8. Divergent Paths
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chapter eight divergent paths World War II further accelerated the divergence of federal policies dealing with public health and individual medical services. Over the course of the 1930s, strong Southern political support, grounded in the region’s experiences with the PHS, helped the PHS secure an expanded role in American public health. A variety of factors worked against federal intervention in individual medicine. Plans for federally backed health insurance for workers stalled as a result of the opposition of the AMA, the lack of a strong base of popular or political support, and the unwillingness of President Roosevelt to push forward on the issue. Compromise or incremental approaches—including catastrophic insurance, direct payments for the indigent, and the PHS’s plan for publically funded catastrophic services, infrastructure, and diagnostic facilities—might have been pursued during the 1930s. Internal divisions among policy makers, both over the substance of policies and over political strategy, ensured that they were not. When the United States mobilized once again for war, the window of opportunity that opened beginning in 1933 was closed. During the war and in its aftermath, the bifurcated federal health policy regime that began to emerge during the 1930s was further reinforced. Pushed forward by the PHS and by the need to ensure that Southern diseases such as malaria would not threaten the war effort, the federal government asserted an increasingly central and direct role in American public health. In Atlanta, the PHS created the Malaria Control in War Areas (MCWA) program, which became the basis for the postwar CDC. Its National Institute of Health began funding biomedical research on an increasingly large scale. In the realm of individual medicine, federal tax policy helped foster a system in which most Americans accessed medical services through employer-sponsored health insurance. Federal money, meanwhile, began pouring into states and localities for the construction of hospitals. During the 1940s, the PHS continued to push for a health policy regime that would encompass both public health and individual medicine. Ultimately , PHS leaders found common ground with the leaders of the Social 158 : CHAPTER EIGHT Security Board on the importance of insurance. Beginning in 1945, President Harry S. Truman offered strong support for a comprehensive health program and for insurance. The bifurcated policy regime that emerged from the war, however, would become locked in during the years and decades that followed. While health policy makers had confronted a variety of alternatives during the 1930s, their choices were now significantly constrained. The creation of federal policies dealing with both public health and individual medicine fostered a new political and policy environment in which the options available during the pivotal period from 1933 through mobilization for World War II were foreclosed. Mobilization After occupying Norway during the spring of 1940, the German Wehrmacht moved swiftly into Belgium, Luxembourg, and then France, taking Paris in June. With the Nazis overcoming much of Europe and Britain under siege, the United States moved toward a war footing. In September 1940, Congress passed legislation creating the nation’s first peacetime draft. In March 1941, it approved the lend-lease program, granting President Roosevelt a great deal of leeway in supplying war matériel to support the British effort to withstand the Nazis. The PHS, which was transferred out of the Treasury Department and into the newly created Federal Security Agency in 1939, was prepared. As the army began training maneuvers in the South, the service engaged in preliminary surveys of local disease conditions.1 The PHS’s venereal disease division, meanwhile, mapped out a plan for working with the military, states and localities, and private groups to deal with the threats of syphilis and gonorrhea.2 In May 1941, the service secured an emergency appropriation to create a new Mosquito Control in Defense Areas program within the States Relations Division (previously known as the Division of Domestic Quarantine).3 The division was now under the control of Assistant Surgeon General Joseph Mountin, a close associate of Thomas Parran, veteran of the World War I extracantonment effort and the rural sanitation program, as well as an outspoken advocate of an increased federal role in public health and individual medical services.4 An onslaught of appropriations followed the Pearl Harbor bombing on December 7, 1941.5 As in the previous war, venereal disease and malaria were viewed as major threats to troops and to war-related industries. In both areas, the PHS took an aggressive stance. Men found to have venereal diseases, DIVERGENT PATHS...