Public Health 1929-1941
Public Health 1929-1941
Public Health 1929-1941Introduction
Suggested Research Topics
The October 1929 stock market crash and following Great Depression brought massive unemployment over the next decade, particularly the next several years. By 1933 25 percent of the U.S. work-force was out of work, amounting to over 12 million people. In reaction President Franklin Delano Roosevelt (served 1933–1945) introduced the New Deal in early 1933 when he took office. The New Deal consisted of a range of federal social and economic relief and recovery programs addressing a broad span of issues including work relief for the unemployed. The rise in poverty contributed to a decline in sanitation and hygiene in the rural areas and inner cities of the nation. The suicide rate was also on the increase.
During the Great Depression the public health movement of the United States had many successes and some spectacular failures. The New Deal programs played a key role in promoting health, particularly among the most impoverished. Leading up to the Great Depression the leading causes of death in the United States had become degenerative conditions. Heart disease and cancer killed twice as many people as influenza, pneumonia, and tuberculosis. Rates of infectious childhood diseases including measles, scarlet fever, whooping cough, and diphtheria had dropped significantly, and deaths from enteritis, typhoid, and paratyphoid fevers had been drastically reduced. These reductions were due in large part to medical advances and public health successes from the previous decades. Knowledge of how disease spread led to public health efforts to clean up water supplies, suppress epidemics through quarantines, and vaccinate populations threatened with infectious diseases. Research demonstrating that poor diet caused pellagra and scurvy and that unpasteurized milk could carry bovine tuberculosis resulted in education on how to prepare and store healthy foods and legislation that monitored the quality and content of food products. After 1932 public health officials in New Deal programs could point to these successes to prove the need for more health care spending as part of providing relief to those most affected by the economic crisis of the Great Depression.
During the period of the government social and economic recovery programs of the New Deal, the 1930s saw the second great push for national health insurance and the second great fight to defeat it. The battle illustrated the struggle between those who worried that health insurance would inevitably lead to government control of the American medical profession. That fear was already felt by many because of the rapidly growing role of the government under Roosevelt in combating Great Depression economic woes. It also highlighted the fear that public health professionals were overstepping their boundaries and treading on territory best left to private physicians. Public health after all was historically an issue of sanitation and water safety, not medicine. Even though medical economists and health insurance supporters such as Isidore Falk could prove how much money illness cost society, that did not mean that society should pay for its prevention. There was also the belief that the federal government could not adequately respond to local needs as they varied, depending on where you lived. Counties in the rural South were in desperate need of doctors, nurses, and hospitals. Cities in the urban North had better access to medical care but continued to suffer from the effects of overcrowding and poor sanitation. Finally there was the belief that additional funding for public health simply was not necessary. Statistics from the Metropolitan Insurance Company showed that despite slashed health department budgets, widespread unemployment, and the general lack of medical care, the death rate continued to decline. Between 1900 and 1930 the average life expectancy of a Caucasian male had increased by 11 years.
Despite such opposition nearly every piece of New Deal legislation provided funds for public health initiatives. The New Deal was President Roosevelt's plan for new reform and relief policies in the United States. Even the Federal Art Project of the Works Progress Administration (WPA), a New Deal agency, designed posters warning against cancer, and the Federal Writers Project created educational brochures
- The Committee on the Costs of Medical Care begins its five-year study of the state of public health in the United States. A joint effort of private philanthropic foundations and government agencies, it examines the economic costs of disease and poor health.
- The Ransdell Act changes the name of the Hygienic Laboratory to the National Institute of Health and gives it authority to provide public funds for medical research.
- The United States Public Health Service begins the Tuskegee Syphilis Study, which withholds medical treatment for syphilis from black American males. The experiment finally ends in 1972.
- Polio vaccine trials are conducted using live polio virus. After nine deaths are reported out of 20,000 inoculations, the vaccine is withdrawn.
- August 14, 1935:
- President Roosevelt signs the Social Security Act that provides federal funds for state and local health programs.
- In response to the increase of deaths from cancer in the United States, the National Cancer Institute is established with unanimous support from every Senator in Congress.
- June 25, 1938:
- Roosevelt signs the Federal Food, Drug, and Cosmetic Act replacing the basically ineffectual 1906 Food and Drugs Act.
- July 1938:
- The National Health Conference gathers public health officials, health care providers, and representatives from labor unions in Washington to discuss the medical needs of the nation.
- The Venereal Disease Act is passed seeking to eradicate venereal disease through education and medical treatment.
- The Wagner Bill, which proposes federal grants to establish state insurance systems, is introduced into the Senate. The bill dies in committee as attention shifts to an increasingly unstable Europe.
describing syphilis and tuberculosis. The Social Security Act provided grants to states for the development of public health and the WPA and the Public Works Administration (PWA) built health centers, hospitals, and laboratories, as well as water and sewer systems. Public health functions were scattered among many government agencies. The Public Health Service, the largest agency devoted to health, was part of the Treasury Department. The Children's Bureau, which handled both maternal and child health, was in the Department of Labor, and the Food and Drug Administration was part of the Department of Agriculture. Unfortunately, because there were so many departments providing public health services during the Depression, some efforts inevitably became bogged down in bureaucratic bickering. Even the Interdepartmental Committee to Coordinate Health and Welfare Activities, a committee formed by President Roosevelt in 1936 to organize health efforts nationwide, fell victim to political influence when Martha Eliot, the assistant chief of the Children's bureau, suggested they all work separately on the sections of the program that would affect their particular agencies.
Failures such as these, however, did not detract from the successes of New Deal legislation. By the start of World War II (1939–1945) the Public Health Service had expanded its traditional role of monitoring and preventing infectious disease, protecting water supplies, and insuring the provision of clean milk, to actively providing both emergency and preventative health care. The public health movement was able to provide a safety net for those too indigent to provide one of their own.
U.S. Public Health Service
At the start of the Great Depression the primary functions of the U.S. Public Health Service were sanitation, investigation, and education. Public health officers had considerable experience tracking down sources of disease and concentrated significant portions of their time on improving sanitary conditions. Since 1912 the Service had been providing health information to the public and by the end of the 1920s, it had worked closely with private philanthropic, or charitable, organizations, local health boards, and other government agencies in campaigns against hookworm, pellagra, and venereal disease. Venereal diseases include syphilis and gonorrhea, two types of disease that attack reproductive organs. Unlike other agencies with strong federal direction, the Public Health Service had to balance the need for federal action with the prevailing opinion that health matters were largely local concerns and best handled by local health boards and by privately-funded agencies. County health departments existed but they were newly created and were not funded by the federal government but rather by the Rockefeller Foundation, that provided nearly three million dollars between 1914 and 1933 to support county health departments. By 1931 there were 599 county health departments providing health services to one fifth of the U.S. population.
An even bigger obstacle for the U.S. Public Health Service was the widely held belief, by both public health non-professionals and medical professionals, that public health was not improved by community action, but instead by personal effort and individual responsibility. In short, the idea of being a good citizen meant learning and practicing good personal hygiene. In 1932 the assistant Surgeon General R.C. Williams called this sense of personal responsibility toward public health, "one of the qualities of individual citizenship that should be fostered by every means at our command." It was "one of the basic elements of greatness of the American nation…which will make possible the development in this country of the most effective system possible of public-health protection" (quoted in R.C. Williams, "The Research Work of the United States Public Health Service"). Yet by the end of the Depression individual responsibility had been replaced by governmental oversight, private funds had been increasingly replaced by public, and the government's role in health had been broadened at local, state, and federal levels. The Social Security Act of 1935 expanded public health spending dramatically by authorizing health grants to states. Additional legislation was passed to battle venereal disease and to establish standards for food and drug products. The decade of the Depression changed the focus, the funding, and the future prospects of federal public health services.
The New Deal programs of President Roosevelt's administration focused on the plight of Americans hurt most by the economic crisis. Beginning with his presidential campaign swing through Tupelo, Mississippi, in the summer of 1932, where he was struck by the pronounced poverty of the population, Roosevelt targeted many programs, such as the Tennessee Valley Authority (TVA), which provided electricity to rural areas of the South, to give people electricity, indoor plumbing, food, and shelter. Only with these basics established did Roosevelt believe the health of the needy could be improved for the long-term. Improved sanitation and hygiene were crucial. Electricity would help keep food fresher and decrease spoiling and would also preserve fruit and vegetables longer for family consumption. Other programs such as the Civilian Conservation Corps (CCC) and the National Youth Administration (NYA) taught youth basic skills to improve hygiene. Of course other programs such as the Works Progress Administration (WPA) provided jobs so people could afford more nutritious diets and maintain better shelters in the first place.
Private Money for Health Care
While government spending on health care was increased with every piece of New Deal legislation, many health care dollars still came from private or corporate sources. A public health care problem was often first brought to the attention of private philanthropic foundations. The Rockefeller Foundation, one of the biggest philanthropic foundations working on health care projects, established the Rockefeller Institute for Medical Research in 1902 and by 1928 had been endowed with 65 million dollars for medical research.
One of their programs, the Rockefeller Sanitary Commission, was established to eliminate hookworm in the south through surveys, education, and treatment. Its efforts inspired interest in public health throughout southern states. Many of the major public health initiatives of the 1930s had the support of these private foundations and organizations. The Red Cross provided funds for many of the early food demonstration projects. The projects demonstrated how various foods could best be prepared and stored to ensure that vitamins were retained and to minimize spoilage while stored. Christmas Seals, the American Red Cross, and the National Tuberculosis Association supported the anti-tuberculosis campaigns. Research on syphilis was funded by the Rockefeller Foundation, the Milbank Memorial Fund, the Rosenwald Foundation, and the Reynolds Foundation.
Corporate philanthropy was also active in health care. Pharmaceutical companies were long-time supporters of medical research. In addition to sponsoring public health research, The Metropolitan Life Insurance Company had provided visiting nurses to their clients since 1909 when it was demonstrated that by providing health care services, the company could reduce the number of death benefit payments. By 1912 the Metropolitan Life Insurance Company was spending half a million annually on their visiting nurse program. By 1939 critics of the program argued the visiting nurses were actually visiting salespeople. Although it would take until 1953 before the program actually stopped, the critical comments highlighted the potential conflict for both privately funded and corporate programs in health care. Unlike the Metropolitan Life Insurance Company or the Rockefeller Institute for Medical Research, the federal government was accountable to all of its citizens and could not appear to be motivated by profit or by private interest.
The Beginning of Legislative Reform: The Committee on the Costs of Medical Care
During the 1920s and 1930s maintaining personal health was portrayed as a civic duty. Illness, however, was recognized as a financial burden that had consequences for society as well as for the individual. The first of three committees during the Depression to study the effects of illness on the economy was actually formed in May 1927, well before the economic crash. Composed of seventeen doctors and dentists, 10 institutional representatives, six public health workers, six social scientists, and nine representatives of the general public, it was funded by philanthropic foundations. The committee was charged with surveying the costs and the quality of medical care. Five years and 28 volumes of reports later, the Committee on the Costs of Medical Care (CCMC) finished its work and published its recommendations. It found that even though, on average, the American people paid about 30 dollars per capita (for each person) annually on health care, the majority of money was spent on recovering from a sudden illness rather than on maintenance of good health or illness prevention.
By 1929 the burden of medical costs fell on those hospitalized and accounted for 50 percent of all medical bills. The Committee also reported that access to medical care depended on where you lived and the difference between rural and urban areas was considerable. In 1929 in South Carolina there was one physician for every 1,431 persons, but in California there was one physician for every 571 patients. If general practitioners were available in rural areas, they typically lacked access to hospital and laboratory facilities. And while there were plenty of physicians in the cities, more than forty five percent of them were specialists who ignored general medical cases. Money was not efficiently spent as evidenced by the fact that physicians used 40 percent of their own income on general expenses of having an office. Patients also spent unwisely, according to the committee, when they bypassed traditional medical care and spent more than $125 million on the services of "cultists and irregular practitioners" and 360 million dollars on special "patent medicines." Health care professionals were inadequately compensated and there was a "shockingly large amount of illness" that went untreated. Most importantly little if any money was spent on preventive services, a situation that C.E.A. Winslow, the public health professor at the Yale School of Medicine and the committee's executive chair, described in "A Program of Medical Care for the United States (1933) as "a grave lack of the applications of modern medical science to the prevention of disease."
The majority of the committee members recommended that rather than working independently, physicians, dentists, nurses, pharmacists, and other medical professionals should be organized into groups, preferably centered around a hospital, and provide complete home, office, and hospital care. Medical costs were to be paid through the use of voluntary health insurance plans that were seen as a necessary first step to equalize the costs of medical care across the population. Local governments were expected to pay for individuals too poor to contribute. The resulting prepaid group practice plans, meaning the cost of healthcare was paid to some extent before illness occurred were not liberal enough for more progressive committee members including Walton Hamilton and Edgar Sydenstricker who feared that voluntary insurance would prevent the establishment of required health insurance plans. The idea was too radical for some healthcare professionals who feared that group practice would apply the principles of mass production to health care and establish a medical monopoly dictating who could practice in any given community. They also viewed voluntary insurance plans as one very quick step away from compulsory medical insurance.
Isidore Falk, the medical economist who led the committee's research staff, vigorously supported many of the recommendations that angered conservative members of the medical establishment. He pointed out that medical costs were fundamentally different from other costs of living. Whereas money for food, clothing, and housing could be budgeted and planned, medical costs were too variable to be budgeted by an individual or a family and needed to be borne over a larger group of people. He suggested the costs might be borne more easily if they were spread over a large group of people, both healthy and unhealthy people. The American Medical Association (AMA) called the committee's recommendations an "incitement to revolution." Declaring that what was at stake was "Americanism versus Sovietism [strong government control] for the American people," the AMA condemned the CCMC's report as a thinly veiled attempt to institute compulsory health insurance and remove control of medical care from medical professionals. Inevitably more attention was paid to the dissenters and to the conflict between the majority and minority reports than to the very real problems of the U.S. health care system that were diagnosed by the CCMC. Unable to generate a consensus within its own group, the CCMC was a political failure at generating health care reform.
The AMA's zealous condemnation of the CCMC's health care proposals was not lost on Franklin Roosevelt or on members of his staff looking at the health care needs of the nation. While medical relief was a large part of the Federal Emergency Relief Act (FERA) of 1933, it was carefully orchestrated and presented within the context of emergency unemployment relief. Broad guidelines were written but the execution of medical relief was left largely in the hands of state and local relief agencies that administered the federal grants. Medical care was available for acute conditions, not chronic. Emergency illnesses were treated but preventative care, which in many cases would have eliminated the need for emergency care, was not authorized. FERA did not provide funds for long-term hospital stays or convalescent care, which is care provided to those gradually recovering from an illness. Treatable conditions were those that "cause acute suffering, interfere with earning capacity, endanger life, or threaten some permanent new handicap that is preventable" (quoted in Brown, Josephine Chapin, Public Relief 1929–1939, 1940, p. 258). More importantly federal rules required that at all times the traditional relationship between physician and patient be respected and protected. Once an individual was approved to receive medical care by the relief administration, the type of care was left in the hands of the physician and not overseen by any government official. The results of this emergency relief were mixed and depended on how well or how poorly the funds were administered at the state and local levels.
FERA succeeded, however, where the CCMC failed. It made the general public and federal, state, and local governments aware of the wide inequality of medical care across the nation. Due to its "Health Inventory," a study of 850,000 families across the country, the lack of medical care in rural areas was again brought to public attention and in 1934, one million dollars of FERA's budget was specifically slated for public health services in rural areas. Nursing programs were also established and run through FERA and through the WPA and PWA. These programs were part health care and part health education with public health nurses making home visits to those too sick to travel or simply unaware of available medical care. Most of the problems associated with FERA related to its structure as an emergency relief organization. It was not designed to handle ongoing health care services and the fluctuations in funding and the limits placed on monies received impacted its ability to provide long-term assistance. It did however establish a very important precedent for federally funded health care.
The Great Depression following the October 1929 stock market crash steadily worsened through 1932. By 1933 25 percent of the U.S. workforce was out of work, amounting to over 12 million people. The resulting economic suffering and need quickly overwhelmed private charities and local government relief agencies. President Herbert Hoover (served 1929–1933), believing in the rule that people are responsible for their own plights and also insisting the Depression would be short-lived, refused to establish an expansive federal response. The poverty found in the United States in 1933 was startling to Americans. The poverty spawned by the Depression further highlighted to the public the poverty that had already existed in many areas of the nation previously, even during the economic boom years of the 1920s. Among those who were concerned was newly elected President Roosevelt.
A Tactical Retreat: Social Security and Health Care
Roosevelt called the Social Security Act of 1935 the beginning of a broader social program and he approached its provisions for health care services with some caution. When Roosevelt formed the Committee on Economic Security in June of 1934 to investigate and define a social security program, three of its five members—Secretary of Labor, Frances Perkins, federal emergency relief administrator, Harry Hopkins, and staff director, Edwin Witte—felt that health insurance would have to wait because of AMA opposition. In his message to Congress on the Social Security Act in January of 1935 Roosevelt stressed the need for governmental unemployment compensation and old-age benefits. He called for federal aid to dependent children and their mothers and asked for additional services for the care of those left homeless by the Depression. And while he asked to strengthen the Federal Public Health Service and increase federal grants to state and local public health agencies, he carefully backed away from the topic of "so-called 'health insurance.'" He did admit, however, that "groups representing the medical profession are cooperating with the Federal Government in the further study of the subject and definite progress is being made" (quoted in B.D. Zevin, ed. Nothing to Fear: The Selected Addresses of Franklin Delano Roosevelt 1932–1945, 1946, p. 43).
This careful sidestepping of the issue of national health insurance recognized the political clout of the AMA and reflected how priorities were changing with the deepening economic crisis. Unemployment insurance was the first priority because millions were unemployed. A safety net for the elderly came next because of Francis Townsend. An advocate for the elderly, Townsend suggested his own unique form of old-age pensions that would provide two hundred dollars a month to anyone over 65 who would retire and boost the economy by spending the money. Although Roosevelt's advisors recognized the need for increased health spending they were leery of inciting the AMA. The AMA, however, went on the offensive as soon as they heard that Walton Hamilton was chairing the Committee on Economic Security's subcommittee on medical care and Edgar Sydenstricker was conducting its technical study. Hamilton and Sydenstricker were the two progressives who dissented from the CCMC's report because it had not recommended compulsory (required) health insurance. The AMA bombarded the White House with protest telegrams and published an editorial in their journal declaring that Roosevelt was using Social Security to force Congress to pass mandatory health insurance. Throughout the rest of 1934 and until the act was signed in August of 1935 the AMA was quick to react and denounce any mention of health insurance. Even when health insurance was left in the Social Security Act as a future subject for study, it was attacked by the AMA, which condemned any insurance plan that would give control of medical benefits to lay people. Roosevelt's reaction to the attacks was to shelve plans for any type of health insurance program within the Social Security Act.
Even though the Social Security Act did not contain provisions for health insurance, it provided millions of dollars for public health services and its impact on state health programs was immediate and significant. Eight million dollars was appropriated for maternal and child welfare and an additional eight million was given to the U.S. Public Health Service to dispense to state and local governments. Additional funds were channeled through other government agencies for the construction of health facilities. In addition to the great infusion of cash, the Social Security Act established federal health standards. In order to qualify for the federal grants, many state and local agencies reorganized resulting in more consistent health care services from state to state. Social Security funds were used for a variety of programs from tuberculosis prevention in Wisconsin to venereal disease control in Missouri. Nearly every state board reported an expansion of services through the use of Social Security funds.
The Final Push for Health Insurance
The last push for health insurance in the 1930s came in an indirect way. By 1935 nearly every New Deal agency was providing federal funds for health care. Due to the variety of agencies dispersing federal monies for health care, Roosevelt created the Interdepartmental Committee to Coordinate Health and Welfare Activities. Chaired by Josephine Roche, the assistant secretary of the Treasury, the committee's mandate, as its name suggests, was to reorganize and consolidate federal health, education, and welfare services. Initially it did concentrate on coordinating programs. By 1937, however, it had created the Technical Committee on Medical Care (TCMC) and gave it the task again (for the third time) of creating a health program to meet the medical needs of the nation. Using the recently completed National Health Survey—conducted with WPA Funds by the U.S. Public Health Service and involving 776,000 families in 22 states—the TCMC endorsed many of the same measures as the previous two committees. In addition to recommending compulsory health insurance in the form of state grants, the TCMC wanted to expand the public health and maternal and child health services of Social Security, build more hospitals, increase medical relief, establish a general medical care program supported by taxes and insurance, and create a workman's compensation program for illness or disability that occurred on the job. Isidore Falk, a committee member for the third time, was again a chief supporter for health insurance. When Roosevelt received the report he did not immediately publish its recommendations. Instead he convened with the National Health Conference in July of 1938 to discuss the results of the National Health Survey and the TCMC's analysis of health care needs.
Held in Washington, DC, the National Health Conference brought together a diverse group of over 170 individuals from the medical profession, public health service, and labor organizations. All of the participants strongly supported the suggested program of the TCMC. The AMA became worried about the positive public response to the National Health Conference and the renewed interest of labor unions in federal health benefits that would "complete the Social Security Act." As a result it tried to back down from its hard-line approach and now offered to support the recommendations of the TCMC with the exception of compulsory health insurance. After the TCMC refused to drop health insurance from its recommendations, the AMA endorsed the expansion of public health services, agreeing that voluntary insurance plans might be acceptable, and hinted that federal funds might be necessary to guarantee care for some. Just when the standoff between the AMA and health insurance supporters seemed to be edging against the AMA, the mid-term congressional elections of 1938 changed the make-up of Congress and made it far more difficult to pass any type of social legislation.
Despite the results of the 1938 election which gave more power to conservatives, Senator Robert Wagner of New York introduced the National Health Bill of 1939. Incorporating most of the TCMC's recommendations, the bill expanded the health provisions of the Social Security Act but left the matter of health insurance to the states. This concession, however, was not enough for the AMA who backed away from their more friendly gestures made before the 1938 election. They campaigned against the entire act with renewed vigor declaring in an editorial that Americans were not interested in "any form of totalitarianism." With attention shifting towards foreign policy due to the rising tensions in Europe and with no firm support from Roosevelt, the Wagner Bill died in Congress.
The Changing Focus of Public Health
While the events of the Depression caused major changes in how public health services were funded, it also resulted in major shifts in the types of services provided. Long-time crusaders against infectious disease, the U.S. Public Health Service had achieved many successes against typhoid, cholera, and tuberculosis. Through the development of municipal water and sewage systems and through the pasteurization of milk supplies, the rates of contagious diseases had been drastically reduced. Due to these successes health was now more likely to be impacted by chronic conditions. Heart disease became the number one killer and identified cancer rates were on the rise. It was only by the late nineteenth century that medical researchers were beginning to understand how cancer develops in the body and this research would carry on during the Depression. The government responses brought on by the Great Depression, mixed with the advances in modern medicine brought this shift in number one killers.
With the introduction of research, which proved the impact of diet on health, more attention was paid to the content and quality of food products. Before the end of the decade, major legislation had been passed that monitored the manufacturing process of both food and drugs. The U.S. Public Health Service expanded their educational efforts with major campaigns against tuberculosis and venereal disease and explaining personal hygiene and prenatal care. Increased federal funding meant increased dollars for vaccination programs, with a special emphasis placed on the development of a polio vaccine. Early use of the vaccine, however, was met with mixed results. Some field trials of these vaccines actually resulted in polio infection of healthy patients that received vaccines. The changing face of public health during the Depression reflected both the medical advances of the previous generation and the new challenges that faced the population. It also reflected the strong personalities and interests of the officials in charge. Public health is a portrait of prevailing medical opinions and the evolution of its service during the Depression mirrored the developments in research and science.
The National Institute of Health
The Public Health Service always had a branch conducting research. Its original research facility, the Hygienic Laboratory, was established in 1887 and was most celebrated for its campaign against cholera and its vaccines and antitoxin serums that had been instrumental in bringing smallpox and diphtheria under control. By 1930 as the rates of infectious disease dropped a new research policy began to pervade the U.S. Public Health Service. The biggest symbol of this change was the creation of the National Institute of Health (NIH).
The newly created NIH was more than a token name change of the Hygienic Laboratory, of which it took the place. It symbolized a shift in the type of research being conducted by the Public Health Service and its sponsorship. For the first time federal grants were offered to scientists conducting basic studies designed to obtain "fundamental knowledge." While still tracking down infectious agents and the sources of parasitic diseases caused by organisms living in a patient, NIH scientists under the direction of Surgeon General Hugh Cumming expanded their efforts and began to research chronic illness. This dual focus was evident in 1931 when the Public Health Service established a laboratory in Montana where it researched and produced a vaccine preventing Rocky Mountain spotted fever and expanded its research efforts into tuberculosis, venereal disease, and infectious childhood diseases. At the same time Cumming and the NIH developed new studies on cancer, including the chemical conditions controlling the growth of normal and abnormal cells, and they began a pilot study of rheumatic heart disease. One of Cumming's more dubious achievements, the initiation of the Tuskegee Syphilis Study in 1932, also reflected greater interest in chronic illness.
Under the direction of Cumming the Macon County Public Health Department began a joint federal and local study of the effects of untreated syphilis in black American males. The U.S. Public Health Service thought they had a rare opportunity to perform a "study in nature." Macon County was selected as the site of the study after an earlier research project, funded by the Rosenwald Foundation showed that one of the highest per capita rates of syphilis in the country was in Macon County, Alabama. The men believed they were patients being offered medical care by the government for their "bad blood," a local way of referring to both the syphilis and anemia that afflicted so many in the county.
Six hundred men, 399 men in the late stage of the disease and 201 control subjects, were offered exams, diagnostic spinal taps, placebos, tonics, aspirins, free lunches, and eventually burial services. Researchers were particularly interested in conducting autopsies on the men so they could study the ravages of syphilis on internal organs. In 1958 survivors received a certificate recognizing their voluntary service and one dollar for every year of service.
At the start of the study, syphilis was being treated with varying degrees of success with arsenic and mercury. By the end of the Depression syphilis was being healed with sulfa drugs, and by the 1950s syphilis was effectively cured by penicillin. The subjects of the Tuskegee Syphilis Study received yearly exams and some treatment for the symptoms caused by syphilis, but never received the standard cures available for their venereal disease. Not only was treatment withheld from the study's participants, the PHS went to great lengths to insure that they were not treated by anyone. Local black American doctors were asked in 1934 to refrain from treating the test subjects for syphilis. In 1941 after a number of the subjects were drafted and sent immediately for treatment, the PHS intervened and requested that 256 participants be excluded from treatment.
While the participants gave their spinal fluid, their blood, their urine, and their bodies, they never gave their permission. Involuntary participants in a government sponsored study, they were written about in 13 reports of the study that were published in medical science journals. The first report was published in 1936, and the final papers were published in the 1960s. The articles were largely ignored by medical ethicists who had long insisted that informed consent of participants was a necessary and ethical requirement of any responsible medical experiment regardless of the potential scientific advances. Supporters of the study claimed it would be a waste to not take advantage of the opportunity to research untreated syphilis. They viewed it as a study in nature that required simple and passive observation. Critics disagreed. They pointed to the deceptions of the PHS doctor and the beliefs of the participants that they were being treated. They also pointed out that at the moment of diagnosis, it was no longer a passive study but an experiment. Diagnosis after all was an action performed on the study's subjects.
Another key national health issue was the rise in the incidence of suicide. Some lasting lore of the stock market crash of 1929 was investors and brokers jumping out of building windows to their death after losing a fortune for themselves or their clients. Though such incidences did occur, the key issue was the prolonged effect of the Great Depression on the mental health of the population. As economic conditions worsened through the early years of the Depression, desperation also grew for many. They saw their options for escape narrowed with suicide remaining one of them. Parents saw their utilities shut off as they could no longer afford the monthly payments leaving their children in declining sanitary conditions. Though many contemplated suicide, relatively few actually did. The suicide rate rose from almost 14 per 100,000 population in 1929 before the Depression to over 17 per 100,000 by 1933 when economic conditions were at their worst. The rate declined from that point.
The greater number of research studies meant, of course, that the NIH needed more research dollars. They were able to achieve these additional funds through the Social Security Act. The Science Advisory Board, established by Roosevelt in 1934 and headed by future Surgeon General Thomas Parran, went to bat for the NIH and recommended that an additional two and a half million dollars be given to the research facility for studies in cancer, heart disease, tuberculosis, malaria, venereal disease, and dental problems. When the Social Security Act was approved, it authorized up to two million dollars for the investigation of disease and problems of sanitation. While Congress never gave the NIH the full two million, they were given increasingly larger sums of money. This made medical research one of the main functions of the U.S. Public Health Service. It also spawned the establishment of the National Cancer Institute in 1937, which was organized as a division of the NIH and became a prototype for many national research institutes established since the 1930s. Illustrating the growing public concern over the rise in cancer, the NCI awarded grants and fellowships to scientists working both within and outside the Institute and demonstrated the benefits of disease-oriented research agencies.
The Impact of the Surgeon General: Thomas Parran and the National Venereal Disease Act
One of the most successful public health campaigns against venereal disease was brought about through the efforts of Roosevelt's Surgeon General, Thomas Parran. Parran, a career public health officer, had been crusading against venereal disease even before he reached the national stage. As the state health commissioner of New York, Parran began a public information campaign aimed at removing the stigma of sexually transmitted disease. Parran approached syphilis and gonorrhea as treatable, infectious diseases, as solvable health problems, not shameful secrets. His educational campaign reflected this straightforward approach. When radio executives at the Columbia Broadcasting System censored his use of the word syphilis, he cancelled his appearance and received far more public attention when newspapers reprinted his censored speech. Parran brought the same direct attitude to his job as Surgeon General where he insisted public health workers use the appropriate medical term rather than vague local expressions that avoided the more formal terms.
Capitalizing on the Social Security grants to states to control venereal disease, Parran stepped up his education campaign and convened a National Conference on Venereal Work in 1936 that was attended by one thousand medical professionals and public health workers. Parran ignored critics who believed syphilis and gonorrhea were moral punishments of immoral behavior and publicized the tremendous costs of venereal disease. Before the advent of sulfa drugs in the mid-1930s and penicillin in the 1940s, treatments could range from three hundred to over a thousand dollars per family member. Yet, left untreated, the costs were even higher. Public health researcher Harry H. Moore attributed 14 percent of mental illness to syphilis, and it could also lead to cardiovascular disease, stillbirth, blindness, and premature death.
In his 1937 best-selling book, Shadow on the Land, Parran called for a "New Deal" for the innocent victims of sexually transmitted diseases, and in 1938 he succeeded when Congress enacted the National Venereal Disease Control Act. The act provided three million in matching grants to states for the first year, with additional funds promised the following two years and even more money slated for research. Despite Parran's success in increasing funding for public education, treatment, and research, venereal diseases remained a significant public health problem until the advent of the widespread use of sulfur drugs, 90 percent effective in curing gonorrhea, and penicillin, 90 percent effective against syphilis in the 1940s.
The Public Fight Against Tuberculosis and Polio
Parran's campaign against venereal disease modeled a process of publicity, education, funding, and research that was used to combat other public health problems of the 1930s. While tuberculosis rates had dropped to 71.1 per one hundred thousand by 1930 (down from two hundred per one hundred thousand in 1900), health departments still considered it the Great White Plague.
Renewed efforts to eradicate the lingering disease again centered on the milk supply and consisted of testing cows for tuberculosis and showing dairy farms how to safely dispose of infected cattle. Health departments also began large-scale screening drives of schoolchildren using recently developed X-ray machines that could take four X-rays a minute. Hoping to catch the disease as early as possible when it was most treatable, health officials combined the screening drives with educational programs on treatment and prevention. By 1940 early screening and treatment and improved living conditions had contributed to an additional drop in the death rate by tuberculosis to 45.9 per 100,000.
The Polio Vaccine Trials
The battle against polio was just starting. With significant outbreaks occurring in 1931, 1932, 1934, and 1939, it spawned a massive research effort that had Roosevelt, as a victim of polio, becoming its most prominent spokesman. Though many pondered whether poorer living conditions in rural areas and inner cities due to poverty caused by the Great Depression might have been driving this increase, researchers even decades later still had little knowledge what caused polio epidemics or even how the virus spread. Beginning in 1934 the President sponsored "Birthday Balls" on his birthday to raise funds and awareness for the Warm Springs Foundation in Georgia where he and many other polio victims received treatment. The Warm Springs Foundation became the National Foundation for Infantile Paralysis in 1938 and Roosevelt's "Birthday Balls" evolved into the annual March of Dimes Campaign during which radio listeners were encouraged to send their dimes to the White House. This campaign marked one of the first large-scale nationwide fundraising efforts and it was a remarkably successful volunteer effort. The March of Dimes Campaign was to provide a much-needed booster for polio research that had suffered a crucial setback during the 1930s.
Research and development of a polio vaccine began early in the 1930s and followed the normal course of vaccine research. Vaccines provoke a response from the immune system. This immune response results in protection from a certain disease and can be achieved through injecting an individual with a vaccine containing a live virus or a vaccine containing a virus that has been deactivated or in effect, is dead. Vaccines had been used by the U.S. Public Health Service to combat a number of infectious diseases including smallpox, diphtheria, and typhoid. Two vaccines were developed against polio in the early 1930s, the Kolmer and Brodie vaccines.
The Kolmer vaccine created by pathologist John Kolmer used a minute amount of live poliovirus, as he believed that it was necessary to create a permanent immune response. After testing the live polio vaccine on a number of monkeys without any noticeable side effects, Kolmer used the vaccine on himself, his wife and children, and 323 other children. Maurice Brodie, a Canadian physician, simultaneously developed a killed-virus polio vaccine. He tested this vaccine on himself and six adult volunteers from the New York Board of Health along with twelve children. From April to September 1935 nearly 11,000 children received Kolmer's live vaccine and nine thousand had received Brodie's killed-virus vaccine. Nine participants apparently died from polio caused by the live virus vaccine, after which Kolmer withdrew his vaccine. His belief that a virus too weak to infect monkeys would be too weak to infect humans was wrong. Brodie's vaccine also proved to be ineffective. Even though members of the American Public Health Association denounced the vaccine trials, both scientists maintained they used proper research methods. The questions raised by the polio vaccine trials were questions of timing. Exactly when does an experimental medicine become safe for clinical trial and, who, or what organization gets to decide it is safe for consumption—the scientist or the government?
The Federal Food, Drug, and Cosmetic Act of 1938
In 1936 Franklin Roosevelt Jr. had a throat infection that quickly turned serious. When Eleanor Roosevelt sought the help of researchers at John Hopkins University, where recent trials using sulfanilamide—a sulfur-containing drug—had shown tremendous success in treating infections, they treated him with sulfanilamide and saved his life. The sudden onslaught of publicity for this "new wonder drug" resulted in its quick adoption by the nation's doctors and health care professionals. Children especially benefited from sulfanilamide, which was very effective against many childhood infections. It also proved to be a remarkably potent remedy for gonorrhea, a fact publicized by Surgeon General Parran in his campaign against venereal disease. It was not a very pleasant drug to take, however, as it came in the form of a large and bitter pill. Therefore when Harold Cole Watkins of the S.E. Massengill Company of Bristol, Tennessee, was able to create a liquid form of the drug in July 1937 using the chemical diethylene glycol, the company excitedly began production and distribution.
Watkins did not conduct any tests on the product since, according to his knowledge, the actions of both ingredients were known to be safe. By September of that same year the product was on the market and it was advertised as particularly "suitable" for children. By October, however, six people who had taken Elixir-Sulfanilamide-Massengill had died. After hearing of the deaths the AMA conducted tests on the elixir and, discovering its toxicity, or the degree to which it was poisonous, quickly notified the press and the Food and Drug Administration (FDA). When the FDA visited Massengill, company president Samuel Massengill informed the FDA representative that he had already telegraphed the salesmen and the wholesalers who had purchased the drug. Unfortunately his telegrams did not contain the reason for the recall as Massengill did not want to admit fault, and more than 240 gallons remained on the market.
The FDA was powerless. They had no legal ground to stand on, as there were no laws preventing the release of a dangerous drug. They were, however, able to claim that the elixir had been mislabeled. Elixirs typically contain alcohol and this one contained the toxic glycol instead. Using the "misbranding," the FDA unleashed their entire force of 239 inspectors and chemists to hunt for the medicine. All but 11 gallons and six pints were retrieved. Tragically 107 people, many of them children, died an agonizing death as a result. The FDA filed criminal charges against Massengill and his firm although the case was never brought to trial. Watkins later committed suicide.
The Elixir-Sulfanilamide deaths revived interest in revising the 1906 Pure Food and Drug Act. A proposed bill was already in Congress whose main objective was to toughen the regulations governing the food, drug, and cosmetic industries. But the bill had been going nowhere for years because of harsh industry opposition. FDA officials, senators, and "consumer-minded" congressmen began the arduous task of creating a bill acceptable to industry yet still protecting consumers. Their legislative effort was spurred on by Ruth de Forest Lamb, the FDA's chief educational officer who authored a book on their fight, and a growing consumer movement nicknamed the "guinea pig muckrakers." The consumers were called this because of their desire to publicly expose misconduct in the food, drug, and cosmetic industries and specifically because of a book called 100,000,000 Million Guinea Pigs, which accused companies of using American consumers as experimental subjects (guinea pigs) for their advertised products.
FDA inspector George Larrick assembled a "Chambers of Horrors" exhibit for Senate hearings on the proposed Food Drug and Cosmetic Act. Eleanor Roosevelt was so impressed by Larrick's Chamber of Horrors that she borrowed the exhibit and put it on display at the White House for Congressional wives to view. Among its "horrors" were food products such as "Bred-Spread," which consisted of food dye, pectin, and grass seeds, and Doe Brand Vanilla Extract, whose one-ounce bottle was actually bigger than its two-ounce bottle.
After a five-year public relations and legislative battle, Roosevelt signed the Federal Food, Drug, and Cosmetic Act on June 25,1938. It gave the FDA oversight of cosmetics and therapeutic devices, authorized packaging and labeling standards for food products, called for factory inspections and safe tolerance levels for "unavoidable poisonous substances" contained in food products. Most importantly it required the manufacturers of new drugs to prove to the FDA with scientifically conducted studies that their products were safe for human consumption.
The Federal Security Agency
Shortly after the Federal Food, Drug, and Cosmetic Act was passed, the FDA was moved from the Department of Agriculture to the newly formed Federal Security Agency. Its move was part of a broad reorganization of federal agencies that Roosevelt undertook in the final years of the Depression. He initially wanted to consolidate the welfare, educational, and health activities of all federal agencies under one Federal Department of Public Welfare which would become a major department of the government with a secretary who would be a member of Cabinet.
Congress, which had become decidedly more conservative in the recent election, did not approve this plan. So instead Roosevelt proposed a new reorganization plan that would establish three general agencies, two of which involved federal relief and assistance efforts. The resulting Federal Security Agency resembled his proposed Public Welfare Department, but was not made a major department of the government and lacked the power of a cabinet-level secretary. It gathered under it umbrella many of the welfare agencies created by New Deal Legislation. The Social Security Board was made part of the Federal Security Agency as well as the United States Employment Service, the Office of Education, the NYA, and the CCC. The Public Health Service was also transferred to the Federal Security Agency. The newly formed agency administered health and welfare and was the forerunner of today's U.S. Department of Health and Human Services.
More About… Public Health Soldiers
The Public Health Service had their fair share of "martyrs" to the cause of researching infectious disease. Research-related deaths were reported during the 1930s in the medical literature and in the popular press along with the most common causes of death occurring from typhus, tularemia, Rocky Mountain fever, psittacosis, and polio. By 1941, 17 PHS workers had died from infections including one bacteriologist, Anna Pabst, who died on Christmas Day in 1936 from meningitis contracted from a laboratory animal. So infectious was the disease psittacosis, which is derived from birds, that investigators at the public health service laboratories developed the disease repeatedly. Several investigators developed more than one illness with one NIH researcher reporting that he had tularemia in 1913, undulant fever in 1928, and parrot fever in 1930. While the number of illness and deaths were small in comparison to the number of workers researching infectious disease, the way they were reported in the press began to change. In the 1920s the Journal of the American Medical Association and the New York Times began indexing research-related deaths under the terms heroes and martyrs. This new attitude towards these medical researchers was indicative of the growing esteem for medical research in the 1920s and 1930s in the popular press.
This same admiration could be seen in several fictional accounts of medical research into infectious disease. The 1934 Broadway play Yellow Jack, which told the story of Walter Reed's yellow fever experiments at the turn of the century, was praised by critics for depicting "what spiritual force it takes to ask such sacrifices." Later turned into a film in 1938, it was one of a number of 1930s films that celebrated the nobility of the medical profession. MGM produced popular feature films such as The White Parade, Women in White, and Men in White (starring highly popular actor Clark Gable), and short films on Pasteur's discovery of a rabies vaccine and on insulin. To the popular press and to Hollywood filmmakers, doctors, researchers, and public health workers were soldiers and heroes in the fight against infectious disease.
The First Campaign for Health Insurance
During the decades preceding the Depression many of the pieces of legislation that were passed during Roosevelt's New Deal had their first airing before Congress and before the American public. The first movement to pass a national health insurance plan happened at the peak of the Progressive Era and was coordinated by the American Association for Labor Legislation (AALL). This group of "social progressives" was founded in 1906 and its mission was to give a more humane and a more socially progressive face to American capitalism. Comprised of academics, social scientists, and labor leaders, it initially focused on eliminating hazardous working conditions. Its first successful campaign was against the occupational disease of phossy jaw, which afflicted workers exposed to phosphorous in match factories. It fought against child labor and its influence was pivotal to the passage of the first federal child labor law in 1916. They also campaigned for unemployment insurance and for a system of workmen's compensation.
In 1912 they turned their attention to health insurance. Inspired by the British National Insurance Act of 1911, the AALL formed a social insurance committee that quickly narrowed their focus to health insurance. After studying the British system of health insurance and comparing it to the liberal insurance benefits available in Germany, the AALL drafted a compulsory health insurance bill that was to cover medical, surgical, and obstetric (pregnancy and childbirth) care for laborers and their families who earned less than twelve hundred dollars annually. The cost of the program was to be split with employers and workers each paying two fifths and state governments contributing the final one fifth.
Initially the proposed system had the support of many. The AMA, who supported the AALL health insurance proposal in editorials published in their journal, thought at the time that a health insurance law was necessary and inevitable and formed its own Committee on Social Insurance in order to smooth "the new sociologic relations between physicians and laymen." Surgeon General Rupert Blue and national leaders in medicine and in national health organizations all spoke in favor of a compulsory health insurance law which Blue called "the next great step in social legislation." Encouraged by the positive preliminary reviews the AALL helped introduce compulsory health insurance bills in New York, Wisconsin, and several other states.
Right about the time the AALL started proposing health insurance, however, the medical profession was beginning to change its mind. While the AMA leadership still supported the proposals for health insurance at the time, their members were revising their opinions. Before World War I (1914–1918) health insurance was seen as a way of insuring their income. By the start of World War I in 1917 many physicians' incomes were on the rise. The higher their earnings, the less likely they were to support a compulsory insurance plan. Many physicians also viewed progressive proposals such as compulsory health insurance as a not-so-subtle attempt to put private physicians under the control of the Public Health Service and force them into group practices where they would be paid a flat rate per patient per year. While they agreed that there needed to be better access to medical care, they felt both their income and their independence were threatened. Working through state medical societies, they began lobbying the state legislatures that were discussing proposed bills. Private insurance companies also foresaw a drop in profits if health insurance bills were passed so they too began lobbying and were joined by labor organizations who thought their priorities should be improving compensation and shortening the work day rather than achieving health coverage. Their combined pressure, coupled with the increasing conservatism of the U.S. voters, resulted in the defeat of every proposed state insurance plan.
The First Campaign Against Syphilis
During World War I the U.S. Public Health Service increased the reach and exposure of its health care duties. They were initially put in charge of maintaining sanitary conditions in army camps. Mostly this meant anti-mosquito campaigns to reduce the threat of malaria and education and training on sanitation and proper camp hygiene.
Once those programs were organized and underway, however, the U.S. Public Health Service established a venereal disease division in order to provide prevention services and medical care for sexually transmitted diseases. Called simply an army appropriation measure, the division was given two hundred thousand dollars for organizational purposes and two million dollars to be given as grants to states. After the end of World War I funding for venereal disease control was gradually reduced until it was finally eliminated in 1923.
The First Maternal and Child Health Bill
During the decade preceding the Depression, the political climate was increasingly conservative and primarily focused on bolstering a weakening economy. It was a difficult environment to discuss the lack of health care needs of anyone. Women and children were the exception. In 1921 the Sheppard Towner Act was signed. This five-year act authorized an annual appropriation of one and a quarter million for the "Advancement of Maternity and Infant Welfare." Although it was considered by some as a demonstration of the type of emotional social legislation favored by women who had recently been given the vote, results of the act could actually be seen in the increasing attention paid to the welfare of children by governmental and philanthropic organizations. The year 1918 had been declared "Child Health Year" by the Department of Labor's Children's Bureau. The Child Health Organization was founded and five years later it was merged with the American Child Hygiene Association to become the American Child Health Association. This Association under the direction of future U.S. President Herbert Hoover (served 1929–1933) conducted a survey of child health in 86 cities and the results were dismal. Half of the 86 cities did not keep accurate birth and death records. Nearly twenty made no provisions for school medical exams. Forty-four percent of the children surveyed had received no vaccinations.
Despite the relatively low amount of money appropriated by the Sheppard Towner Act, especially given the relatively high level of need demonstrated by both private and public agencies, the Act was attacked by the AMA. While critics agreed that every mother and child should receive adequate medical care, they didn't think the federal government should pay for it. Although there was much grousing by the AMA and several state medical societies, forty states immediately applied for the federal grants made available by the act. They were used to increase the number of public health nurses and implement health education programs in schools. By 1924 all but three states were taking advantage of the money. Unfortunately, opposition by the AMA grew louder and the act, which was renewed for two years in 1926, was allowed to expire in 1929. It did however, serve as a preliminary model for federally matched grants to states, meaning states must provide funding to match federal funds, a particularly popular feature of New Deal legislation, and it paved the way for the grants to mothers of dependent children in the Social Security Act of 1935.
The First Food and Drug Act
When the Federal Food, Drug, and Cosmetic Act of 1938 was passed, it replaced a law that most public health service employees thought was ineffectual and useless. The 1906 Pure Food and Drug Act had started out with some muscle however. Brought about through the efforts of Dr. Harvey Wiley who headed up the Division of Chemistry, the "Wiley" law prohibited the manufacture and interstate shipment of "adulterated" or "misbranded" foods and drugs. Members of the food manufacturing industry originally inspired it seeking to decrease competition from highly processed foods, such as oleomargarine. Trade representatives also wanted federal standards that would eliminate the manufacturers' need to "manufacture differently for every state." A grassroots consumer movement similar to the one that would spur passage of the 1938 Act soon joined business interests and the General Federation of Women's Clubs and the National Consumers League lobbied hard for the "Wiley Act."
Wiley's motivation came from his own research. In 1902 he began the "Poison Squad," a group of male volunteers who agreed to eat foods treated with measured amounts of chemical preservatives in order to demonstrate their ill effect on health. The Poison Squad experiments, which went on for five years, fed the male volunteers foods laced with borax salicylic acid, sulphurous acid, benzoic acid, and formalde-hyde. Wiley's research demonstrated that preservatives should be used only when necessary and that they should be proven safe by the producer before eaten by the consumer. Both of these provisions were part of the 1906 Act.
The weaknesses in the Pure Food and Drug Act were quickly apparent. While the law allowed the government to go to court against mislabeled products, there was no explanation of what a properly labeled product looked like. This was somewhat remedied by the 1913 Gould Amendment which required contents to be declared. Food adulteration continued unchecked, however, because no standards had been set for what constituted a true product. Who decided what jam consisted of, and why couldn't it be made without fruit? Patent medicines went largely unsupervised as well because the government had to prove that the false claim of the product was done intentionally. The manufacturer need only show that he personally believed in the product's effectiveness in order to escape prosecution.
Despite the weaknesses of legislation such as the Pure Food and Drug Act of 1906 and the Sheppard Towner Act of 1921, they were important and vital steps towards the more revolutionary legislation of the 1930s. It would take the mis-steps of the progressive era, the failure of the state health insurance proposals, and the death of the first federal program aimed at mothers and their children to provide the necessary lessons on who stood on what side—who believed social legislation was not only just but inevitable and who believed it was just plain socialism.
The expansion of federally funded health care services during the Depression provoked a wide variety of reactions. Even though Presidents Hoover and Roosevelt shared a common interest in improving the health care of their citizens, their approaches were radically different. The same disparities were also evident at the organizational level with the AMA violently opposing every attempt to remove medical care from their control while several other organizations silently and not so quietly cheered for the government expansion. Even at the individual level, opinions of health care and funding for services varied widely and depended on income level and on personal superstitions and beliefs of how disease spread.
When Herbert Hoover was elected president of the United States, he brought a long history of child health advocacy to his new job. The first president of the American Child Health Association (CHA) in the 1920s, Hoover was instrumental in the fundraising successes of the organization. During his tenure as CHA president, the group raised several million dollars for health education and child health demonstration projects. Hoover believed that public health services had the power to radically change human life and that the elimination of disease was merely a matter of "administration and moderate expenditure." Proclaiming public health as essential as public education, he declared that society would be rewarded "a thousand fold in economic benefits and infinitely more in reduction of suffering and promotion of human happiness" (quoted in R.C. Williams. "The Research Work of the United States Public Health Service," p. 82). Unfortunately Hoover's public health efforts as president of the United States were not as glowing as his successes in the private sector. Although he was a strong supporter of federal aid for county health work and convened a White House Conference on Child Health and Protection in both 1929 and in 1930, he was hampered by his economic policies that restricted the use of federal money for relief efforts. During his administration, funding for health care was slashed in an effort to slow the decline of the U.S. economy.
Although Roosevelt was elected in 1932 on the basis of campaign promises to eliminate national debt and reduce federal spending even further, by the time he took office the state of the economy required drastic and emergency measures. This had an immediate impact on health care. Roosevelt ordered the Health Inventory, a study conducted by the Federal Emergency Relief Administration that surveyed 850,000 families across the nation. The study results were used to campaign for increases in rural health spending and the expansion of public health nursing. Although he did not take the same personal interest in children's health that Hoover did, Roosevelt was actually far more successful in providing funding for public health programs that targeted the needs of children including the Social Security Act's provisions for aid to families with dependent children. Ultimately, Roosevelt approached health care needs pragmatically and politically. While it is true that all of the major acts of the New Deal did contain funding for health care, he was quick to abandon initiatives that would not serve him politically.
The Social Security Act was to have contained provisions for health insurance until AMA opposition became so strong that Roosevelt told his Secretary of Labor Frances Perkins to file separate recommendations on health insurance that he later declined to make public. After the National Health Conference of 1938, Roosevelt was initially so enthusiastic about a national health program that he wanted to make it a campaign issue for the 1938 elections. He later backed off that plan and decided the 1940 presidential election would be a better forum. In the end, it was not a campaign issue in either election. The 1939 bill died a much quicker death in Congress because it lacked Roosevelt's support, and when later asked about health insurance in 1943, Roosevelt told a Senate committee chairman that, "We can't go up against the State Medical Societies; we just can't do it." Critics of the Roosevelt administrations claim that his support of any initiative, be it health care or social security, depended entirely on who lobbied the most. Ironically, even though health care programs were supported erratically during the twelve years of his presidency, health care spending vastly increased.
The American Medical Association
Although initially the American Medical Association, (AMA) supported compulsory health insurance plans—even going so far as to establish their own committee in 1916 to investigate what they then believed was an inevitable reorganization of the medical system—by the advent of the Roosevelt administrations, they were decidedly anti-insurance of any kind. By the Depression, the AMA viewed federal emergency relief as an invasion, a violation of the patient/physician relationship. It was a decidedly single-minded stance supported vigorously by an "active minority" of primarily urban specialists that held most of the influential positions within the organization during the 1920s and 1930s.
Opposing any change in how physicians were compensated, the AMA publicly lobbied and actively boycotted any individual or organization advocating government intervention in health care. Instead of viewing health insurance as a means to guarantee payment, the AMA viewed it as a way of putting medical service in control of non-medical personnel. The AMA response was to try and limit the number of doctors by encouraging medical schools to restrict their admissions. They also adopted more stringent requirements for foreign doctors seeking U.S. licenses. Despite being run by a vocal minority, the AMA continued to gather new members. A doctor had to belong to a local medical society in order to have access to hospital privileges and malpractice insurance. In order to be in a local medical society, a doctor had to join the national organization. In this way the AMA was able to sustain membership even though the membership was not being well represented by the organization.
The AMA was striking a difficult balance. Physicians' incomes had dwindled, as people were far more likely to spend their money on food and housing than on medical care. In fact people were likely to spend their money on just about anything except medical care. By 1933 physicians had seen their average income drop 47 percent nationwide. The rate of default (failure to pay) on medical bills was more than twice as high as the default rate for rent and mortgages. Even though their income was dropping the AMA still believed everyone should have access to medical care "whether able to pay or not." It was far more difficult, however, to convince poorer doctors to provide free medical service. These less-privileged professionals were also the most likely dissenters from the AMA position opposed to insurance.
Despite the AMA opposition to any form of health insurance, voluntary or compulsory, there were several forms of health insurance plans that were available during the Depression. Some of them were even federally funded. Medical cooperative societies had been around since 1929. They were organized around the principles of group practice, prepayment for services, preventive care, and patient participation in designing medical services available. Cooperatives were found commonly in rural communities. During the New Deal they served as good models for the medical plans created by the Resettlement Administration (RA) that took over many functions of the Federal Emergency Relief Administration (FERA) for rural areas. FERA was a New Deal program established in 1933 that provided funds to states to assist in relief efforts for those affected citizens by the Great Depression.
Part of the RA's broad relief plan for rural communities were several medical prepayment plans that operated throughout the Dakotas in the late 1930s. There was also private insurance that started with prepaid insurance plans for hospital stays. Under the guidance of the American Hospital Association these plans offered coverage for hospital costs only, not physicians' fees. Later additional plans of voluntary prepaid coverage for physicians' services were started in several states. The AMA viewed these voluntary plans, eventually renamed Blue Cross and Blue Shield, with reservations. They appeared less threatening, however, if controlled by county medical societies and were carefully endorsed following the National Health Conference of 1938.
The British and German Systems of Healthcare
Many of these alternative medical societies and voluntary insurance plans were based on European models. European countries tended to be far more liberal in social legislation. Great Britain had been guaranteeing healthcare for their citizens since 1911, when the British National Insurance Act established compulsory unemployment and health insurance through approved societies. Local committees administered benefits that included doctor visits, drugs, appliances, and sanatorium care for patients with tuberculosis. Germany had a national health care system as early as 1883 that provided medical benefits through a network of locally run independent funds. Sick-funds grouped workers where they lived on the basis of their occupation or industry. Medical benefits included physician visits, surgery, drugs, and eyeglasses, while maternity benefits lasted generally six weeks. Employees contributed two-thirds of the cost and employers paid one-third.
Supporters of compulsory insurance in the U.S. pointed to the wide access to healthcare in Great Britain and Germany. Detractors pointed to the lack of efficiency and to the control exercised by the local organizations that would surely try and limit medical expenditures in order to remain economically healthy.
Anti-Vaccine and Anti-Vivisection Societies: "Your Dog and Your Baby"
With the increase in medical research in the first three decades of the twentieth century, there was an accompanying backlash against the use of animals in medical experiments and the testing of new vaccines and medicines on vulnerable populations. For the anti-vaccine and anti-vivisection societies it was not a question of "your dog or your baby," as medical researchers would say, but rather "your dog and your baby." It was only a matter of time before ambitious researchers would turn their attention to human beings.
The anti-vaccination movement had been around as long as vaccines were developed against infectious disease. Long a pillar of public health care programs, vaccinations were viewed with great suspicion by many that received them. During a smallpox epidemic in Milwaukee in 1894, riots broke out in the city's German and Polish neighborhoods where parents refused to comply with the city's vaccination program. So effective were their demonstrations that the city council dismissed the health commissioner and reduced the powers of the local health department.
While membership and interest in these societies peaked during the 1880s and 1890s, there was a brief surge during the 1930s in response to stories of the polio vaccine trials and reports in the popular press of the use of orphans, soldiers, and prisoners in research trials. In 1933 the New England Anti-Vivisection Society had 534 members. By 1944 that number had increased to five thousand. Experiments on infants and children received special attention by anti-vivisection societies and they raised questions about the consent of so-called volunteers who were being used with their parents' permission. Because children lacked the cognitive ability to consent with full knowledge to medical experiments, critics commented that the use of the term volunteer was inaccurate. Castigating these "unnatural parents" for exposing their children to dangerous infections, they used their stories to demonstrate the need for government oversight of medical research.
The American Public
There did seem to be some detachment between physicians and their patients. In the American Institute of Public Opinion Survey conducted from 1938 to 1939, 42 percent of respondents said they had put off going to a doctor because of the cost. Sixty-three percent of physicians believed that the people of their communities were receiving adequate medical care and that included those who could not pay for it. The physicians that were polled overwhelmingly approved of voluntary insurance plans and believed that voluntary plans would increase their income. Eighty-one percent of all the respondents thought the government should be responsible for providing medical care for people unable to pay. More than half of them were willing to pay taxes to fund such a system.
The public as it was becoming more educated about disease and health was becoming more concerned about health issues, particularly with the increased incidence of polio and greater awareness of cancer. The unknowns about polio regarding how it spreads and what causes it generated a good deal of fear in the population. As a result the public was largely supportive of the new governmental efforts to tackle some of these health issues. As with New Deal programs, in general, support was less critical at first and the call for universal health care was strongest in the early part of the Great Depression. Fears of the rapidly growing government, particularly among congressional members, by the later 1930s tempered their enthusiasm for health care proposals. In addition Congress and the public were continually bombarded by the medical profession that fought hard in opposition to any government role in the health care field. Swayed to a large degree by the arguments in opposition to national health care programs, patients feared losing control over their freedom of choice of doctor and type of care received. Such public sentiments would carry forward for the rest of the twentieth century.
Many of the public health achievements of the 1930s had far reaching consequences. Public health historians point to Thomas Parran's anti-venereal disease campaign as the first time a Surgeon General used science to advance a politically unpopular position. Luther Terry used the same tactics in 1964 to warn about the hazards of smoking and hepatitis, and C. Everett Koop approached HIV/AIDS in the same manner in the 1980s. Historians also point to the 1938 Federal Food, Drug, and Cosmetic Act as one of the most significant achievements of the Food and Drug Administration. Amended in 1962 to more stringently regulate prescription drugs, the act has been used repeatedly to safeguard consumers against food additives, pesticides, and harmful agents. The Social Security Act created a permanent vehicle for distributing funds to the public for welfare needs. Even though the Depression ended with World War II Social Security did not and it was amended in 1939 to extend coverage and raise benefits and in 1956 to include disability insurance. Health insurance would have to wait though until 1965 when Lyndon Johnson's War on Poverty created Medicare and Medicaid, health programs that made comprehensive health care available to millions of poor Americans.
The U.S. Public Health Service celebrated its bicentennial anniversary in 1998. Now part of the U.S. Department of Health and Human Services, a cabinet-level department since 1953, the U.S. Public Health Service today faces new versions of many historic challenges. Instead of yellow fever, polio, or cholera, the Public Health Service fights against HIV/AIDS, hepatitis C, and the Hunter Virus. While the last case of smallpox occurred more than three decades ago and polio could be stamped out worldwide in the next decade, there are renewed concerns about more virulent strains of malaria and tuberculosis and the even more unsettling threats of bioterrorism. The Public Health Service is still carrying out many programs initiated during the 1930s including vaccination programs, sanitation efforts, prenatal care, and screening programs for cancer. Working through eight divisions—including the Food and Drug Administration, the Centers for Disease Control and Prevention, the Agency for Health Care Policy, and the National Institutes of Health—the Public Health Service's mission remains the same, to use the advancements of science to improve human health.
Grace Abbott (1878–1939). Social activist and author of the 1938 book The Child and the State, Grace Abbott was Chief of the Department of Labor's Children's Bureau. Initially trained as a teacher Abbott worked for immigrants' rights before joining the Children's Bureau in 1917 where she was made director of the child labor division and put in charge of enforcing the first child labor law. Abbott was one of the authors of the provisions for Aid to Dependent Children in the Social Security Act of 1935.
Walter G. Campbell (1877–1963). Campbell started his career with the Food and Drug Administration in 1907 when he was appointed one of the first 28 food and drug inspectors. Later promoted to chief inspector by Harvey Wiley, the author of the1906 Pure Food and Drugs Act, Campbell devised the legal process for the first seizure of a product in violation, wrote the first Inspector's Manual in 1908, and set up the FDA's first project system to ensure uniform enforcement. During the 1930s Campbell directed the five-year campaign for the passage of the 1938 Food, Drug, and Cosmetic Act. Campbell remained in charge of enforcement for nearly forty years and became the first "Commissioner of Food and Drugs" in 1940, retiring in 1944.
Hugh Smith Cumming, M.D. (1869–1948). Surgeon General of the U.S. Public Health Service from 1920 to 1936. Hugh Smith Cumming joined the Marine Hospital Service in 1894 and was involved with immigration and quarantine duty in 1912 when the Marine Hospital Service became Public Health Service. He was also active in controlling water pollution through the Hygienic Laboratory and was a sanitary advisor for the Navy during World War I. Cumming was appointed Surgeon General in 1920. Initially he was concerned with the care of veterans that was the responsibility of the Public Health Service until Congress created the Veterans Bureau in 1922. He also revised immigration policies so that immigrants received medical exams in their country of origins eliminating the number of immigrants who were turned back after making the trip to the United States. Cummings expanded the work of the Hygienic Laboratory and supervised its transformation into the National Institute of Health. Cummings also expanded PHS work in the areas of mental health and drug addiction and oversaw the first expansion of the PHS corps to admit dentists, pharmacists, and sanitary engineers. Hugh Cumming retired as Surgeon General and from active duty in the PHS in 1936.
Ruth de Forest Lamb (1896–1978). Ruth de Forest Lamb was the Food and Drug Administration's chief educational officer during their five year campaign to pass the 1938 Federal Food, Drug, and Cosmetic Act. Author of The American Chamber of Horrors, which exposed manufacturers who violated the 1906 Pure Food and Drug Act, she organized consumer support for the 1938 law. Her career before the FDA included degrees in economics, history, and biochemistry and stints as a writer with New York newspapers and advertising firms.
Isidore Falk (1889–1984). One of the first "medical economists," Isidore Falk was originally trained as a bacteriologist and later developed a model for social research on medical care that was to be used until the end of World War II. Author of numerous publications on the economics of medical care including Security Against Sickness: A Study of Health Insurance, Falk served on the Committee on the Costs of Medical Care, the Committee on Economic Security, and on the Technical Committee on Medical Care.
Harry H. Moore (1881–1960). Author of American Medicine and the People's Health, Moore was a public health economist with the U.S. Public Health Service until he left to serve as staff director of the Committee on the Costs of Medical Care. In 1927 Moore argued that medical services in the United States were poorly distributed and badly organized when he said, "What exists is not so much a system as a lack of system."
Thomas Parran, M.D. (1892–1968). Surgeon General of the U.S. Public Health Service from 1936 to 1948. Thomas Parran began his career in the Public Health Service in the field of rural sanitation. He later took on assignments in rural health services administration and the control of communicable diseases. After completing a six-month course of study in public health at the Hygienic Laboratory, he became Chief of PHS's Division of Venereal Disease. Parran viewed venereal disease as a medical condition and a solvable public health problem and he campaigned accordingly to change public opinion away from moral condemnation of venereal diseases. Parran served as the health commissioner of New York under then-Governor Franklin Roosevelt and he worked primarily on revamping the state's county health departments to accommodate the needs of the Depression.
Roosevelt appointed Parran to the Committee on Economic Security, which drafted the Social Security Act of 1935. Following the retirement of Surgeon General Hugh Cumming, President Roosevelt appointed Parran as Surgeon General. Parran used the office of Surgeon General to launch a national campaign against syphilis with funds from the Social Security Act that supported efforts to identify and treat syphilis. In 1937 Parran published Shadow on the Land in which he stated that "Studies show that syphilis cuts in half the ability to do a full day's work, doubles the load of the unemployables. Yet the cost of finding and treating a case of syphilis among rural Negroes is less than one week's relief wages. If the Government were to take one fifty-second of the annual average wage, one week's pay, and spend it in finding and treating syphilis, the results would more than pay for the cost in better labor efficiency" (quoted in Susan M. Reverby, ed. Tuskegee's Truths: Rethinking the Tuskegee Syphilis Study. Chapel Hill: University of North Carolina Press, 2000, p. 66). In 1938, largely due to Parran's long campaign, the National Venereal Disease Control Act was signed.
In addition to his campaign against syphilis Parran also successfully reorganized the Public Health Service into four bureaus, a structure that would last until 1967, and expanded NIH research. Parran later chaired the International Health Conference during which the World Health Organization (WHO) was organized.
Parran also supported national health insurance and focused on creating a regionally organized health services infrastructure. The AMA attacked Parran for his views, and President Truman's decision not to reappoint him in 1948 may have been the result. Parran retired from the PHS in 1948 but remained active in international health organizations until his death.
The U.S. Public Health Service added a nursing division early in the 1930s and worked closely with other government agencies such as the Children's Bureau and their Child Health Nursing Project and with private organizations such as the National Organization for Public Health Nursing. By 1936 more than six thousand graduate nurses were employed by the Works Projects Administration who ran over 75 projects in 16 different states.
The following two excerpts are from the Federal Writers Project on American Life Histories. Two nurses, one working in a rural county and the other employed by a city hospital, describe a day in their work life. Their language and attitudes, although typical for the decade, do contain some racially insensitive material.
South Carolina Writers' Project
Mrs. Martin, Public Health Nurse
Date of First Writing February 10, 1939
Name of Person Interviewed Mrs. Walter W. Herbert (White)
When my husband was in the hospital and the situation was so desperate, I knew that I had to do something quickly. Fortunately I had nursing to turn to. It was in 1933, in the day of the FERA, before it was changed to the WPA, I applied for, and succeeded in getting, a place with the public health department, and went to work. I worked very hard, and when a change was made in the administration and all the other nurses were let out, I was kept on and put in charge of the newly organized department.
Then in 1936 I heard that there was a vacancy in the City and County Health Department I know that if I should get it that it would be a permanent position and would take me off the WPA. So I applied, and to my surprise, got it. I really hated to give up my work on the WPA, and shall feel eternally grateful for the chance given to me through the New Deal. But I had to think of the future. [L]et me show you a letter which I received a few days ago. It will give you an idea of some of my experiences. Here it is, written in pencil: "Dear Mrs. Martin: today is two weeks Ive been confined to bed very ill now little Helen has had feaver since Saturday very high feaver all night if the nurse comes there today tell her to please be sure come here to see about her for me. Thanks, Helen's Mother.
I went to this house which consisted of one large room—nothing more. It was almost bare. In a corner some sacking had been nailed to the rafters in order to give a slight amount of privacy to the bed and its occupants, for mother and daughter were in the same bed. I found that the neighbors had become so concerned about the condition of the family that they had taken up a collection to pay for the services of a doctor. So, of course, I could do little for them. I did, however, bathe and freshen them up as much as possible under the circumstances, and left a note for the doctor telling him what I had done. I had given temperature readings. The little girl's temperature was 103 degrees. If he had not been called I would have telephoned an ambulance and taken them to the hospital immediately, but public health nurses never interfere when a regular doctor has been called. The child has double pneumonia. It is a pathetic case, though only one of many.
At nine o'clock every morning I am at my office. I spend an hour checking over reports and letters, and taking telephone calls. Then the doctor and I attend to these calls before visiting at least one, and often two or three, schools before lunch time, where we examine and test the children for various symptoms of disease, including eye-trouble; teeth, heart and lungs affections. Every child is weighed, and a card index is carefully kept of each case. After lunch I go to the hospital and work in the wards doing dressings until five o'clock. Often at night I attend classes, either teachers classes or first aid.
South Carolina Writers' Project
The County Health Nurse
Date of First Writing January 31, 1939
Name of Person Interviewed Miss Mattie Ingram
"Want to come with me for a trip into the country? I'm making the rounds of my colored pre-natals this afternoon." Miss Brunson, the plump little blue-uniformed county health nurse smiled and held open the door of her car invitingly, while she transferred her familiar black bag to the back seat beside a stack of newspapers.
"What's in that?" she repeated my question as she stepped on the starter. "Nothing more exciting than a stethoscope, a fluid for testing urine, and some first aid articles. And the newspapers are for those nearing confinement. We have so little to work with among the Negroes, you know. They seldom enough sheets and those they have are usually so dirty that there's danger of infection. We have found that newspapers solve the problem satisfactorily.
"How did I come to be a nurse?" She laughed and pushed back a curl which the brisk spring breeze had whipped across her face. "Well, I really wanted to go to college, but I happened to have been born one of a family of twelve children on a farm in South Georgia. A farmer with a dozen children to feed and clothe doesn't save much toward college educations for them, so I had to be content with high school. When I graduated, I decided to be a nurse and entered training in Macon. I finished my course in 1920, did private and institutional work for nine years, had one year of public health work and came here about nine years ago."
Miss Brunson slowed down and turned off the highway onto a country road. "You want to know something about my work? Well, I conduct three venereal and three prenatal and well-baby clinics each month, instruct a weekly class of mid-wives, examine and vaccinate school children and, in between times, do home visiting. I can tell you, it keeps me pretty busy."
… The nurse gestured in the direction of the cabin. "The woman who lives there—Sara Roberts—won't have her baby for sometime yet, but she hasn't been coming in to the clinics lately and she needs to take the shots for syphilis. In spite of the fact that twice as many Negroes in this county took treatment for venereal diseases this year as last, it is still hard to persuade them to keep up the treatments. No matter how carefully we explain, they become alarmed when they begin to feel the effects of the shots."
… The nurse's eyes were thoughtful. "It's a vicious circle. When they don't take treatment for venereal disease, the babies die and that makes the mortality rate for South Carolina appallingly high. And when they do take the treatment, the birthrate shoots up just as appallingly. Although that makes the vital statistics records look pretty, it clutters up this part of the earth with thousands of ragged, half-fed children.…"
"Do I find it depressing? Well, yes, in a way. But I try not to let myself think about it when I am off the job. I do other things in order not to think about it.…
We have to keep remembering not to be impatient about it, and to hold on to our sense of humor. There's a lot to appeal to the sense of humor in this work, if you don't get too serious to see it.
- Trace how the office of Surgeon General has changed depending on the needs of society and depending on the interests of individual surgeon generals.
- Analyze the FDA recall of Elixir-Sulfanilamide in 1937 and compare it with more recent FDA recalls.
- Compare the daily lives and working experiences of public health nurses working in rural counties and in urban areas.
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