The history of public health in the United States studies the US history of public health roles of the medical and nursing professions; scientific research; municipal sanitation; the agencies of local, state and federal governments; and private philanthropy. It looks at pandemics and epidemics and relevant responses with special attention to age, gender and race. It covers the main developments from the colonial era to the early 21st century.
At critical points in American history the public health movement focused on different priorities. When epidemics or pandemics took place the movement focused on minimizing the disaster, as well as sponsoring long-term statistical and scientific research into finding ways to cure or prevent such dangerous diseases as smallpox, malaria, cholera. typhoid fever, hookworm, Spanish flu, polio, HIV/AIDS, and COVID-19. The acceptance of the germ theory of disease in the late 19th century caused a shift in perspective, described by Charles-Edward Amory Winslow, as "the great sanitary awakening". Instead of attributing disease to personal failings or God's will, reformers focused on removing threats in the environment. Special emphasis was given to expensive sanitation programs to remove masses of dirt, dung and outhouse production from the fast-growing cities or (after 1900) mosquitos in rural areas. Public health reformers before 1900 took the lead in expanding the scope, powers and financing of local governments, with New York City and Boston providing the models.
Since the 1880s there has been an emphasis on laboratory science and training professional medical and nursing personnel to handle public health roles, and setting up city, state and federal agencies. The 20th century saw efforts to reach out widely to convince citizens to support public health initiatives and replace old folk remedies. Starting in the 1960s popular environmentalism led to an urgency in removing pollutants like DDT or harmful chemicals from the water and the air, and from cigarettes.Jan Kirk Carney, A History of Public Health: From Past to Present (2022) onlineJohn C. Burnham, Health Care in America: A History (Johns Hopkins UP, 2015) online.John Duffy, The Healers: A History of American Medicine (U of Illinois Press, 1976) online A high priority for social reformers was to obtain federal health insurance despite the strong opposition of the American Medical Association and the insurance industry. After 1970 public health causes were no longer deeply rooted in liberal political movements. Leadership came more from scientists rather than social reformers. Activists now focused less on the government and less on infectious disease. They concentrated on chronic illness and the necessity of individuals to reform their personal behavior—especially to stop smoking and watch the diet—in order. to avoid cancer and heart problems.Jesse Bump, "Public health needs to reform–Here's the way forward," Harvard Public Health (February 13, 2023) https://harvardpublichealth.org/policy-practice/public-health-needs-to-reform-heres-the-way-forward/ online.John C, Burnham, Healthcare in America, a history (2015) pp.467–486.Paul Starr, The social transformation of American medicine: The rise of a sovereign profession and the making of a vast industry (Basic, 1983). 379–419.
Colonial era to 1789
The healthcare system began in the Colonial Era. Localistic community-oriented care was typical, with families and neighbors providing assistance to the sick using traditional remedies and herbs. New immigrants to the colonies had high death rates from their exposure to a new disease environment. However, by the second generation death rates were lower than in England because there was much more food and less crowding. Becoming a regular doctor was difficult. Finally in 1765 the first medical school opened at the College of Philadelphia. That city opened a hospital in 1751; the second one opened in New York City in 1791. By 1775 the 13 colonies had 3,500 to 4,000 regular doctors. About one in ten was formally trained, usually in England or Scotland. They had a clientele among the wealthier classes, but the popular image was one of distrust.Richard H. Shryock, "Eighteenth Century Medicine in America," Proceedings of the American Antiquarian Society (Oct 1949) 59#2 pp 275–292. onlinePaul Starr, The Social Transformation of American Medicine (1983) pp. 30-54.Daniel J Boorstin, The Americans: The Colonial Experience (1958_ pp. 209–239, 401–405.
Colonial death rates and family patterns
The Chesapeake region --Maryland and Virginia—experienced high mortality rates, particularly among new arrivals from England. This high death rate significantly impacted family structures and slowed population growth. Men immigrated far more than women, so there was a persistent shortage of females in the Chesapeake colonies, which further stifled natural population increase and lowered rates of marriage for men. Due to the high mortality rates and unbalanced sex ratio, traditional family structures were difficult to maintain. Many families consisted of step-parents, step-children, and half-siblings, creating complex family networks. By contrast, New England had lower death rates, and much more family stability, and enabled the patriarchal New Englanders to better make long-term plans for acquiring enough land to provide farms for the next generation.Daniel Blake Smith "Mortality and Family in the Colonial Chesapeake," Journal of Interdisciplinary History 8.3 (1978): 403-427 online."Themes and Variations in Family Patterns" Digital History TOPIC ID 76 (2021) onlineDaniel Scott Smith, "The demographic history of colonial New England." Journal of Economic History 32.1 (1972): 165-183. online
Smallpox Smallpox was pandemic but vaccination was introduced in the 1750s. In the 1775–1782 North American smallpox epidemic data based on remnant settlements indicate at least 130,000 people died in the epidemic that started in 1775.Elizabeth A. Fenn, Pox Americana: The Great Smallpox Epidemic of 1775–82 (Hill and Wang, 2001) online.
During the Revolution General George Washington insisted his soldiers get inoculated else his forces might get decimated or the British try to use smallpox as a weapon.Richard J. Werther, "George Washington and the First Mandatory Immunization" Journal of the American Revolution (2021) online
The New Nation to 1900 Statistics and sanitation Lemuel Shattuck (1793–1859) of Boston promoted legislation that required a better statewide system for the local registration of vital information on births and deaths. He specified the need for precise details on age, sex, race, and occupation, as well as standard terminology for diseases and cause of death. This law was passed in 1842 and was soon copied by most other states.Tulchinsky and Varavikova, "A history of public health." His proposals greatly expanded the questionnaires used in the Massachusetts state census of 1845. He was a key consultant for the 1850 United States census. He helped convince Congress to fund a much more complex census, and he designed most of the interview forms used by door-to-door canvassers. His Report on the Sanitary Condition of Massachusetts in 1850 on a sanitary survey of Massachusetts was farsighted. It explained how to remove the giant mounds of dirt, horse dung, and outhouse production that were overwhelming the neighborhoods of fast growing cities. It inspired reforms in many cities that faced the same public health crisis.Brian Beach, "Water Infrastructure and Health in U.S. Cities" NBER Working Paper 28563 (2021) DOI 10.3386/w28563
Metropolitan Board of Health in New York City
The Metropolitan Board of Health was established in 1866 by the Radical Republican who controlled the New York state legislature. It became a model for many major cities due to its innovative approach and effectiveness in addressing public health issues. The state government gave the city's Board extensive powers to create, execute, and judge ordinances related to public health. This comprehensive authority allowed for swift and effective action in addressing health crises. The Board leadership consisted of four police commissioners, the health officer of the Port of New York, and four commissioners appointed by the governor, three of whom were required to be physicians. This diverse makeup ensured a balance of expertise and perspectives. Within weeks of its formation, the Board secured agreements with city butchers to clean up and relocate slaughterhouses, imposed health standards on the milk industry, improved water supply, and began cleaning city streets. When the cholera epidemic broke out in the spring of 1866, the Board successfully fought it with a stringent health code, house-to-house inspections, disinfectants, and quarantines. This resulted in a significantly lower death toll in New York City compared to other major cities. The Board's formation was preceded by a comprehensive sanitary inspection of New York City, which revealed widespread poor living conditions in the slum districts. This data-driven approach to identifying and addressing public health issues was modelled after Shattuck's statewide work in Massachusetts. It became a standard practice in other cities. Furthermore, the Board recognized the connection between housing, politics, morals, and health, setting a precedent for addressing the social determinants of health.John Duffy, A History of Public Health in New York City, 1866-1966 (1968) online pp.1–31."1866 – The Metropolitan Health Act was passed in New York" online
The success of New York City's Metropolitan Board of Health in improving public health conditions and managing disease outbreaks demonstrated the effectiveness of a centralized, empowered health authority. This model was subsequently adopted by other cities and states, shaping the future of public health administration in America.
Medical education
Many of the early medical schools in the United States were founded by alumni of the University of Edinburgh Medical School, in Scotland. The nation's first medical school opened in 1765 at the College of Philadelphia by John Morgan and William Shippen Jr. It evolved into the University of Pennsylvania's Perelman School of Medicine. In New York City in1767, Dr. Samuel Bard opened a medical school. In 1814 it became Columbia University's Vagelos College of Physicians and Surgeons. Harvard Medical School opened in 1782; Dartmouth in 1797; Yale in 1810.