentration of filth, was considered
in and of itself a cause of disease. "In the absence of specific etiological
concepts, the social and physical conditions which accompanied urbaniza-
tion were considered equally responsible for the impairment of vital bodily
functions and premature death." (Rosenkrantz, 1972)
At the same time, public responsibility for the health of the population
became more acceptable and fiscally possible. In earlier centuries, disease
was more readily identified as only the plight of the impoverished and
immoral. The plague had been regarded as a disease of the poor; the wealthy
could retreat to country estates and, in essence, quarantine themselves. In
the urbanized nineteenth century, it became obvious that the wealthy could
not escape contact with the poor. "Increasingly, it dawned upon the rich that
they could not ignore the plight of the poor; the proximity of gold coast and
slum was too close." (Goudsblom, 1986) And the spread of contagious
disease in these cities was not selective. Almost all families lost children to
diphtheria, smallpox, or other infectious diseases. Because of the the deplor-
able social and environmental conditions and the constant threat of disease
spread, diseases came to be considered an indicator of a societal problem as
well as a personal problem. "Poverty and disease could no longer be treated
simply as individual failings." (Fee, 1987) This view included not only
contagious disease, but mental illness as well. Insanity came to be viewed at
least in part as a societal failing, caused by physical, moral, and social
tensions.
The Development of Public Activities in Health
Edwin Chadwick, a London lawyer and secretary of the Poor Law Com-
mission in 1838, is one of the most recognized names in the sanitary reform
movement. Under Chadwick's authority, the commission conducted studies
of the life and health of the London working class in 1838 and that of the
entire country in 1842. The report of these studies, General Report on the
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60
THE FUTURE OF PUBLIC HEALTH
Sanitary Conditions of the Labouring Population of Great Britain, "was a
damning and fully documented indictment of the appalling conditions in
which masses of the working people were compelled to live, and die, in the
industrial towns and rural areas of the Kingdom." (shave, 1984) Chadwick
documented that the average age at death for the gentry was 36 years; for the
tradesmen, 22 years; and for the laborers, only 16 years. (Hanlon and
Pickett, 1984) To remedy the situation, Chadwick proposed what came to be
known as the "sanitary idea." His remedy was based on the assumption that
diseases are caused by foul air from the decomposition of waste. To remove
disease, therefore, it was necessary to build a drainage network to remove
sewage and waste. Further, Chadwick proposed that a national board of
health, local boards in each district, and district medical officers be appoin-
ted to accomplish this goal. (shave, 1984)
Chadwick's report was quite controversial, but eventually many of his
suggestions were adopted in the Public Health Act of 1848. The report,
which influenced later developments in public health in England and the
United States, documented the extent of disease and suffering in the popula-
tion, promoted sanitation and engineering as means of controlling disease,
and laid the foundation for public infrastructure for combating and prevent-
ing contagious disease.
In the United States, similar studies were taking place. Inspired in part by
Chadwick, local sanitary surveys were conducted in several cities. The most
famous of these was a survey conducted by Lemuel Shattuck, a Massa-
chusetts bookseller and statistician. His Report of the Massachusetts Sanitary
Commission was published in 1850. Shattuck collected vital statistics on the
Massachusetts population, documenting differences in morbidity and mor-
tality rates in different localities. He attributed these differences to
urbanization, specifically the foulness of the air created by decay of waste in
areas of dense population, and to immoral life-style. He showed that the
poor living conditions in the city threatened the entire community. "Even
those persons who attempted to maintain clean and decent homes were
foiled in their efforts to resist diseases if the behavior of others invited the
visitation of epidemics." (Rosenkrantz, 1972)
Shattuck considered immorality an important influence on susceptibility
to ill health and in fact drunkenness and sloth did often lead to poor health
in the slums-but he believed that these conditions were threatening to all.
Further, Shattuck determined that those most likely to be affected by disease
were also those who, either through ignorance or lack of concern, failed to
take personal responsibility for cleanliness and sanitation of their area.
(Rosenkrantz, 1972) Consequently, he argued that the city or the state had
to take responsibility for the environment. Shattuck's Report of the Massa-
chusetts Sanitary Commission recommended, in its "Plan for a Sanitary
Survey of the State," a comprehensive public health system for the state.
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A HISTORY OF THE PUBLIC HEALTH SYSTEM
61
The report recommended, among other things, new census schedules; regu-
lar surveys of local health conditions; supervision of water supplies and waste
disposal; special studies on specific diseases, including tuberculosis and
alcoholism; education of health providers in preventive medicine; local
sanitary associations for collecting and distributing information; and the
establishment of a state board of health and local boards of health to enforce
sanitary regulations. (Winslow, 1923; Rosenkrantz, 1972)
Shattuck's report was widely circulated after publication, but because of
political upheaval at the time of release nothing was done. The report "fell
flat from the printer's hand." In the years following the Civil War, however,
the creation of special agencies became a more common method of handling
societal problems. Massachusetts set up a state board of health in 1869. The
creation of this board reflected more a trend of strengthened government
than new knowledge about the causes and control of disease. Nevertheless,
the type of data collected by Shattuck was used to justify the board. And the
board relied on many of the recommendations of Shattuck's report for
shaping a public health system. (Rosenkrantz, 1972; Hanlon and Pickett,
1984) Although largely ignored at the time of its release, Shattuck's report
has come to be considered one of the most farsighted and influential docu-
ments in the history of the American public health system. Many of the
principles and activities he proposed later came to be considered fundamen-
tal to public health. And Shattuck established the fundamental usefulness of
keeping records and vital statistics.
Similarly, in New York, John Griscom published The Sanitary Condition
of the Labouring Population of New York in 1848. This report eventually led
to the establishment of the first public agency for health, the New York City
Health Department, in 1866. During this same period, boards of health were
established in Louisiana, California, the District of Columbia, Virginia,
Minnesota, Maryland, and Alabama. (Fee, 1987; Hanlon and Pickett, 1984)
By the end of the nineteenth century, 40 states and several local areas had
established health departments.
Although the specific mechanisms of diseases were still poorly under-
stood, collective action against contagious disease proved to be successful.
For example, cholera was known to be a waterborne disease, but the precise
agent of infection was not known at this time. The sanitary reform movement
brought more water to cities in the mid-nineteenth century, through private
contractors and eventually through reservoirs and municipal water supplies,
but its usefulness did not depend primarily on its purity for consumption, but
its availability for washing and fire protection. (Blake, 1956) Nonetheless,
sanitary efforts of the New York Board of Health in 1866, including inspec-
tions, immediate case reporting, complaint investigations, evacuations, and
disinfection of possessions and living quarters, kept an outbreak of cholera
to a small number of cases. "The mildness of the epidemic was no more a
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62
THE FUTURE OF PUBLIC HEALTH
stroke of good fortune, observers agreed, but the result of careful planning
and hard work by the new health board." (Rosenberg, 1962) Cities without a
public system for monitoring and combatting the disease fared far worse in
the 1866 epidemic.
During this period, states also established more public institutions for care
of the mentally ill. Dorothea Dix, a retired school teacher from Maine, is the
most familiar name in the reform movement for care of the mentally ill. In
the early nineteenth century, under Poor Law practices, communities that
could not place their poor mentally ill citizens in more appropriate institu-
tions put them in municipal jails and almshouses. Beginning in the middle of
the century, Dix led a crusade to publicize the inhumane treatment mentally
ill citizens were receiving in jails and campaigned for the establishment of
more public institutions for care of the insane. In the nineteenth century,
mental illness was considered a combination of inherited characteristics,
medical problems, and social, intellectual, moral, and economic failures. It
was believed, despite the prejudice that the poor and foreign-born were
more likely to be mentally ill, that moral treatment in a humane social setting
could cure mental illness. Dix and others argued that in the long run
institutional care was cheaper for the community. The mentally ill could be
treated and cured in an institution, making continuing public support unnec-
essary. Some 32 public institutions were established due to Oix's efforts.
Although the practice of moral treatment proved to be less successful than
hoped, the nineteenth-century social reform movement established the
principle of state responsibility for the indigent mentally ill. (Grob, 1966;
Foley and Sharfstein, 1983)
New ideas about causes of disease and about social responsibility stimu-
lated the development of public health agencies and institutions. As environ-
mental and social causes of diseases were identified, social action appeared
to be an effective way to control diseases. When health was no longer simply
an individual responsibility, it became necessary to form public boards,
agencies, and institutions to protect the health of citizens. Sanitary and
social reform provided the basis for the formation of public health organiza-
tions.
Public health agencies and institutions started at the local and state levels
in the United States. Federal activities in health were limited to the Marine
Hospital Service, a system of public hospitals for the care of merchant
seamen. Because merchant seamen had no local citizenship, the federal
government took on the responsibility of providing their health care. A
national board of health, which was intended to take over the responsibilities
of the Marine Hospital Service, was adopted in 1879, but, opposed by the
Marine Hospital Service and many southern states, the board lasted only
until 1883 (Anderson, 1985) Meanwhile, several state boards of health, state
health departments, and local health departments had been established by
the latter part of the nineteenth century. (Hanlon and Pickett, 1984)
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A HISTORY OF THE PUBLIC HEALTH SYSTEM
LATE NINETEEN rH CENTURY: ENTER BACTERIOLOGY
63
Another major set of developments in public health took place at the close
of the nineteenth century. Rapid advances in scientific knowledge about
causes and prevention of numerous diseases brought about tremendous
changes in public health. Many major contagious diseases were brought
under control through science applied to public health. Louis Pasteur, a
French chemist, proved in 1877 that anthrax is caused by bacteria. By 1884,
he had developed artificial immunization against the disease. During the
following few years, discoveries of bacteriologic agents of disease were made
in European and American laboratories for such contagious diseases as
tuberculosis, diphtheria, typhoid, and yellow fever. (Winslow, 1923)
The identification of bacteria and the development of interventions such
as immunization and water purification techniques provided a means of
controlling the spread of disease and even of preventing disease. The germ
theory of disease provided a sound scientific basis for public health. Public
health measures continued to be focused predominantly on specific conta-
gious diseases, but the means of controlling these diseases changed dramati-
cally. Laboratory research identified exact causes and specific strategies for
preventing specific diseases. For the first time, it was known that diseases
had single, specific causes. Science also revealed that both the environment
and people could be the agents of disease. During this period public agencies
that had been developed to conduct and enforce sanitary measures refined
their activities and expanded into laboratory science and epidemiology.
Public responsibility for health came to include both environmental sanita-
tion and individual health.
The Development of State and
Local Health Department Laboratories
To develop and apply the new scientific knowledge, in the 1890s state and
local health departments in the United States began to establish laborato-
ries. The first were established in Massachusetts, as a cooperative venture
between the State Board of Health and the Massachusetts Institute of
Technology, and in New York City, as a part of the New York City Health
Department. These were quickly followed by a state hygienic laboratory in
Ann Arbor, Michigan, and a municipal public health laboratory in Provi-
dence. (Winslow, 1923)
These laboratories concentrated on improving sanitation through detec-
tion and control of bacteria in water systems. W. T. Sedgwick, consulting
biologist for Massachusetts, was one of the most famous scientists in sanita-
tion and bacteriologic research. In 1891 he identified the presence of fecal
bacteria in water as the cause of typhoid fever and developed the first sewage
treatment techniques. Sedgwick followed his research on typhoid with many
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64
similar investigations of epidemics.
THE FUTURE OF PUBLIC HEALTH
"With the relish of a good storyteller,
Sedgwick would unravel a plot in which the villain was a bacterial organism;
the victim, the unwitting public; the hero, sanitary hygiene brought to life
through the application of scientific methods." (Rosenkrantz, 1972) In the
1890s, Sedgwick also conducted research on bacteria in milk and was one of
the main spokesmen for restrictive rules on the handling and pasteurization
of milk.
Laboratory research was also applied to diagnosis of disease in individ-
uals. Theobald Smith, director of the pathology laboratory in the federal
Bureau of Animal Industry, earned an international reputation for his
identification of the causes of several diseases in animals and the develop-
ment of techniques to produce artificial immunity against them. Later, as
director of a state laboratory in Massachusetts, Smith developed vaccines,
antitoxins, and diagnostic tests against such diseases as smallpox, men-
ingitis, tuberculosis, and typhoid. He established the principle of using
biological products to produce immunity to a specific disease in the individ-
ual and argued that research on the process of disease in the individual as
well as the cause of disease in the environment was necessary to develop
effective interventions. (Rosenkrantz, 1972)
In New York, the city health department laboratory also promoted diag-
nosis of contagious diseases in individuals. New York was one of the first
health departments to begin producing antitoxins for physicians' use, and
the department offered free laboratory analyses. (Starr, 1982) Hermann
Biggs, pathologist and later commissioner of the New York City Health
Department, suggested the application of bacteriology to detecting and
controlling cholera. W. H. Park, another pathologist in the laboratory,
introduced bacteriological diagnosis of diphtheria and production of diph-
theria antitoxin. (Winslow, 1923)
The Successes of Bacteriology
Some of the comments of the time reveal the enthusiasm with which the
public health workers embraced the new scientific foundation for their
efforts. Scientific measures were seen as replacing earlier social, sanitary,
moral, and religious reform measures to combat disease. Science was seen as
a more effective means of achieving the same desirable social goals. Sedg-
wick declared, "before 1880 we knew nothing; after 1890 we knew it all; it
was a glorious ten years." (Fee, 1987) Charles Chapin, superintendent of
Health of Providence, Rhode Island, who published Sources and Modes of
Infection in 1910, argued for strictly scientific measures of infectious disease
control. Chapin believed that time spent on cleaning cities was wasted, that
instead health officers should concentrate on controlling specific routes of
disease transmission. "There was little more reason for health departments
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A HISTORY OF THE PUBLIC HEALTH SYSTEM
65
to assume responsibility for street cleaning and control of nui-
sances, . . . than 'that they should work for free transfers, cheaper commu-
tation tickets, lower prices for coal, less shoddy in clothing or more rubber in
rubbers.... "' (Rosenkrantz, 1972) Herbert Hill, director of the Division
of Epidemiology of the Minnesota Board of Health, compared the new
epidemiologist to a hunter seeking a sheep-killing wolf: "Instead of finding
in the mountains and following inward from them, say, 500 different wolf
trails, 499 of which must necessarily be wrong, the experienced hunter goes
directly to the slaughtered sheep, finding there and following outward
thence the only right trail . . . the one trail that is necessarily and inevitably
the trail of the one actually guilty wolf." (Hill, as quoted by Fee, 1987)
The new methods of disease control were remarkably effective. For exam-
ple, prior to 1908 17 American cities had death rates from typhoid fever of 30
or more per 100,000 population; 18 had death rates between 15 and 30 per
100,000. After water filtering systems were put in place, only 3 of the same
cities had rates exceeding 15 per 100,000. (Winslow, 1923) In another
example, the number of deaths from yellow fever in Havana dropped from
305 to 6 in a single year after a team of American military scientists led by
Walter Reed identified mosquitoes as carriers of the yellow fever virus.
(Winslow, 1923)
As public health became a scientific enterprise, it also became the pro-
vince of experts. Prevention and control of disease were no longer tasks of
common sense and social compassion, but of knowledge and expertise.
Health reforms were guided by engineers, chemists, biologists, and physi-
cians. And the health department gained stature as a source of scientific
knowledge in health. It became clear that not only public and individual
restraint were needed to control infectious disease, but also state agency
epidemiologists and their laboratories were needed to direct the way. (Ros-
enkrantz, 1974)
EARLY TWENTIETH CENTURY: THE MOVE TOWARD PERSONAL CARE
Further Development of State and Local Health Agencies
In the early twentieth century, the role of the state and local public health
departments expanded greatly. Although disease control was based on
bacteriology, it became increasingly clear that individual persons were more
often the source of disease transmission than things. "The work of the
laboratory led the Board to define the existence and character of an increas-
ing number of the most dangerous diseases and to provide medical means for
their control." (Rosenkrantz, 1972) Identification and treatment of individ
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66
THE FUTURE OF PUBLIC HEALTH
ual cases of disease were the next natural steps. Massachusetts, Michigan,
and New York City began producing and dispensing antitoxins in the 1890s.
Several states established disease registries. In 1907, Massachusetts passed a
law requiring reporting of individual cases of 16 different diseases. Required
reporting implied an obligation to treat. For example, reporting of cancer
was later added to the list, and a cancer treatment program began in 1927.
It also became clear that providing immunizations and treating infectious
diseases did not solve all health problems. Despite remarkable success in
lowering death rates from typhoid, diphtheria, and other contagious dis-
eases, considerable disability continued to exist in the population. There
were still numerous diseases, such as tuberculosis, for which infectious
agents were not clearly identified. Draft registration during World War I
revealed that a substantial portion of the male population was either physi-
cally or mentally unfit for combat. (Fee, 1987) It also became clear that
diseases, even those for which treatment was available, still predominantly
affected the urban poor. Registration and analysis of disease showed that the
highest rates of morbidity still occurred among children and the poor. On the
premise that a healthier society could be built through health care for
individuals, health departments expanded into clinical care and health edu-
cation. In the early twentieth century, the New York and Baltimore health
departments began offering home visits by public health nurses. New York
established a campaign for education on tuberculosis. (Winslow, 1923)
School health clinics were set up in Boston in 1894, New York in 1903,
Rhode Island in 1906, and many other cities in subsequent years. (Bremner,
1971) Numerous local health agencies set up clinics to deal with tuberculosis
and infant mortality. By 1915, there were more than 500 tuberculosis clinics
and 538 baby clinics in America, predominantly run by city health depart-
ments. These clinics concentrated on providing medical care and health
education. (Starr, 1982)
As public agencies moved into clinical care and education, the orientation
of public health shifted from disease prevention to promotion of overall
health. Epidemiology provided a scientific justification for health programs
that had originated with social reforms. Public health once again became a
task of promoting a healthy society. In the twentieth century, this goal was to
be achieved through scientific analysis of disease, medical treatment of
individuals, and education on healthy habits. In 1923, C. E. A. Winslow
defined public health as the science of not only preventing contagious
disease, but also of "prolonging life, and promoting physical health and
efficiency." (Winslow, as quoted in Hanlon and Pickett, 1984)
The Growth of Federal Activities in Health
Federal activities in public health also expanded during the late nineteenth
century and the early twentieth century. The National Hygienic Laboratory,
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A HISTORY OF THE PUBLIC HEALTH SYSTEM
67
established in 1887 in the Marine Hospital in Staten Island, New York,
included divisions in chemistry, zoology, and pharmacology. In 1906, Con-
gress passed the Food and Drug Act, which initiated controls on the manu-
facture, labeling, and sale of food. In 1912, the Marine Hospital Service was
renamed the U.S. Public Health Service, and its director, the surgeon
general, was granted more authority. Although early Public Health Service
activities were modest, by 1918 they included administering physical and
mental examinations of aliens, demonstration projects in rural health, and
control and prevention of venereal diseases. (Hanlon and Pickett, 1984) In
1914, Congress enacted the Chamberlain-Kahn Act, which established the
U.S. Interdepartmental Social Hygiene Board, a comprehensive venereal
disease control program for the military, and provided funds for quarantine
of infected civilians. (Brandt, 1985)
Federal activities also grew to include promoting programs for individual
health and providing assistance to states for campaigns against specific
health problems. The Children's Bureau was formed in 1912, and the first
White House Conference on child health was held in 1919. (Hanlon and
Pickett, 1984) The Sheppard-Towner Act of 1922 established the Federal
Board of Maternity and Infant Hygiene, provided administrative funds to
the Children's Bureau, and provided funds to states to establish programs in
maternal and child health. This act was the first to establish direct federal
funding of personal health services. In order to receive federal funds, states
were required to develop a plan for providing nursing, home care, health
education, and obstetric care to mothers in the state; to designate a state
agency to administer the program; and to report on operations and expendi-
tures of the program to the federal board. The Sheppard-Towner Act was
the impetus for the federal practice of setting guidelines for public health
programs and providing funding to states to implement programs meeting
the guidelines. Although federally initiated, the programs were fully state-
run. (Bremner, 1971) As the federal bureaucracy in health grew and pro-
grams requiring federal-state partnerships for health programs were devel-
oped, the need for expertise and leaders in public health increased at both
the federal and state level.
M~D-TwENr~ETH CENruRY: FURTHER EXPANSION OF THE GovERNMENr
ROLE IN PERSONAL HEALTH
From the 1930s through the 1970s, local, state, and federal responsibilities
in health continued to increase. The federal role in health also became more
prominent. A strong federal government and a strong government role in
ensuring social welfare were publicly supported social values of this era.
From Roosevelt's New DeaLin the 1930s through Johnson's Great Society of
the 1960s, a federal role in services affecting the health and welfare of
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THE FUTURE OF PUBLIC HEALTH
individual citizens became well established. The federal government and
state and local health agencies took on greater roles in providing and
planning health services, in health promotion and health education, and in
financing health services. The agencies also continued and increased activ-
ities in environmental sanitation, epidemiology, and health statistics.
Federal Activities
Federal programs in disease control, research, and epidemiology ex-
panded throughout the mid-twentieth century. In 1930, the National Hy-
gienic Laboratory relocated to the Washington, D . C., area and was renamed
the National Institute of Health (NIH). In 1937, the Institute greatly ex-
panded its research functions to include the study and investigation of all
diseases and related conditions and the National Cancer Institute was estate,
fished as the first of the research institutes focused on particular diseases or
health problems. By the 1970s NIH grew to include an Institute for Neuro-
logical and Communicative Disorders and Stroke, an Institute for Child
Health and Human Development, an Institute for Environmental Health
Sciences, and an Institute of Mental Health, among others. In 1938, Con-
gress passed a second venereal disease control act, which provided federal
funds to states for investigation and control of venereal diseases. In 1939, the
Federal Security Agency, housing the Public Health Service and national
programs in education and welfare, was established. The Public Health
Service also continued to expand. During World War II, the Center for
Disease Control was established, and shortly thereafter, the National Center
for Health Statistics. (Hanlon and Pickett, 1984)
Federal programs supporting individual health services and state pro-
grams also continued to grow, both in number of health problems and types
of citizens addressed. The Social Security Act was passed in 1935. One title
of the act established a federal grant-in-aid program to the states for estab-
lishing and maintaining public health services and for training public health
personnel. Another title increased the responsibilities of the Children's
Bureau in maternal and child health and capabilities of state maternal and
child health programs. The National Mental Health Act, establishing the
National Institute of Mental Health as a part of NIH, was passed in 1946.
This institute was also authorized to finance training programs for mental
health professionals and to finance development of community mental
health services in local areas, as well as to conduct and support research. The
Medicare and Medicaid programs, titles 18 and 19 of the Social Security Act,
were passed in 1966. These programs enabled federal payment for health
services to the elderly and federal-state programs for payment for health
services to the poor. (Hanlon and Pickett, 1984) The Partnership in Health
Act of 1966 established a "block grant" approach for a variety of programs,
providing federal funding of state and county activities in general health,
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A HISTORY OF THE PUBLIC HEALTH SYSTEM
69
tuberculosis control, dental health, home health, and mental health, among
others. The block grant was used by the federal government as incentive to
states and counties for further development of their health services.
(Omenn, 1982) The Comprehensive Health Planning Act, passed in 1967,
established a nationwide system of health planning agencies and allowed
development of community health centers across the country. (Hanlon and
Pickett, 1984)
State and Local Activities
Expansion of state activities in health paralleled the growth in federal
activities. Many of the changes on the federal level stimulated or supported
state programs. States expanded their activities in health to accommodate
Medicaid, health promotion and education, and health planning, as well as
many other federally sponsored programs. Medicare and Medicaid in partic-
ular had a tremendous impact at the state level. To participate in Medicaid,
states had to designate a single state agency to direct the program, setting up
a dichotomy between public health services and Medicaid services. Also,
most states experienced a sudden growth in programs and program costs
with the advent of Medicare and Medicaid. For example, federal funding for
the institutionalized mentally ill became available for the first time through
Medicaid, allowing expansion of these services and their costs in many
states. (Turner, 1977)
Some federal programs of the 1960s also inspired growth of health services
in local health departments and in private health organizations. Maternal
and child health, family planning, immunization, venereal disease control,
and tuberculosis control offered financial and technical assistance to local
health departments to provide these services. Other federal programs devel-
oped at this time allowed funds and technical assistance to be provided
directly to private health care providers, bypassing state and local govern-
ment authorities. The Comprehensive Health Planning Act was an example
of this trend. It allowed federal funding of neighborhood or community
health centers, which were governed by boards composed of a consumer
majority and related directly to the federal government for policy and
program direction and finances. The National Health Service Corps Pro-
gram, in which the federal government directly assigned physicians to pro-
vide medical care to citizens in underserved areas, is another example of
unilateral federal action for health care.
THE LATE TWENTIETH CENTURY: A CRISIS IN CARE AND FINANCING
By the 1970s, the financial impact of the expansion in public health
activities of the 1930s through the 1960s, including new public roles in the
financing of medical care, began to be apparent. Per capita health expendi
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THE FUTURE OF PUBLIC HEALTH
tures increased from $198 in 1965 to $334 in 1970. During the same period,
the public sector share of this sum rose from 25 percent to 37 percent.
(Anderson, 1985) The social values of earlier decades came under criticism.
Containing health costs became a national objective. The Health Mainte-
nance Act of 1973, promoting health maintenance organizations as a less
costly means of health care, and the National Health Planning and Re-
sources Development Act of 1974, setting up a certification system for new
health services, are examples of this effort. (Turner, 1977)
In the current decade, efforts toward cost containment continue. Al-
though health needs and health services have not diminished, political and
social values of the time encourage fiscal constraint. Current values also
emphasize state responsibility for most health and welfare programs. Block
grants were implemented in 1981, consolidating the federal grants-in-aid to
the states into four major groups and cutting back the amount of grant
money (some of the cuts were restored in 1983~. Medicaid was altered to give
greater leeway to the states in the design and implementation of the pro-
gram, although the federal share of Medicaid financing was not changed.
Changes also have been made in Medicare payment policies to restrain the
increase in costs, especially for hospital care. (Omenn, 1982) At the same
time, new health problems have continued to surface. AIDS, a previously
unknown contagious disease, is reaching epidemic proportions. Greater
numbers of hazardous by-products of industry are being produced and
disposed of in the environment. Many other issues are of growing concern
asbestos exposure, side effects from pertussis vaccines, Alzheimer's disease,
alcoholism and drug abuse, and homelessness are just a few. New health
problems continue to be identified, conflicting with concerns about the
growth of government and government spending in health.
CONCLUSION
Although science provided a foundation for public health, social values
have shaped the system. The task of the public health agency has been not
only to define objectives for the health care system based on facts about
illness and health, but also to find means to implement health goals within a
social structure. "The boundaries of public health shave changed] over time
with the perception of new health and social problems and with political,
economic, and ideological shifts within the government and the nation."
(Fee, 1987) The history of public health has been one of identifying health
problems, developing knowledge and expertise to solve problems, and rally-
ing political and social support around the solutions.
Despite the huge successes brought about by scientific discovery and
social reforms, and despite a phenomenal growth of government activities in
health the solving of public health problems has not taken place without
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A HISTORY OF THE PUBLIC HEALTH SYSTEM
71
controversy. Repeatedly, the role of the government in regulating individual
behavior has been challenged. For example, as early as 1853, Britain's Board
of Health was disbanded because Chadwick, its director, "claimed a wide
scope for state intervention in an age when laissez-faire was the doctrine of
the day." (shave, 1984) The relationship between public health and private
medical practice has also been much debated. In 1920, the New York
Medical Society vehemently opposed and succeeded in defeating a proposal
for a system of public rural clinics throughout the state. (Starr, 1982) Argu-
ments about the scope of public health and the extent of public sector
responsibility for health continue to this day.
The development of a scientific base for public health allowed some
consistency in the public health system across the country. All of the states in
the United States are involved in some manner in sanitation, laboratory
investigation, collecting vital statistics, regulation of the environment, epi-
demiology, administering vaccines, maternal and child health, mental
health, and care of the poor. How local systems conduct these programs
differs greatly from area to area. Changing values over both time and place
have allowed great variety in the implementation of public health programs
across the country.
The following chapter, which summarizes the current public health system
in the United States and public health activities in six states visited by the
committee, illustrates the variety of approaches to public health which have
evolved throughout the current system.
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Representative terms from entire chapter:
mentally ill
