Lecture Seven: Public Health

Why Public Health at all?

1. Why let in dangerous people?
2. Is health so very complicated?
3. Is fun more important than health?
4. Does God want us to die?  Does God want them to die?
5. For your own good, for the public good: the incontestable mandate

Three Kinds of Public Health

1. Reactive: responding to epidemics
   • Boards of Health
2. Police: regulating commerce
   • Medical registrars, nuisance convictions
3. Proactive: preventing disease; improving life
   • Liberal evangelicals
   • Utilitarians
   • Moralists (the Chadwick Report, 1842)

The American Context

1. Individual Liberty
2. States' rights
   • The marine hospital service
3. The evangelical mandate
4. Americanism vs. foreigners

Public Health and the Federal Government

1. 1798: Marine Hospital Service
2. 1879-1882: U.S. National Board of Health - $500,000
3. 1902: U.S. Public Health Service and Marine Hospital Service
4. 1912: Public Health Service
5. Post-World War II: National Institutes of Health

Health and Immigration

1. Opposition to Scotch-Irish/German in 18th Century
   • George Washington, "ignorant"
   • Benjamin Franklin, "most stupid"
2. Population Statistics
   • 1785-1830: 375,000
   • 1830-1860: 4.5 million, including 1.7 million Irish (1841-1860) and 1.4 million Germans; Catholic population increases from 75,000 to 3 million
   • 1864: Immigration encouragement; 1875: Immigration restriction; 1879, 1882: health related versions (contagion, dependency, mental illness)
   • 1882-1943: Chinese Exclusion Act (100,000 Chinese by 1880)
   • 1891: Medical exclusion (epileptics, beggars, and anarchists)
   • 1907: Dillingham Commission (Slavs, Hebrews, Italians; literacy test)
   • 1921: numerical quotas
   • 1924: National Origins Act

Constituencies for Public Health

1. State Issues: population, prosperity, authority
2. Community Issues: property, public safety, disease
3. Class Issues: political and economic power, access to medical care
4. Professional Issues: Who controls? Doctors or others?

San Francisco

1. March-May 1900: Suspicion of plague in Chinatown - cordon sanitaire
2. Late May 1900: Federal decision against inoculation
3. June 1900: Federal decision against racial quarantine

Typhoid Mary

1. Mary Mallon (1869-1938)
2. 1907: Soper Investigation
3. 1907-1910: First confinement
4. 1915-1938: Second confinement
5. Issues: gender roles, ethnicity, class, politics
6. Why did Mallon become the cause celebre?

Disease theories and government

1. Contagion
2. Miasm
3. Epidemic constitution, atmosphere
4. Social sin

New York City

Population statistics:

Public health

1. 1842:
   • Croton Aqueduct
   • N.Y. Association for Improving the Condition of the Poor
2. 1845: Sanitary Condition of the Laboring Population of New York, John Griscom
3. 1864: Report on the Sanitary Condition of the City (Citizens Commission)
4. 1866: Metropolitan Health Act
   • Medical inspectors, disinfectant stations, hospitals, laboratory

Griscom vs. Hartley: Progressive and Conservative Evangelicals

1. Griscom: Environmental evangelism
2. Hartley: Sin and Grace - What must I do?
3. Public health as religious freedom?
4. Their attitudes to St. Vincent's and Dr. McNeven

New York City, Fifth Ward in 1864

1. Population: ~22,000
2. 74 blocks (32 good, 25 mixed, 17 bad)
3. Houses: 1244, including 450 tenements (more than 3 families, but most fewer than 6 families)
4. Most of the rest are boarding houses
5. Liquor stores: 341 (1:3.65 dwellings)
6. Brothels: 81+
7. Stores, Etc.: 283
8. Factories: 151
9. Stables: 108

Interpretations of New York City's Experience

1. "The passage of the ... act was hailed as a great victory for American democracy, yet what it did was to take away from New York voters responsibility for the City's health" - J. Duffy
2. Pioneering in the expansion of medical responsibility
3. An anodyne to social tension; Draft riots of 1863
4. Professionals on the make

The Peculiar Problem of Slavery: In Whose Interest is Health?

1. Power of the sick role: freedom through disease?
2. Slave diseases
   • Racial: malaria, tuberculosis (tabes mesenterica), pneumonia
   • Corn-pork diet: selling quarters crops
     1. "that [some] ... sold ... food indicates that ... some received sufficient nutrition from their regular rations"
   • Environment: hookworm, respiratory diseases, typhoid
   • Medical care: whipping, medicine as punishment?, reliance on folk healing