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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
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
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
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
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.
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
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)
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
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
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
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,
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
68 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,
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
70 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
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. REFERENCES Anderson, O. W. 1985. Health Services in the United States: A Growth Enterprise Since 1875. Health Administration Press, Ann Arbor, Mich. Blake, Nelson M. 1956. Waterfor the Cities: A History of the Urban Water Supply Problem in the United States. Syracuse University Press, Syracuse, N.Y. Brandt, Allan M. 1985. No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880. Oxford University Press, New York. Bremner, Robert H., ed. 1971. Children and Youth in America: A Documentary History. Harvard University Press, Cambridge, Mass. Chave, S. P. W. 1984. "The Origins and Development of Public Health." In Oxford Textbook of Public Health, Vol. 1: History, Determinants, Scope, and Strategies, W. W. Holland, R. Detels, and G. Knox, eds. Oxford Medical Publications, Oxford University Press, New York. Fee, Elizabeth. 1987. Disease and Discovery: A History of the Johns Hopkins School of Hygiene and Public Health 1916-1939. Johns Hopkins University Press, Baltimore. Foley, Henry A., and Steven S. Sharfstein. 1983. Madness and Government: Who Cares for the Mentally Ill? American Psychiatric Press, Inc., Washington, D.C. Goudsblom, Johan. 1986. "Public Health and the Civilizing Process." The Milbank Quarterly 64~2~:161-88. Grob, Gerald N. 1966. The State and the Mentally Ill: A History of Worcester State Hospital in Massachusetts, 1830-1920. University of North Carolina Press, Chapel Hill, N.C.
72 THE FUTURE OF PUBLIC HEALTH Hanlon, G., and J. Pickett. 1984. Public Health Administration and Practice. Times Mirror/ Mosby. Omenn, G. S. 1982. "What's Behind Those Block Grants in Health? New England Journal of Medicine 306(17):1057-60. Rosenberg, Charles E. 1962. The Cholera Years. University of Chicago Press, Chicago, Ill. Rosenkrantz, Barbara G. 1972. Public Health and the State. Harvard University Press, Cam- bridge, Mass. Rosenkrantz, Barbara G. 1974. "Cart Before the Horse: Theory, Practice, and Professional Image in American Public Health." Journal of History of Medicine and Allied Sciences 29:55-73 Starr, P. 1982. The Social Transformation of American Medicine. Basic Books, Inc., New York. Turner, John B., editor in chief. 1977. Encyclopedia of Social Work, seventeenth edition. National Association of Social Workers, Washington, D.C. Winslow, C. E. A.1923. The Evolution and Significance of the Modern Public Health Campaign. Journal of Public Health Policy, South Burlington, Vt. Wohl, Anthony S. 1983. Endangered Lives: Public Health in Victorian Britain. Harvard Univer- sity Press, Cambridge, Mass.