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A Historically Based Thought Experiment: Meeting New Challenges For Children’s Health And Well-Being
In fall 2004 we proposed a way to use the lessons of the past to inform U.S. children’s health policy, given the increasingly critical needs of children in this country. Continuing in that tradition and beyond, we describe here the founding and early work of the Children’s Bureau and consider how it might be a model for the near future. We propose the creation of a Department of Children’s Affairs (DoCA), which would unite the various federal agency–level initiatives aimed at children’s health and well-being, much as the Department of Homeland Security did for terrorism defense activities after 9/11.
IN FALL 2004 WE WROTE AN IMPASSIONED PLEA to use the lessons of the past to inform children’s health policy in the United States.1 In all candor, we hardly expected many to pay attention; as historians, we are used to being ignored or, at best, tolerated as window dressing when major events need a "bit of historical context." This is unfortunate for many reasons. Historians have a great deal to offer to those struggling with policy dilemmas, precisely because they have a nuanced and contextualized view of how the dilemmas began and evolved, but also because a study of the past reveals many useful models and good ideas that still deserve to be acted upon. This is particularly true in the case of U.S. child health and welfare policy. As a historical thought experiment, we suggest looking back to the early twentieth century, when it appeared for the briefest of moments that children would be the centerpiece of U.S. domestic policy, with the founding of the Children’s Bureau in 1912. Where would we be today if the vision that propelled the founders of this first federal agency devoted exclusively to child welfare had been realized? What if the United States now created a cabinet-level agency dedicated to children? Shortly after 9/11, there was a hue and cry to unite the many government agencies working to protect citizens by preventing and deterring terrorist attacks and responding to various internal threats and catastrophic events. One result of this was the creation of the Department of Homeland Security, to unite activities related to terrorism defense under one federal agency. One shudders to wonder what crisis—domestic or international, human-induced or natural—would be needed to found a Department of Children’s Affairs (DoCA) that might similarly unite the many disparate federal departments that all contribute to the well-being of children but work without coordination and in agencies possessing other primary agendas. In this brief Commentary we describe the founding and early work of the Children’s Bureau and consider how it might be a model for the future.
The Children’s Bureau, the world’s first governmental agency to consider the problems of children, once served as a model that inspired the creation of similar agencies in other countries. Momentum to establish this agency in the United States grew in the first decade of the twentieth century, thanks to the combined efforts of grassroots women’s organizations and Progressive social reformers. Support from the General Federation of Women’s Clubs and the National Congress of Mothers and an endorsement at the 1909 White House Conference on the Care of Dependent Children led to legislative initiatives. They succeeded in 1912, overcoming opposition from those who feared that the Children’s Bureau would focus its work on child labor protection. Early work. The Children’s Bureau concentrated its early work on the problem of infant mortality, with field investigations of why babies died, a push for birth registration, and the distribution of educational materials—pamphlets on prenatal and infant care, and subsequent materials about young children. Children’s Bureau staff members answered thousands of letters from mothers who wrote in response to these materials. The bureau also worked with local "Baby Week" campaigns designed to educate mothers about infant care, helped sponsor the Children’s Year that began in April 1918, and promoted the development of infant hygiene divisions within state health departments. Other work of the Children’s Bureau included studies of and work for children with special needs, including the handicapped, the homeless, the orphaned, and the delinquent. Following the model of the U.S. Department of Agriculture Extension services, the Children’s Bureau mobilized grassroots organizations to support its work, uniting with volunteer organizations as well as local agencies in their baby-saving work. As political scientist Theda Skocpol has observed, local supporters proved to be critical political allies, much as farmers were counted on to lobby for federal funding for agricultural Extension work.2 Premier achievement. The Children’s Bureau’s premier achievement was the Sheppard-Towner Infancy and Maternity Protection Act of 1921. This legislation directed federal funds to the states. Under its watch, infant mortality rates fell from 95.7 per 1,000 live births in 1915–1919 to 53.2 in 1935–1939, and although a direct correlation between the efforts of the bureau and the drop in mortality is difficult to document, its efforts were far-reaching.3 Historian Kriste Lindenmeyer tallied the work, finding that it supported 183,252 health conferences for mothers and babies, 2,978 permanent child health or diagnostic clinics (or both), 19,723 classes, and the distribution of 21 million pieces of literature. More than four million infants and preschool children and approximately 700,000 pregnant women were served through the state programs.4 Political compromises and loss of power. During its heyday, the Children’s Bureau made necessary political compromises; it largely avoided antagonizing business interests that were fearful of child labor legislation. To escape the animus of conservative opponents, it ignored the results of its own investigations that found "poverty as the primary cause for infant deaths." Despite making many compromises, conducting aggressive public relations campaigns, and establishing a wide range of community allies, the Children’s Bureau and particularly the Sheppard-Towner Act provoked major opposition from the American Medical Association (AMA). Funds for the act ceased in 1929, the bureau was excluded from the planning of the 1930 White House Conference on Child Health and Protection, and subsequent New Deal programs moved away from the "whole child" approach championed by the bureau’s founders and leaders. With federal programs increasingly organized by function rather than by constituency, child health programs that were once the province of the Children’s Bureau came under the domain of the U.S. Public Health Service. Moreover, maternity and infancy programs received only limited funding because of political opposition to national health schemes and competition from expanding private insurance plans.5 Signs of renewed interest. The Children’s Bureau might have lost its power, but its raison d’être remains. Several recent developments suggest that the time is ripe to focus once again on the whole child and to improve child health in part by focusing on family income and community well-being. In the Department of Veterans Affairs (VA) we have a model of a constituency-based, cabinet-level agency. Recent attention to the problem of racial and income disparities in health care—the result of both epidemiological investigations and a growing concern to evaluate the outcomes of federally supported programs—has once again suggested the need to view health status as a social indicator. The creation of the National Center on Minority Health and Health Disparities is one sign of this renewed interest. Congressional recognition of child health problems and their need for remediation, as evidenced by the funding of the National Children’s Health Act, the monitoring of National Institutes of Health (NIH) funding in pediatric health, and funding for the State Children’s Health Insurance Program (SCHIP), also suggests a revitalized interest in children. The critical question, then, is whether or not there exists the political, social, and economic will necessary to persuade a plurality of voters and their representatives to legislate a plan that would enable the United States to fully embrace the idea it developed nearly a century ago: a federal agency devoted to children.
Let’s begin our thought experiment. It is 2020, and we are watching a presidential address marking the inauguration of the new DoCA. The president recalls how, exactly 100 years after the founding of the Children’s Bureau, the DoCA began its work. She describes the effects of universal coverage for all citizens under age twenty-one; the rising standards of health, welfare, and education for children; and the role this new agency plays in our national life. And since this is a thought experiment, we have written a portion of her imaginary speech: In the health field we see that the funding of infant, child, and adolescent health research, while still divided among multiple NIH agencies, is now fully coordinated with the DoCA in establishing priorities for research based on sound epidemiological principles. In mandating that priority for health care research be given to illnesses that cause days to be lost from work or school before age sixty, funding streams have been redirected. More children are included in clinical trials; and more clinical trials involve treatment for common ailments such as asthma, diabetes, psychological disorders, and substance abuse. The rebalancing of medical research and increased reimbursement for primary care have led to growing numbers of physicians and nurses entering the primary care fields—with an important spillover effect resulting in growth in geriatric medicine. Investigations of the environmental causes of disease now receive greater attention, thanks to the preliminary findings of the still ongoing National Children’s Study. Fantasies aside, how might we ever get to the point where a future president of the United States would actually deliver such an address?
When will the imperative to act finally trump self-serving institutional cultures, national lethargy, interest-group politics, and political intransigence? What if we declared children’s needs a national emergency? What if the data about the numbers of children living in poverty, dying needlessly in infancy, lacking medical services, failing to get a high-quality education, suffering as crime victims, or being drawn into delinquency captured the American imagination and provoked a dynamic response? Imagine creating a DoCA. First, a commission would identify all government agencies dealing with children and needing to be brought under the leadership of the new department. This would mean shifting the Department of Education from a cabinet-level agency to a division within the new DoCA, a challenging but necessary task. In other cases, divisions would report to the DoCA while remaining under a different agency. The NIH, for example, would report on pediatric research programs within its various divisions and would receive direction from a joint DoCA and Department of Health and Human Services (HHS) working group. The Children’s Bureau, now a minor agency housed within the Administration for Children and Families, would shift to the DoCA along with other HHS agencies serving children. Second, there would be full funding for the new department; rather than combining the budgets of the agencies to be absorbed, the DoCA would receive the funds needed to fulfill its mandated responsibilities. Included in this mandate would be universal child health insurance; expanded services for the disabled; and new initiatives in violence prevention, housing, and education. Support would come from the expanding federal revenue stream resulting from increased federal excise taxes on alcohol, tobacco, firearms, and ammunition. Obviously, a DoCA is a thought experiment, and whether it will ever be proposed, passed, fully funded, and implemented is subject to vigorous speculation, if not outright sneers. A more likely scenario would involve reviving, redesigning, and expanding the Children’s Bureau so that it would report directly to the president and have a mandate to evaluate federal policies relating to children in the areas of health, social welfare, and education and to advocate for improved services and increased oversight of existing programs. Holly Grason and Bernard Guyer have proposed such a plan, using the Older Americans Act as a model.6 Whether the bold plan of creating a cabinet-level agency or a politically feasible effort to expand the mandate and shift the reporting lines of an existing agency, it is clear that we need to expand the mission of the federal government to serve the nation’s youngest citizens. Let us begin the conversation by looking at history. With the centennial of the Children’s Bureau approaching, we should recall the vital work done by that agency. We should celebrate, too, the civic engagement that united local membership-based organizations with Progressive reformers and professionals who, under the command of the Children’s Bureau, labored to investigate and improve the health and welfare of infants, children, and mothers. The achievements of the Children’s Bureau in the opening decades of the twentieth century—when it faced political opposition, government infighting, and the economic strictures imposed by the Great Depression—should be regarded as an inspiration. Why not try, in the twenty-first century, to meet the needs of the whole child and finish the work reformers and civic activists set out to accomplish nearly 100 years ago?
Janet Golden is a professor of history, Rutgers University at Camden, in New Jersey. Howard Markel (howard{at}umich.edu) is the George E. Wantz Distinguished Professor of History and director, Center for the History of Medicine, University of Michigan in Ann Arbor. The authors thank Jeffrey Levi for his comments on an earlier draft of this essay.
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