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Child Health Perspectives |
PERSPECTIVE
Children’s Public Health Policy In The United States: How The Past Can Inform The Future
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As we struggle to respond to child public health problems in the twenty-first century, the past provides many core lessons. This paper explores three of them: the need to focus on the environment that makes children sick rather than on sick children; the need to attack the biggest problems, not the most scientifically interesting ones; and the need to provide services where children are most likely to be. To illuminate these lessons, we discuss important child public health efforts in the nineteenth and twentieth centuries.
Near the end of his life, President Harry S. Truman admonished a journalist, "There is nothing new in the world except the history that you don’t know."1 As historians of medicine and public health, we interpret this advice to suggest that understanding history is critical to the development of informed policy discussions today and in the years to come. Perhaps nowhere in the field of health policy is this adage more cogent than in how we plan for our most valuable asset: our children.
In 1900 the Swedish author and feminist Ellen Key proclaimed the twentieth century to be "the century of the child."2 She had good reasons to make such a proclamation. Coincident with a burgeoning child welfare movement in the United States were tremendous advances in public health, particularly in children’s health. The conquest of many of the most deadly infectious diseases; the creation of a national public health infrastructure; the building of hospitals, clinics, medical schools, and research laboratories; and the allocation of resources to solving the problems behind infant and child mortality all signaled our country’s commitment to preserving and protecting the health of its citizens and to ensuring the well-being of future generations.
The second half of the twentieth century was an era when access to care expanded, thanks to exponential growth in Americans’ personal income as well as the creation of an array of new government health programs such as Medicare, Medicaid, Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for children, and, more recently, the State Children’s Health Insurance Program (SCHIP). But there is more work to be done in this area, and nothing will do more to guarantee access to care for all U.S. citizens than the creation of a national health insurance program. Although we regard access to and the provision of appropriate, high-quality services as vital, we say little about this here. We concentrate instead on child public health as an expansive domain in which the social and medical needs of all children are the focus. We suggest a few critical historical lessons that children’s health care professionals and policymakers ought to consider as an agenda is set for the twenty-first century.
| Lesson 1: Focus On The Environment That Makes Children Sick Rather Than On Sick Children |
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 Top Lesson 1: Focus On... Lesson 2: Attack The...Lesson 3: Child Public...Conclusion: We Don’t...Editor's NotesNOTES |
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Then. A century or more ago, those interested in preserving the lives of infants and children had little choice but to approach the issue from an environmental perspective, largely because they lacked the means to prevent specific illnesses or to treat them effectively. As a result of a broad-based, environmentally focused effort, the extraordinarily high U.S. infant mortality rate—the most visible health problem during the second half of the nineteenth century—was successfully attacked and ameliorated. Sanitary engineering yielded clean water for Americans of all ages. Improvements in the milk supply, combined with legislative measures and efforts by local public health departments, culminated in mandatory pasteurization regulations that helped reduce infant deaths linked to feeding problems, diarrhea, and dehydration. In addition, the education of mothers, the construction of neighborhood health clinics, and the opening of visiting nurse services helped families prevent or cope with children’s illnesses. Contributing to the success of these public health measures were rising incomes, which facilitated improved living conditions, better nutrition, more years of schooling, and reduced workloads for children and families.3
Primary movers and shakers. Reformers, civic officials, physicians, and the media all played important roles in this national crusade to "save the babies." Philanthropists supported milk stations, where clean milk was distributed to poor children, and funded settlement houses and other places where children and parents received education and social services. City health departments created and supported visiting nurse programs, municipal dispensaries, and bacteriology labs for testing suspected cases of infectious disease and for producing vaccines and diphtheria antitoxin. Doctors developed the specialty of pediatrics, served children in clinical and residential settings ranging from hospitals to orphanages, and investigated and discovered methods for treating and eventually for preventing major killers. Journalists and newspapers exposed the problems of poverty and the workplace exploitation of children and championed new initiatives. One such initiative was the creation of White House Conferences, national meetings of experts and activists that were held every decade beginning in 1909 to address the ever-changing needs of children.
Rural reforms. More broadly, there was a growing awareness by many U.S. citizens during the first half of the twentieth century of the health problems of children living in rural communities, of children who left school early to work long hours on farms and in other workplaces, and of children whose school attendance was compromised by poor health. This led to several new forms of public health promotion including well-baby shows at county fairs, medical inspection of schools, rural visiting nurse programs, and the distribution of maternal advice literature in both rural and urban immigrant communities.4
Government programs. By the second decade of the twentieth century, the federal government had joined the effort to combat maternal and infant mortality by enacting the Sheppard-Towner Maternity and Infancy Care Act of 1921, a triumph of Progressive Era activism. This law provided matching funds to the states that passed enabling legislation and created agencies to promote infant and maternal health. Many programs underwritten by Sheppard-Towner targeted poor and working-class families and provided important health services such as infant hygiene classes for mothers and health inspection programs for infants and children. Despite its effectiveness, however, the program was short-lived; Congress did not renew the law in 1927 because of organized opposition. Physicians’ groups argued that these programs compromised their professional autonomy and limited their incomes, while political opponents claimed that federal health initiatives were harbingers of socialism. Also, the health and welfare needs of the elderly gained political attention during this period, draining interest and dollars away from child public health. Eventually children’s interests were relegated to the domain of welfare, and although poverty was indeed a major factor in the poor health of many infants and children, a focus on income problems and on keeping family assistance to a minimum did little to meet the need for children’s preventive and medical care.
And now. Ironically, many of the problems facing infants and children today are those that require broad-based environmental responses similar to those applied a century or more ago. In 1999 the five leading causes of death for children ages one to fourteen were accidental injury, congenital anomalies, malignant neoplasms, heart disease, and homicide.5 Not all of these can be prevented (or treated) solely with the application of scientific research, nor can advances in medical science be universally applied if a considerable number of U.S. families lack access to health care. Environmentalism and the merging of social and medical approaches to public health remain valid methods for improving the well-being of U.S. children today.
| Lesson 2: Attack The Biggest Health Problems, Not The Most Scientifically Interesting Ones |
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| TopLesson 1: Focus On...Lesson 2: Attack The...Lesson 3: Child Public...Conclusion: We Don’t...Editor's NotesNOTES |
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Then. The dramatic success of efforts in the late nineteenth and early twentieth centuries to lower infant mortality rates had a paradoxical effect: Attention to the fundamental health problems confronting infants and children waned, while scientific interest in and funding for less prevalent but more intellectually challenging health issues expanded. Modern scientific medicine has delivered important breakthroughs for child public health, such as the development of immunizations against major childhood killers including measles, diphtheria, whooping cough, and polio-myelitis; new inroads against childhood cancers; effective attacks on problems associated with premature birth and birth defects; and techniques for solving a host of surgical problems. Yet as the medical and scientific establishments created a research infrastructure poised to deliver these advances after World War II, it also moved away from the humanitarian environmentalism that marked the early twentieth century’s crusade for children’s health.
And now. Today many cutting-edge, academic pediatricians spend much of their time hunting down the genetics of rare metabolic diseases and childhood cancers or developing surgical interventions for equally rare congenital malformations, while a sizable proportion of U.S. children are becoming overweight or obese, with all of the attendant complications and health consequences. At the same time, developmental specialists are researching what makes children "anxious" by scanning their brains, and parents are demanding simple solutions, often in the form of a pill, to make their children more manageable or pleasant, while children with serious mental and developmental problems are unable to get the medical attention they need or benefit from the long-term effects of scientific research on their condition.
From public interventions to private measures. Other developments have also complicated efforts to attack many important child health problems. The focus in medicine has shifted away from public interventions and toward private ones, as health maintenance has increasingly come to be seen as an individual responsibility. Many health problems that we encounter today—such as poor nutrition, obesity, and substance abuse—are seen as caused solely by the behavior of those who experience them and outside the domain of medicine. Nevertheless, these problems represent major threats to the health of children.
Medicine is not enough. The substantial decrease in child deaths attributable to environmentally defined public health measures resting on medical intervention via vaccines and treatments shows what sustained, broadly conceived efforts can accomplish. Yet scientific medicine alone is not enough, as demonstrated by low vaccination rates, especially among the poor and those concerned about the rare problems associated with these biological agents. Public health education remains as critical as it was a century ago.
Economic challenges. Funding is also a concern. In the past the debate was whether public or private provision of care was the answer. Today the calculus is much the same, although it is complicated by the burgeoning growth of health care as a for-profit business, which creates a situation in which the treatment rather than the prevention of illness is financially rewarded. Just as Progressive Era reformers had to confront those who opposed the provision of maternal and child health services, policymakers in the twenty-first century must be prepared to negotiate with multiple stakeholders and to grapple with complex economic challenges.
Hidden suffering. As in the nineteenth century, we must begin by standing on the street corner (or perhaps in the shopping mall) and observing the infants, children, and adolescents who pass by. The briefest glance today often reveals many who are overweight; wheezing with asthma; abusing dangerous substances such as alcohol, tobacco, and marijuana; and carrying guns or other weapons. Perhaps more alarming is the hidden suffering revealed in the astoundingly high homicide and suicide rates among children and adolescents. These public health problems can be ameliorated. But it will take a concerted effort to bring media interest and citizens’ attention to these problems, to force them to the top of the national agenda.6
| Lesson 3: Child Public Health Professionals Need To Go Where The Children Are |
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| TopLesson 1: Focus On...Lesson 2: Attack The...Lesson 3: Child Public...Conclusion: We Don’t...Editor's NotesNOTES |
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Then. Going into the communities where patients have the greatest need is hardly a twenty-first-century invention. Doctors, public health workers, nurses, social workers, and many others have been a major part of improving the health of the urban and rural poor by playing an active role in their lives and communities for much of U.S. history.
Dispensaries/clinics. Perhaps best known was the nineteenth-century U.S. movement to create free dispensaries. Originally developed in Great Britain during the late eighteenth century, dispensaries soon appeared in U.S. cities—Philadelphia (1786), New York (1791), Boston (1796), and Baltimore (1800). Socially conscious Americans established these dispensaries with a sincere desire to improve conditions for the poor, albeit often through a filter of moralism or judgment. Although many of these dispensaries operated with minuscule budgets and resources, they grew dramatically in size and in number of patients treated during the nineteenth century. In 1860, for example, New York City dispensaries treated 134,069 patients; in 1900 the number was 876,000, most of whom were newly arrived immigrants.
Essentially, these were free-standing, neighborhood outpatient clinics where medical examinations and minor surgical procedures were performed, along with health education and the dispensing of medications and later, clean milk. Many dispensaries were devoted to the needs of working people and held evening hours for them, while others were focused on specific specialties, such as obstetrics. Dispensaries were also major training centers for a large numbers of U.S. physicians, many of whom went on to become leaders of the medical profession.
As U.S. medicine became more hospital-centered, increasingly reliant on medical technology, and as university hospitals and medical schools established their own outpatient clinics during the early and mid-twentieth century, dispensaries lost their cachet for many ambitious physicians-in-training. In addition, as the number of doctors in private practice expanded, beginning in the 1930s, the medical profession often objected to and obstructed the delivery of free medical care in dispensaries or municipal and state-run "welfare" clinics or community health centers. By the dawn of World War II, dispensaries were all but moribund. Nevertheless, it is vital to note these clinics’ critical role in advancing children’s health in the United States.7
Focus on schools. The development of the U.S. public health movement during the late nineteenth century was accompanied by another major social trend: mass public education. Because the numbers of school children expanded more quickly than the buildings in which to educate them, public school facilities were overcrowded and often detrimental to the health of students. Many public schools were poorly lit, poorly ventilated, and simply unsanitary. Inadequate plumbing and sewage systems meant that urban "halls of learning" were often filled with the stench of poorly working toilets, while rural facilities relied on primitive outhouses.
Sanitary and health conditions for students became a major concern for pediatricians and parents in the late nineteenth and early twentieth centuries and led to the systematic medical inspection of public schools nationwide. In 1893 the City of New York appointed the nation’s first school medical inspector; this was followed by a similar appointment in 1894 in Boston, when a team of fifty physicians was organized to supervise the health needs of Boston’s fifty school districts. By 1913, 443 U.S. cities or towns were conducting medical inspection of schools on a frequent, routine basis.8
A major focus of these inspections, beyond the safety and sanitary conditions of the buildings themselves, was surveillance for the prevalent infectious diseases of childhood and, if discovered in the days before vaccines and antibiotic therapies, their rapid containment by quarantine. Teachers, nurses, social workers, and pediatricians all worked together to facilitate these means of disease control.
And now. Over the course of the twentieth century, medicine made remarkable progress against infectious scourges, and school health professionals began to focus on the other issues related to the mental, physical, and social health of children. From vision and hearing screens to scoliosis examinations, from hygiene classes and physical education to today’s evaluations for "low-morbidity, low-mortality" problems such as learning disabilities and behavioral problems, this avenue of health care has been a major means of preventing, treating, and halting maladies that seriously threaten the well-being of children.
The value of school-based clinics, as well as neighborhood health centers that have evening hours, is obvious, as are their limitations. There are debates over the provision of reproductive services, the failure sometimes to link these clinics to advanced facilities and medical providers when serious illnesses are uncovered, and administrative problems such as the failure to provide children who have vision or hearing problems with eyeglasses or hearing aids. More troubling, community clinics—especially those that are overworked and under-staffed—cannot always ensure that every school-age child is fully immunized or can obtain and properly take the medications they need.
As useful as they are, community-based clinics are not a panacea for children’s health needs. Over the past decade, especially, for-profit health care groups and other providers have followed well-to-do and middle-class consumers into their neighborhoods with satellite facilities. But poor communities, whether rural or urban, also require a dense network of easily accessible, high-quality providers. One important lesson of the past suggests the need to build on existing school-based programs and establish medical offices and facilities adjacent to schools.
| Conclusion: We Don’t Exactly Repeat The Past, But That Doesn’t Give Us Permission To Ignore It |
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| TopLesson 1: Focus On...Lesson 2: Attack The...Lesson 3: Child Public...Conclusion: We Don’t...Editor's NotesNOTES |
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History teaches us little if it does not help us to realize that the problems of child public health are not going away. And yet, while there is much to be learned from the social activism and sense of community responsibility that spawned the public health efforts for children described here, we must not simply romanticize the achievements of the past. Indeed, during the decades that followed the Great Depression, the competitive divisions between public health workers, social welfare workers, and the medical profession erupted into deep chasms, often at the expense of the poorest and youngest Americans. Echoes of these arguments were heard again in debates over Medicare and Medicaid, as physicians, health insurance companies, and other groups challenged their value by claiming that they represented "socialized medicine," and these themes continue to resonate today.
One thing we can learn from the past, however, is that efforts to help children, especially those from impoverished or immigrant backgrounds, require the cooperation of diverse groups with differing agendas but ultimately a common purpose to construct an effective public health enterprise. There are social architects who can keep such an edifice intact, but only with constant labor and attention.9
Physicians, public health professionals, policymakers, and, indeed, all Americans have a major stake in meeting a new century of challenges to children’s health with creative, fiscally responsible, and culturally sensitive solutions. These include refining and developing community and school-based clinics; new public health education programs for diverse populations; linking such efforts with the education of today’s health professionals; active research on health conditions that have strong social, economic, and cultural foundations; and, finally, universal access to health care for all U.S. children.
The history of children’s public health in the United States teaches us that ignoring social conditions and expecting to solve these problems through medical investigations or via federal funding streams, rather than through overlapping, mutually reinforcing efforts of many parties, often yields limited results. But we cannot think of a better history lesson for children’s health care professionals than the one that tells us great achievements can be accomplished. Indeed, nothing less than our future depends upon all of us acting on this charge.
| Editor's Notes |
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| TopLesson 1: Focus On...Lesson 2: Attack The...Lesson 3: Child Public...Conclusion: We Don’t...Editor's NotesNOTES |
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Howard Markel (howard{at}umich.edu) is the George E. Wantz Professor of the History of Medicine, professor of pediatrics and communicable diseases, and director of the Center for the History of Medicine, University of Michigan, in Ann Arbor. Janet Golden is associate professor of history, Rutgers University, in Camden, New Jersey.
The authors thank Ed Schor, Commonwealth Fund vice president, for his support for this project and Jeffrey Levi of the Center for Health Services Research and Policy at the George Washington University for his comments on an earlier draft. The research for this paper was generously supported by the Commonwealth Fund.
| NOTES |
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| TopLesson 1: Focus On...Lesson 2: Attack The...Lesson 3: Child Public...Conclusion: We Don’t...Editor's NotesNOTES |
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- D. McCullough, Truman (New York: Simon and Schuster, 1992), 463.
- E. Key, The Century of the Child (New York: G.P. Putnam’s Sons, 1900).
- R. Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850–1929 (Ann Arbor: University of Michigan Press, 1999).
- A.M. Stern and H. Markel, eds., Formative Years: Children’s Health in the United States, 1880–2000 (Ann Arbor: University of Michigan Press, 2001).
- R.A. Meckel, "Levels and Trends of Death and Disease in Childhood, 1620 to the Present," in Children and Youth in Sickness and Health: A Handbook and Guide, ed. J. Golden, R.A. Meckel, and H.M. Prescott (Westport, Conn.: Greenwood Press, 2004), 20.
- See Duane Alexander, director, National Institute of Child Health and Human Development, Testimony on Fiscal Year 2005 Budget Request before the Senate Committee on Labor-HHS-Education Appropriations, 1 April 2004, www.hhs.gov/budget/testify/b200404010.html (10 June 2004).
- S.S. Goldwater, "Dispensaries: A Growing Factor in Curative and Preventive Medicine," Boston Medical and Surgical Journal 172, no. 17 (1915): 613–617; and C.E. Rosenberg, "Social Class and Medical Care in Nineteenth Century America: The Rise and Fall of the Dispensary," in Readings in the History of Medicine and Public Health, 3d rev. ed., ed. J.W. Leavitt and R.L. Numbers (Madison: University of Wisconsin Press, 1977), 157–171.
- L.H. Gulick and L.P. Ayers, Medical Inspection of the Schools, 2d ed. (New York: Russell Sage Foundation/Survey Associates, 1913); L.M. Terman, The Hygiene of the School Child (Boston: Houghton Mifflin, 1914); and W.S. Cornell, Health and Medical Inspection of School Children (Philadelphia: F.A. Davis, 1913).
- H. Markel, "For the Welfare of Children: The Origins of the Relationship between U.S. Public Health Workers and Pediatricians," American Journal of Public Health 90, no. 6 (2000): 893–899
[Abstract/Free Full Text] ; Urban Institute, "Uninsured Children Are Much Less Likely to Receive Medical Care," 11 September 2003, www.urban.org/urlprint.cfm?ID=8573 (10 June 2004); and K.L.S. Pettit, G.T. Kingsley, and C.J. Coulton, "Neighborhoods and Health: Building Evidence for Local Policy," 30 May 2003, www.urban.org/urlprint.cfm?ID=8499 (10 June 2004).
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