restricted access 1. Health at Home, Health Abroad
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chapter one health at home, health abroad The early contours of federal health policy were shaped by two factors: federalism and international relations. For constitutional reasons and for purely practical reasons, the lion’s share of health-related government action in early America was highly local. Writing in 1824, Supreme Court chief justice John Marshall declared “health laws of every description” to be among the wide array of powers “not surrendered to the general government ” by the states.1 Federal action was sparked, however, by trade and by war.2 As early as 1798, Congress created the Marine Hospital Service, an organization charged with operating a system of compulsory hospital insurance for sailors. During the second part of the nineteenth century, the service’s mandate grew to include quarantine efforts, the inspection of immigrants, and basic scientific research. Expanding into the Caribbean after the Spanish-American War, American authorities encountered serious and debilitating diseases, including yellow fever, malaria, and hookworm. For the first time, national authorities became involved in public health operations on a large scale. American public health work abroad drew attention to conditions in the American South, where many of the same diseases were present, and also to the inability of Southern state and local governments to confront these diseases. With the promotion and regulation of health broadly understood to be an area of state authority under the Constitution, it was private philanthropy that took the first major step against these diseases at home. In 1909, John D. Rockefeller announced the creation of the Rockefeller Sanitary Commission for the Eradication of Hookworm, an endeavor that sought to rid the South of hookworm.3 These developments, which I explore in this chapter, would have important implications for health policy in the United States, leading to a debate over the appropriate role of the federal government in public health and ultimately paving the path toward expanded federal intervention. 14 : CHAPTER ONE States, the Federal Government, and Health Following the Elizabethan poor law tradition, local governments in America were obliged to help the indigent sick access health services beginning during the colonial period. Localities typically hired a physician to treat the poor, usually on a part-time basis. States, townships, and counties also had responsibility for the health needs of prisoners and other public charges. Beyond this, some illnesses, such as tuberculosis and venereal disease, were considered issues of special public concern, demanding government action even where the sick individual was not indigent or a public charge. Over the course of the nineteenth century, most states built tuberculosis sanitoriums , as well as facilities to house those with mental illnesses and the blind. Private philanthropy supplemented and in many cases preceded government action to promote health. In northeastern cities, charities founded “dispensaries,” which distributed drugs to the urban poor and treated minor ailments. Dispensaries also administered vaccinations, a crucial public health function.4 As a general rule, they remained privately funded, although some received state and local funding. Their great strength was the role they played in medical education, offering clinical experience to future physicians and serving as a stepping-stone to higher status within the profession.5 Often private philanthropies contributed funds to combat specific diseases such as tuberculosis and to improve maternal and infant health. Private philanthropy also played a central part in the development of hospitals, which were typically geared toward care for the indigent sick. In addition to their role in individual medicine, states and localities were the primary sites of action in public health work. During the second half of the nineteenth century, these efforts were vastly expanded. Inspired by the growing sanitarian movement in Great Britain, attempts to regulate sanitary conditions became commonplace in American cities. In the final decades of the century, the bacteriological revolution further accelerated the development of local health regulation and promotion. The germ theory of disease drew attention to the role of specific pathogens in causing illness, leading officials to further focus attention on the relationship between individual health status and the health of the community.6 The extent and quality of health efforts varied significantly across the nation. Health efforts were concentrated in the industrializing North, where municipal governments and states issued regulations intended to further goals such as access to clean water, a hygienic milk supply, improved infant and maternal health, a population vaccinated against smallpox, and ade- HEALTH AT HOME, HEALTH ABROAD : 15 quate reporting of deaths from contagious disease. Health work lagged...


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