Health Divided

Public Health and Individual Medicine in the Making of the Modern American State

Daniel Sledge

• Publisher: University Press of Kansas
• Year: 2017
• Print ISBN: 9780700624317
• eBook ISBN: 9780700624324
• Topic: Politics & International Relations
• Subtopic: North American History
• Index: Politics & International Relations

The United States’ health care system stands out for its strict division of policies dealing with public health and individual medicine. Seeking to explain how this division came to be, what alternative paths might have been taken, and how this shapes the contemporary landscape, Daniel Sledge offers nothing less than a reinterpretation of the making of modern American health policy in Health Divided.

Where previous scholars have focused on failed attempts to adopt national health insurance, Sledge demonstrates that the development of health policy cannot be properly understood without considering the connections between public health policy and policies dealing with individual medicine. His work shows how the distinct politics of the formative years of health policy—and the presence of debilitating diseases in the American South—led to outcomes that have fundamentally shaped modern policies and disputes. Until the end of the nineteenth century, health care in the United States was seen as a local issue, with the sole exception being the government's role in providing care to seamen and immigrants. Then, as Health Divided reveals, the health problems that plagued the American South in the early twentieth century, from malaria to hookworm and pellagra, along with the political power of the southern Democrats during the New Deal, fueled the emergence of national intervention in public health work. At the same time, divisions among policymakers, as well as the resistance of the American Medical Association, led to federal inaction in the realm of individual medical services—setting the stage for the growth of employer-sponsored health insurance.

The vision of those who built the institutions that became the Centers for Disease Control and Prevention was, we see here, far more expansive and innovative than has previously been realized—and it came surprisingly close to succeeding. Exploring the history behind its failure, and tracing the inextricable links between public health and national health policy, this book provides a valuable new perspective on the origins of America’s disjointed health care system.

chapter one

health at home, health abroad

The early contours of federal health policy were shaped by two factors: federalism and international relations. For constitutional reasons and for purely practical reasons, the lion’s share of health-related government action in early America was highly local. Writing in 1824, Supreme Court chief justice John Marshall declared “health laws of every description” to be among the wide array of powers “not surrendered to the general government” by the states.¹ Federal action was sparked, however, by trade and by war.² As early as 1798, Congress created the Marine Hospital Service, an organization charged with operating a system of compulsory hospital insurance for sailors. During the second part of the nineteenth century, the service’s mandate grew to include quarantine efforts, the inspection of immigrants, and basic scientific research.

Expanding into the Caribbean after the Spanish-American War, American authorities encountered serious and debilitating diseases, including yellow fever, malaria, and hookworm. For the first time, national authorities became involved in public health operations on a large scale. American public health work abroad drew attention to conditions in the American South, where many of the same diseases were present, and also to the inability of Southern state and local governments to confront these diseases. With the promotion and regulation of health broadly understood to be an area of state authority under the Constitution, it was private philanthropy that took the first major step against these diseases at home. In 1909, John D. Rockefeller announced the creation of the Rockefeller Sanitary Commission for the Eradication of Hookworm, an endeavor that sought to rid the South of hookworm.³

These developments, which I explore in this chapter, would have important implications for health policy in the United States, leading to a debate over the appropriate role of the federal government in public health and ultimately paving the path toward expanded federal intervention.

States, the Federal Government, and Health

Following the Elizabethan poor law tradition, local governments in America were obliged to help the indigent sick access health services beginning during the colonial period. Localities typically hired a physician to treat the poor, usually on a part-time basis. States, townships, and counties also had responsibility for the health needs of prisoners and other public charges. Beyond this, some illnesses, such as tuberculosis and venereal disease, were considered issues of special public concern, demanding government action even where the sick individual was not indigent or a public charge. Over the course of the nineteenth century, most states built tuberculosis sanitoriums, as well as facilities to house those with mental illnesses and the blind.

Private philanthropy supplemented and in many cases preceded government action to promote health. In northeastern cities, charities founded “dispensaries,” which distributed drugs to the urban poor and treated minor ailments. Dispensaries also administered vaccinations, a crucial public health function.⁴ As a general rule, they remained privately funded, although some received state and local funding. Their great strength was the role they played in medical education, offering clinical experience to future physicians and serving as a stepping-stone to higher status within the profession.⁵ Often private philanthropies contributed funds to combat specific diseases such as tuberculosis and to improve maternal and infant health. Private philanthropy also played a central part in the development of hospitals, which were typically geared toward care for the indigent sick.

In addition to their role in individual medicine, states and localities were the primary sites of action in public health work. During the second half of the nineteenth century, these efforts were vastly expanded. Inspired by the growing sanitarian movement in Great Britain, attempts to regulate sanitary conditions became commonplace in American cities. In the final decades of the century, the bacteriological revolution further accelerated the development of local health regulation and promotion. The germ theory of disease drew attention to the role of specific pathogens in causing illness, leading officials to further focus attention on the relationship between individual health status and the health of the community.⁶

The extent and quality of health efforts varied significantly across the nation. Health efforts were concentrated in the industrializing North, where municipal governments and states issued regulations intended to further goals such as access to clean water, a hygienic milk supply, improved infant and maternal health, a population vaccinated against smallpox, and adequate reporting of deaths from contagious disease. Health work lagged behind in much of rural America, and particularly in the South.

Although health work was primarily local, the federal government had a role in promoting the health of Americans almost from the beginning. In 1798, Congress created the United States Marine Hospital Service, which was given the task running a system of hospitals and compulsory health insurance for sailors. Connected to the nation’s system of customhouses and founded with an eye toward the relationship between trade and disease, the service was a bureau of the Treasury Department. Sailors, a highly mobile group, often crossing international and interstate boundaries, were taxed, and in return they received access to medical care.

Throughout much of its early existence, the MHS was a disjointed and patronage-prone operation. Legislation passed in 1870, however, placed the service on firmer ground. Among other organization matters, the legislation created the coordinating position of supervising surgeon general. During the early 1870s, supervising surgeon general John Maynard Woodworth (a former Union Army medical officer) reorganized the service along military lines, with its physicians holding rank in a uniformed corps. This system was later enshrined in statute, with service officers receiving formal commissions from the president.⁷

These patterns of government activity were broadly accepted. Large-scale epidemics, however, called prevailing approaches into question. In 1878, with the Caribbean’s ongoing yellow fever problem apparently growing in magnitude, Congress passed legislation granting the MHS a role in overseeing local quarantine efforts and allowing it to engage in its own. Already on the ground in the port cities where it operated hospitals for sailors, the MHS appeared the best candidate for policing the nation’s borders against the threat of yellow fever. Before an appropriation could be made for the MHS’s new quarantine powers, however, a major outbreak of yellow fever struck the lower Mississippi Valley, killing as many as 20,000.⁸

With Southern politicians briefly mobilized in support of federal action, the 1878 quarantine legislation was superseded by an even more ambitious project: the formation of a new National Board of Health. Created in 1879, the board was authorized “to advise state and local boards of health, to obtain and publish pertinent health information, to inquire into public health questions, and to plan for a permanent national health organization.”⁹ Asserting a connection between public health and the regulation of commerce, the board’s authorization might under different circumstances have provided a framework for greater federal involvement in public health. Southern states, however, rapidly became antagonistic toward the agency’s perceived intrusions on their quarantine prerogatives. When no major yellow fever epidemic occurred between 1879 and 1883, Congress declined to continue funding the board.¹⁰

The passing of this experiment allowed the MHS to reclaim the limited quarantine role it had been granted in 1878.¹¹ Now the service began cooperating with American representatives abroad, collecting information on the threat of disease aboard ships calling at foreign ports, including Havana, Vera Cruz, London, and Liverpool. Later in the decade, it created its own series of quarantine stations to supplement the existing state-based system.¹² During the 1890s, the MHS’s role was further expanded, both in response to increasing immigration and in response to growing knowledge of bacteriology and acceptance of the germ theory of disease. In 1890, its officers were given control over the medical inspection of immigrants at the port of New York; the next year, the MHS gained formal control over the medical inspection of all immigrants. Also in 1890, Congress passed legislation giving the president authority to direct the surgeon general to issue regulations intended to stop the interstate spread of four diseases: cholera, yellow fever, smallpox, and plague.¹³

This limited assertion of authority over the interstate spread of disease was complemented and expanded in 1893 by new legislation intended to pave the way for a fully national system of quarantine. The surgeon general was directed “to examine the quarantine regulations of all state and municipal boards of health, and to cooperate with and aid the local boards in the enforcement of the regulations.” Where regulations did not exist or were deemed insufficient, the secretary of the treasury was “authorized to make additional regulations, which must operate uniformly.” The legislation also granted the MHS authority to combat the interstate spread of all contagious diseases through the use of the quarantine.¹⁴ In 1899, the MHS opened a tuberculosis sanatorium in Fort Stanton, New Mexico, and began investigating the need for a federal facility for caring for lepers—clear signs of its growing interest in the domestic transmission of disease.¹⁵

Significantly, the new legislation did not bar states from operating their own quarantine stations, providing that they could instead transfer them to the MHS as they saw fit. As a result, state and local authorities continued to control the quarantine at important ports into the twentieth century. Louisiana did not transfer its facilities, including the station in New Orleans, to the service until 1907. Boston, meanwhile, transferred its station in 1915. New York became the last state to fully cede its quarantine stations in 1921.¹⁶

Yellow Fever

Dramatic events often contain the seeds of potential change. They focus the attention of the media, the public, and politicians, placing interested leaders in a position to define or redefine both the nature of a problem and its appropriate remedy. Disruptive and unpredictable occurrences, it is often argued, are the central driving force behind significant policy change in the United States.¹⁷ The yellow fever outbreak of 1897 was, at least potentially, one such event. Introduced from Cuba into Mississippi, the disease swiftly spread throughout the South. With state and local governments throughout the region at odds, the federal government largely looked on from the sidelines. The MHS’s poor response during the episode was particularly glaring, as was the likelihood that the disease had been introduced by individuals who slipped past the MHS-operated quarantine at Ship Island, Mississippi.

As the epidemic subsided with the onset of colder weather, Congress began considering proposals aimed at expanding the role of the federal government in public health and addressing the failures of coordination made clear over the course of the outbreak.¹⁸ These plans were quickly forgotten, however, after April 25, 1898, when the United States declared war against the Spanish empire. The energy that briefly sparked a debate over how the United States might better coordinate public health activities was now redirected toward Havana, Cuba, the point of origin for the 1897 outbreak.

Though the Spanish-American War was over in a matter of months, its consequences were, in the early assessment of Massachusetts senator Henry Cabot Lodge, “many, startling, and of world-wide meaning.”¹⁹ The fruits of American victory were formalized in December, when the two nations signed a treaty granting the United States possession of...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• List of Abbreviations
• Introduction
• 1 Health at Home, Health Abroad
• 2 Public Health and Health Insurance
• 3 War and Its Aftermath
• 4 “Some Very Dangerous Precedents”
• 5 Economic Security
• 6 “The Religion of Mankind’s Future”
• 7 An Integrated Approach
• 8 Divergent Paths
• 9 Health Divided
• Conclusion
• Notes
• Bibliography
• Index
• Back Cover