Public health

“The golden age of public health” dawned at the beginning of the 20th century. As social reformers and public officials increasingly accepted environmental and epidemiological factors as the causes of the commonly fatal diseases of tuberculosis, diphtheria, typhoid fever, and cholera, they turned toward medicine for the answer. Directing new attention toward epidemic disease and educating the public in social hygiene, states abandoned the old practice of politically appointed public health officers and instead relied on medical experts to establish new rules and procedures to protect public health. City and state governments created boards of health to intervene in epidemics and regulate sources of contagion and disease, such as water supply and sewage systems, commercial milk production, and workplace ventilation. They also strengthened their efforts to immunize children against ailments such as diphtheria, to quarantine affected populations, especially immigrants, and to treat infectious diseases such as tuberculosis through isolation in public sanitariums.

There was tension, however, between public health officials and the private practice of MEDICINE. In every attempt to open up public health services, whether in private maternity hospitals, public schools, or community clinics, the new power of the American Medical Association (AMA) made itself felt. Even as medical knowledge and practice expanded, the AMA’s ability to lobby for new state licensing boards and higher standards of medical education stymied lay practitioners. Its growing control over prescription drugs and medical treatment also made itself felt. By the end of the 1920s, the medical profession had been able to turn public health programs from a threat to private practice to an indirect subsidy for private physicians.

Epidemic disease, however, was the one area in which public health reigned. The principal reason why governments gave new powers to public health departments was the medical discovery of the origin, course, and treatment of such diseases as tuberculosis and diphtheria. The importance of factors such as exposure to disease in the spread of contagion, and the impact of the urban environment, required new public measures. Successful treatment of these two diseases alone promised a decline in the mortality rate, as they were among the leading causes of death in the late 19th and early 20th centuries.

Campaigns to control tuberculosis led the way. In 1904, the National Association for the Study and Prevention of Tuberculosis took steps to conduct studies, educate the public, and broadcast findings about the disease. Local and state campaigns followed. A leader in this effort was the state of New York, where the State Charities and Aid Association formed a Committee for the Prevention of Tuberculosis. New findings about the contagious nature of the disease led to a demand for greater reporting and oversight, and in 1908, the New York state legislature passed a law mandating that physicians report tuberculosis cases. While it was rescinded, reporting on the disease increased; and overall the rate of infection slowed incredibly between 1907 and 1917. Improved nutrition, better general health care, and the pasteurization of milk provided a context for the decline of tuberculosis. Isolation of tuberculosis patients in newly established state sanitariums stopped the epidemic spread of the disease and forced a decline in tuberculosis as one of the major causes of death. Within the sanitariums themselves, the period saw little change in cure rates, as medical practitioners continued to experiment with treatments. The better food, fresh air, and personal rest that were offered to minimally infected patients probably aided their recovery, while the severely ill tended to die in isolation from their families.

The creation of the United States Public Health Service in 1902 was emblematic of new trends in public health and medicine. The United States had been slow to create a public health agency because, unlike European industrial states, the federal government had a vested interest in relying on private health care. Congress had created a National Board of Health in 1879 but abolished it only four years later. In 1902 and 1912, Congress finally expanded the Marine Hospitals for seamen into the Public Health Service. It also took on medical research and care in the area of occupational health and safety, although it remained tied closely to manufacturing concerns in its work. For the most part, however, it left medical authority in the hands of local and state governments and private organizations. Voluntary associations such as ethnic benevolent societies, fraternal organizations, unions, and private employers provided some measure of health care and diagnosis. Health insurance, even in the private sector, was underdeveloped. And dispensary medicine, long the refuge of the poor, was under siege from private medical doctors.

During the period, public health officials directed attention to those areas of public health shunned by private practitioners. They addressed the spread of sexually transmitted diseases such as syphilis (Paul Ehrlich invented salvarsan, for treatment of syphilis, in 1910; although only partly effective, it became available through public venereal disease clinics) and created new, if largely ineffective, laws

Demonstration at the Red Cross Emergency Ambulance Station in Washington, D. C., during the influenza pandemic of 1918 (Library of Congress)

That regulated or prohibited prostitution. During World War I, concern over venereal disease led to increasing control of towns around military bases, sex education in military training, and the increased use of condoms. The war generally increased the willingness to allow state and federal interventions in public health matters.

The Influenza Epidemic of 1918-19, or Spanish Flu Epidemic, was a proving ground for the new powers of the state to regulate public health. Viewed in total numbers of lives lost, it was possibly the most devastating epidemic in history and claimed more than 25 million lives worldwide in a relatively short period of time. At least 12,500,000 people died in India alone; in Samoa 25 percent of the population perished in the epidemic. The magnitude of loss throughout the United States was such that some towns were decimated. The sudden onset of the flu, rapid loss of life, and the quick disappearance of the disease revealed the limitations of medical knowledge and public health measures as the disease spread rapidly and without any certain treatment.

There were three distinct waves to the outbreak of the epidemic. The first wave was thought to have originated in Kansas in March 1918. The cases were comparatively mild, and few Americans paid much attention to it. There were other, more pressing considerations at the time. The war in Europe, the Treaty of Versailles, and the Russian Revolution captured the headlines more than the outbreak of flu. The second wave of cases, however, caused greater alarm. During the hot summer months, a lethal strain of the Spanish flu virus emerged. This more deadly strain worked extremely fast. It raced through both city and countryside. Unlike its relatively mild predecessor, this virus brought pneumonia soon after the initial infection. The flu strain struck the armed forces and the civilian population hard. The third and final wave of the flu surfaced the following winter, when it cost millions of citizens their lives. It was more deadly than either of its predecessors. It disappeared, however, as fast as it had appeared. By spring, the epidemic had run its course. The social effects of the epidemic were pronounced. Unlike most flu outbreaks, which affect the young and the aged, nearly half the victims of the Spanish Flu were men and women between the ages of 20 and 40. The epidemic thus added to the losses endured during World War I. The wildfire spread of the flu also brought new caution to a medical field that could no longer know with certainty that infectious diseases could be cured. Epidemic disease revealed the real limitations of the nation’s health care delivery system.

Another area of weakness was in the provision of medical care for war VETERANS. Over 300,000 veterans had returned from the war in Europe in need of care in hospitals, sanitariums, and asylums. Prior to the war, the U. S. Public Health Service had no responsibility for providing military health care. In 1919, however, Congress assigned the Public Health Service responsibilities for veterans with service-related disabilities, including tuberculosis, neuropsychiatric disorders, and general medical and surgical cases. Given the lack of facilities, the PHS opened to veterans the 20 marine hospitals under its supervision and leased other hospital facilities from the army and navy, bringing the number to 62 hospitals. Even these were inadequate to care for the thousands of disabled veterans. In 1921, under the administration of Warren G. Harding, Congress passed the first Langley Act, which authorized $18.6 million for veterans’ hospital construction. It was in this period of time that veterans’ medical care was moved from the Department of the Treasury to the VETERANS Bureau. Medical care for disabled veterans had become a major investment in the public health care system.

In the case of pregnant mothers and young children, the health care system was engaged in an experiment with government-funded medical education. The interest of progressives in child welfare, evidenced in the creation of MOTHERS’ PENSIONS, became the focus of women’s organized efforts for a national health program under the Maternity and Infant Health Care Act, or SHEPPARD-TowNER Act, of 1921. Under the authority of the Children’s Bureau, the program helped to nurture the public health nursing service and generally contributed to the continuing decline in infant mortality. Congress allowed the funding of the controversial program to expire in 1929. Competition between Public Health Service doctors and the nurse practitioners who provided health care under the Children’s Bureau program had shadowed the program from the beginning.

The same competition that plagued publicly funded maternity and infant child care was an issue in the provision of BIRTH CONTROL as well. Between 1900 and 1920, radicals such as Margaret Sanger and Emma Goldman battled for the right of poor women to have access to new birth control methods and safe abortions. Many in the medical profession, however, opposed methods of contraception both for reasons of personal belief and due to a lack of medical regulation. Sanger pushed for the adoption of the spring-loaded vaginal diaphragm, which she originally argued should be available at neighborhood clinics and from nurse-midwives. Seeking to pave the way for easily accessible birth control, Sanger eventually allied herself with the medical profession in creating Planned Parenthood, an organization dedicated to motherhood by choice. Not until the 1930s, however, did she succeed in getting birth control and fertility seen as a public health concern. By then, the medical profession had succeeded in limiting public health initiatives and expanding its role even in the provision of health care to the general public.

Further reading: John Duffy, The Sani-tarians; A History of American Public Health (Urbana: University of Illinois Press, 1990); Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982); L. C. Taylor, The Medical Profession and Social Reform, 18851945 (New York: St. Martin’s Press, 1974).