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Introduction History and Context of Public Health Care James W. Holsinger Jr. and F. Douglas Scutchfield The history of public health in the United States demonstrates cycles of action and inaction, funding and a lack thereof. From its inception in 1798 until the post–September 11, 2001, period, the development of public health, according to Fee and Brown, has been “consistently plagued by organizational inefficiencies, jurisdictional irrationalities, and chronic underfunding. It is apparent that public health—in addition to lacking the support it deserves—has long been subject to a social and cultural discounting, especially in comparison to high-technology medicine, which undermines its authority.”1 A review of its history results in understanding that public health is favored politically and fiscally during and immediately after periods of crisis, only to slip into obscurity once the crisis has passed. The result of such attention and inattention is the lack of a clear trajectory in providing for the health of the American population and its communities. Seaport Epidemics and the First Boards of Health On July 16, 1798, President John Adams signed an act passed by the Fifth Congress of the United States that provided for “the temporary relief and maintenance of sick or disabled seamen in the hospitals or other proper institutions now established in the several ports of the United States, or in ports where no such institutions exist, then in such other manner as he [the secretary of the treasury] shall direct.”2 The act was a response to epidemic diseases such as smallpox, typhoid fever, plague, and especially yellow fever that were ravaging the eastern seaports. Notions of public health were rudimentary at best, with quarantine being one of the most effective mechanisms for dealing with outbreaks of epidemics, which were often thought to be initiated by seamen returning from lengthy voyages to foreign lands. These returning merchant seamen, who were often ill and lacked family at their ports of 2   Holsinger and Scutchfield debarkation, were a burden on seaport communities, and the need to care for them resulted in the creation of the Marine Hospital Service. This new system also assured healthier merchant mariners for the nation’s expanding commercial ventures. In addition to the efforts of the federal government, local and state governments were attempting to protect their populations from the various catastrophic infectious diseases that traumatized port cities, such as the yellow fever epidemic of 1793 in Philadelphia.3 Although the responses to yellow fever were broad based, they usually involved cities creating boards of health. “From about 1793 to 1806 yellow fever posed a major threat up and down the East Coast and created a heightened consciousness of public health, then understood as the set of measures undertaken to protect the local population from epidemic disease. Philadelphia organized a Board of Health in 1794; Baltimore in 1797; Boston in 1799; Washington, D.C., in 1802; and New Orleans in 1804.”1 In dealing with the public health issue of epidemic diseases, the lack of a clear understanding of the theoretical basis of infectious disease was a major impediment to disease control. For example, during this period, the contagionist and miasmatist theories of public health intervention competed for favor among boards of health. The contagionist theory was based on controlling environmental conditions as well as isolating infected individuals by quarantine. Houses, belongings, and goods were fumigated in an effort to contain the contagion of epidemic disease. The miasmatist theory was based on the development of protective measures against malodorous urban nuisances such as garbage and filth of all kinds, which resulted in garbage removal and street cleaning. Given the local nature of these two theories of the spread of disease, local communities became deeply involved in dealing with epidemic infectious diseases during this period of our nation’s history. The U.S. Constitution does not specifically reserve health as a power of the federal government; therefore, each state bears responsibility for the health of its citizens. As a result, various states enacted legislation authorizing local public health boards to utilize their police powers to enforce quarantines and disinfection measures (contagionist theory) and to undertake garbage removal and street cleaning (miasmatist theory). However, as would happen again and again in the ensuing years, as the threat to the public’s health from yellow fever and other infectious diseases diminished, so did the enthusiasm for public health measures. Business leaders were opposed to continuing the practices developed by the local boards because they believed such activities...

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