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. (Chave, 1984; Fee, 1987)
The link between science, the development of interventions, and organization 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 alleviate 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 diseases. 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, inoculation with material from smallpox scabs was also accepted as an effective means of containing this disease once the threat of an epidemic was declared.) By the end of the eighteenth century, several cities, including Boston, Philadelphia, New York, and Baltimore, had established permanent 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 American colonies. (Grob, 1966; Starr, 1982) By the eighteenth century, several communities had reached a size that demanded more formal arrangements 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 Williamsburg, Virginia in 1773. (Turner, 1977)
The Nineteenth 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 responsibility for citizen’s health. Protecting health became a social responsibility. Disease control continued to focus on epidemics, but the manner of controlling 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 Massachusetts 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 outbreaks 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 urbanization 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 deplorable 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 Commission 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 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.” (Chave, 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 appointed to accomplish this goal. (Chave, 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 population, promoted sanitation and engineering as means of controlling disease, and laid the foundation for public infrastructure for combating and preventing 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 Massachusetts 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 mortality 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 Massachusetts Sanitary Commission recommended, in its “Plan for a Sanitary Survey of the State,” a comprehensive public health system for the state.
The report recommended, among other things, new census schedules; regular 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 documents in the history of the American public health system. Many of the principles and activities he proposed later came to be considered fundamental 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 understood, 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 inspections, 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 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 institutions 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 unnecessary. Some 32 public institutions were established due to Dix’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 stimulated the development of public health agencies and institutions. As environmental 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 organizations.
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)