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.

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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)

Late Nineteenth Century: Enter Bacteriology

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 contagious diseases,
but the means of controlling these diseases changed dramatically. 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 sanitation 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 laboratories. 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 Providence. (Winslow, 1923)

These laboratories concentrated on improving sanitation through detection and control of bacteria
in water systems. W. T. Sedgwick, consulting biologist for Massachusetts, was one of the most
famous scientists in sanitation 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 similar investigations of
epidemics. "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 individuals. 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
development 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, meningitis, tuberculosis, and typhoid. He established the principle of
using biological products to produce immunity to a specific disease in the individual 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 diagnosis 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 diphtheria
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. Sedgwick 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 to assume responsibility for street cleaning and control of nuisances, …
than 'that they should work for free transfers, cheaper commutation 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 example, 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 province 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
physicians. 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.
(Rosenkrantz, 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 increasing number of the
most dangerous diseases and to provide medical means for their control." (Rosenkrantz, 1972)
Identification and treatment of individual 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 diseases, 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 physically 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 education. 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
departments. 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, established in 1887 in the Marine Hospital
in Staten Island, New York, included divisions in chemistry, zoology, and pharmacology. In 1906,
Congress passed the Food and Drug Act, which initiated controls on the manufacture, 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
expenditures 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 staterun. (Bremner, 1971) As the federal bureaucracy in health grew and programs requiring
federal-state partnerships for health programs were developed, the need for expertise and leaders
in public health increased at both the federal and state level.

Mid-Twentieth Century: Further Expansion of the Governmental 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 Deal in the 1930s through Johnson's Great Society of the 1960s, a
federal role in services affecting the health and welfare of 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 activities in environmental sanitation,
epidemiology, and health statistics.
Federal Activities

Federal programs in disease control, research, and epidemiology expanded throughout the mid-
twentieth century. In 1930, the National Hygienic Laboratory relocated to the Washington, D.C.,
area and was renamed the National Institute of Health (NIH). In 1937, the Institute greatly
expanded its research functions to include the study and investigation of all diseases and related
conditions and the National Cancer Institute was established as the first of the research institutes
focused on particular diseases or health problems. By the 1970s NIH grew to include an Institute
for Neurological 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, Congress 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 programs 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
establishing 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, 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
particular 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 developed
at this time allowed funds and technical assistance to be provided directly to private health care
providers, bypassing state and local government 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 Program, in which the federal government directly assigned physicians to provide 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 expenditures 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 Maintenance Act of 1973, promoting health maintenance organizations as a
less costly means of health care, and the National Health Planning and Resources 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. Although 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
program, 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.

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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 [have 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 rallying
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 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." (Chave, 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) Arguments 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,
epidemiology, 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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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. Water for the Cities: A History of the Urban Water Supply Problem in
the United States. Syracuse University Press, Syracuse, N.Y.