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This commentary is based on the classroom activity: Public Health Reform in the 19th century
Q1: Describe what is taking place in sources 1 and 4. How does source 6 help to explain why water pipes were eventually laid in all British towns?
A1: Source 1 shows a man selling buckets of water. Source 4 is a painting of men laying water pipes. In source 6, Thomas Hawkley claims that water transported by carriers cost one farthing a bucket. However, when piped directly into people's homes, it cost the customer only a farthing for 79 gallons. Nottingham showed that
it was far cheaper to pipe water into people's homes than to sell it by the bucket.
Q2: How does source 3 help to explain why historians do not always agree about how bad public health was in the 19th century?
A2: Source 3 reveals that officials in Hexham had "cooked" the figures and therefore published death-rates that were inaccurate. Robert Rawlinson's account also suggests that there were occasions when opponents of public health reform tried to bribe Board of Health Inspectors. In this case, the attempt at bribery failed. However, in some other cases in might have been successful.
This source indicates that published death-rates and the reports written by Board of Health Inspectors were not always accurate. Historians disagree about how often these attempts to falsify the statistics took place. As a result, historians do not always agree how bad public health was in the 19th century.
Q3: Why did people living in Carrier Street write to The Times in July, 1849?
A3: People in Carrier Street were living in terrible housing conditions. They had probably complained to their landlords without success. Maybe someone had told them that important people like Queen Victoria and MPs read The Times newspaper. Probably someone involved in social reform had recommended them to write to The Times. Perhaps they had helped them to write the letter and told them the address of The Times. At this time some MPs were beginning to take a close interest in housing conditions. They probably hoped that one of these MPs would take up their case in the House of Commons. Maybe they thought that the letter might shame their landlords into taking action.
Q4: Study source 9. Describe one aspect of the British economic system today that is similar to the late 18th century. Describe one that is different.
A4: One aspect of the British economic system today that is the same as the late 18th century is that it is based on private capital (capitalism). The aspect that is different is that the doctrine of laissez-faire "has been sharply modified or rejected".
Q5: (a) What is the meaning of the term laissez-faire? (b) Is George Hudson (source 2) a supporter or opponent of laissez-faire? (c) Use the information in sources 8 and 10 to explain why most MPs gradually changed their mind about the doctrine of laissez-faire.
A5: (a) Laissez-faire is a belief that governments should not interfere in economic affairs. However, this policy caused serious problems in the 19th century (source 8). Gradually attitudes began to change and Parliament was persuaded to pass legislation such as the Factory Acts which controlled the actions of manufacturers.
(b) George Hudson was a supporter of laissez-faire. He thought private enterprise was dealing with health problems: "I think that the evils resulting from defective sanitary regulations had been very much exaggerated". Hudson was totally opposed to government intervention: "The country is sick of centralisation of commissions of inquiries. The people want to be left to manage their own affairs; they do not want Parliament to be so paternal as it wishes to be - interfering in everybody's business".
(c) Source 10 shows a man representing the British government distributing Acts of Parliament to local councils portrayed as pigs. In the early part of the 19th century the British government left it up to private companies to provide services such as the supply of water and the removal of sewerage. This example of laissez-faire resulted in serious health problems in Britain's industrial towns and cities and by the middle of the century Parliament began passing legislation that encouraged some local councils to provide services such as the removal of sewerage.
Q6: What were the short-term and long-term reasons for Parliament passing the 1848 Public Health Bill?
A6: The short-term reason for Parliament passing the 1848 Public Health Act was an attempt to deal with the outbreak of cholera that was spreading through Europe. However, MPs had known about the arguments in favour of a Public Health Act since the publication of Edwin Chadwick's report in 1842. Some MPs were convinced by Chadwick's arguments that there was a strong connection between an inefficient sewerage system, impure water supplies and infectious diseases. These MPs took the long-term view that an efficient system of sewage removal and a constant supply of cheap, fresh water, would eventually result in a fall in Britain's death-rate. Although these MPs supported a Public Health Act, they were opposed by those who favoured laissez-faire. It was only when cholera was spreading through Europe in 1848 that some laissez-faire MPs agreed to vote for the Public Health Act.
Late 18th century Edit
On July 16, 1798, President John Adams signed the first Federal public health law, "An act for the relief of sick and disabled Seamen." This assessed every seaman at American ports 20 cents a month. This was the first prepaid medical care plan in the United States. The monies were used for the care of sick seamen and the building of seamen's hospitals. This act created the Marine Hospital Service under the Department of the Treasury. In 1802 Marine Hospitals were operating in Boston Newport Norfolk and Charleston, S.C. and medical services were contracted in other ports.  
19th century Edit
Another of the earliest health care proposals at the federal level was the 1854 Bill for the Benefit of the Indigent Insane, which would have established asylums for the indigent insane, as well as the blind and deaf, via federal land grants to the states. This bill was proposed by activist Dorothea Dix and passed both houses of Congress, but was vetoed by President Franklin Pierce. Pierce argued that the federal government should not commit itself to social welfare, which he stated was the responsibility of the states.  
After the American Civil War, the federal government established the first system of medical care in the South, known as the Freedmen's Bureau. The government constructed 40 hospitals, employed over 120 physicians, and treated well over one million sick and dying former slaves. The hospitals were short-lived, lasting from 1865 to 1870. Freedmen's Hospital in Washington, D.C. remained in operation until the late nineteenth century when it became part of Howard University. 
The next major initiative came in the New Deal legislation of the 1930s, in the context of the Great Depression. 
In the first 10–15 years of the 20th century Progressivism was influencing both Europe and the United States.  Many European countries were passing the first social welfare acts and forming the basis for compulsory government-run or voluntary subsidized health care programs.  The United Kingdom passed the National Insurance Act of 1911 that provided medical care and replacement of some lost wages if a worker became ill. It did not, however, cover spouses or dependents. As early as the 1912 presidential election, former president Theodore Roosevelt vaguely called for the creation of a national health service in the 15th plank of his Progressive Party platform.  However, neither Roosevelt nor his opponents discussed health care plans in detail, and Roosevelt lost the election to Woodrow Wilson.  A unique American history of decentralization in government, limited government, and a tradition of classical liberalism are all possible explanations for the suspicion around the idea of compulsory government-run insurance.  The American Medical Association (AMA) was also deeply and vocally opposed to the idea,  which it labeled "socialized medicine". In addition, many urban US workers already had access to sickness insurance through employer-based sickness funds.
Early industrial sickness insurance purchased through employers was one influential economic origin of the current American health care system.  These late-19th-century and early-20th-century sickness insurance schemes were generally inexpensive for workers: their small scale and local administration kept overhead low, and because the people who purchased insurance were all employees of the same company, that prevented people who were already ill from buying in.  The presence of employer-based sickness funds may have contributed to why the idea of government-based insurance did not take hold in the United States at the same time that the United Kingdom and the rest of Europe was moving toward socialized schemes like the UK National Insurance Act of 1911.  Thus, at the beginning of the 20th century, Americans were used to associating insurance with employers, which paved the way for the beginning of third-party health insurance in the 1930s.
With the Great Depression, more and more people could not afford medical services. In 1933, Franklin D. Roosevelt asked Isidore Falk and Edgar Sydenstricter to help draft provisions to Roosevelt's pending Social Security legislation to include publicly funded health care programs. These reforms were attacked by the American Medical Association as well as state and local affiliates of the AMA as "compulsory health insurance." Roosevelt ended up removing the health care provisions from the bill in 1935. Fear of organized medicine's opposition to universal health care became standard for decades after the 1930s. 
During this time, individual hospitals began offering their own insurance programs, the first of which became Blue Cross.  Groups of hospitals as well as physician groups (i.e. Blue Shield) soon began selling group health insurance policies to employers, who then offered them to their employees and collected premiums. In the 1940s Congress passed legislation that supported the new third-party insurers. During World War II, industrialist Henry J. Kaiser used an arrangement in which doctors bypassed traditional fee-for-care and were contracted to meet all the medical needs for his employees on construction projects up and down the West coast.  After the war ended, he opened the plan up to the public as a non-profit organization under the name Kaiser Permanente.
During World War II, the federal government introduced wages and price controls. In an effort to continue attracting and retaining employees without violating those controls, employers offered and sponsored health insurance to employees in lieu of gross pay. This was a beginning of the third-party paying system that began to replace direct out-of-pocket payments.
Following the world war, President Harry Truman called for universal health care as a part of his Fair Deal in 1949 but strong opposition stopped that part of the Fair Deal.   However, in 1946 the National Mental Health Act was passed, as was the Hospital Survey and Construction Act, or Hill-Burton Act. In 1951 the IRS declared group premiums paid by employers as a tax-deductible business expense,  which solidified the third-party insurance companies' place as primary providers of access to health care in the United States.
In the Civil Rights era of the 1960s and early 1970s, public opinion shifted towards the problem of the uninsured, especially the elderly. Since care for the elderly would someday affect everyone, supporters of health care reform were able to avoid the worst fears of "socialized medicine," which was considered a dirty word for its association with communism.  After Lyndon B. Johnson was elected president in 1964, the stage was set for the passage of Medicare and Medicaid in 1965.  Johnson's plan was not without opposition, however. "Opponents, especially the AMA and insurance companies, opposed the Johnson administration's proposal on the grounds that it was compulsory, it represented socialized medicine, it would reduce the quality of care, and it was 'un-American.'"  These views notwithstanding, the Medicare program was established when the Social Security Amendments of 1965 were signed into law on July 30, 1965, by President Lyndon B. Johnson. Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are either age 65 and over, or who meet other special criteria.
In 1970, three proposals for single-payer universal national health insurance financed by payroll taxes and general federal revenues were introduced in the U.S. Congress.  In February 1970, Representative Martha Griffiths (D-MI) introduced a national health insurance bill—without any cost sharing—developed with the AFL–CIO.  In April 1970, Senator Jacob Javits (R-NY) introduced a bill to extend Medicare to all—retaining existing Medicare cost sharing and coverage limits—developed after consultation with Governor Nelson Rockefeller (R-NY) and former Johnson administration HEW Secretary Wilbur Cohen.  In August 1970, Senator Ted Kennedy (D-MA) introduced a bipartisan national health insurance bill—without any cost sharing—developed with the Committee for National Health Insurance founded by United Auto Workers (UAW) president Walter Reuther, with a corresponding bill introduced in the House the following month by Representative James Corman (D-CA).  In September 1970, the Senate Labor and Public Welfare Committee held the first congressional hearings in twenty years on national health insurance. 
In January 1971, Kennedy began a decade as chairman of the Health subcommittee of the Senate Labor and Public Welfare Committee, and introduced a reconciled bipartisan Kennedy–Griffiths bill proposing universal national health insurance.  In February 1971, President Richard Nixon proposed more limited health insurance reform—an employer mandate to offer private health insurance if employees volunteered to pay 25 percent of premiums, federalization of Medicaid for the poor with dependent minor children, and support for health maintenance organizations (HMOs).  Hearings on national health insurance were held by the House Ways and Means Committee and the Senate Finance Committee in 1971, but no bill had the support of committee chairmen Representative Wilbur Mills (D-AR) or Senator Russell Long (D-LA). 
In October 1972, Nixon signed the Social Security Amendments of 1972 extending Medicare to those under 65 who have been severely disabled for over two years or have end stage renal disease (ESRD), and gradually raising the Medicare Part A payroll tax from 1.1% to 1.45% in 1986.  In the 1972 presidential election, Nixon won re-election in a landslide over the only Democratic presidential nominee not endorsed by the AFL–CIO in its history, Senator George McGovern (D-SD),  who was a cosponsor of the Kennedy-Griffiths bill, but did not make national health insurance a major issue in his campaign. 
In October 1973, Long and Senator Abraham Ribicoff (D-CT) introduced a bipartisan bill for catastrophic health insurance coverage for workers financed by payroll taxes and for Medicare beneficiaries, and federalization of Medicaid with extension to the poor without dependent minor children.  In February 1974, Nixon proposed more comprehensive health insurance reform—an employer mandate to offer private health insurance if employees volunteered to pay 25 percent of premiums, replacement of Medicaid by state-run health insurance plans available to all with income-based premiums and cost sharing, and replacement of Medicare with a new federal program that eliminated the limit on hospital days, added income-based out-of-pocket limits, and added outpatient prescription drug coverage.  In April 1974, Kennedy and Mills introduced a bill for near-universal national health insurance with benefits identical to the expanded Nixon plan—but with mandatory participation by employers and employees through payroll taxes and with lower cost sharing—both plans were criticized by labor, consumer, and senior citizens organizations because of their substantial cost sharing. 
In August 1974, after Nixon's resignation and President Gerald Ford's call for health insurance reform, Mills tried to advance a compromise based on Nixon's plan—but with mandatory participation by employers and employees through premiums to private health insurance companies and catastrophic health insurance coverage financed by payroll taxes—but gave up when unable to get more than a 13–12 majority of his committee to support his compromise plan.     In December 1974, Mills resigned as chairman of the Ways and Means Committee and was succeeded by Representative Al Ullman (D-OR), who opposed payroll tax and general federal revenue financing of national health insurance. 
In January 1975, in the midst of the worst recession in the four decades since the Great Depression, Ford said he would veto any health insurance reform,  and Kennedy returned to sponsoring his original universal national health insurance bill.  In April 1975, with one third of its sponsors gone after the November 1974 election,  the AMA replaced its "Medicredit" plan with an employer mandate proposal similar to Nixon's 1974 plan.  In January 1976, Ford proposed adding catastrophic coverage to Medicare, offset by increased cost sharing.  In April 1976, Democratic presidential candidate Jimmy Carter proposed health care reform that included key features of Kennedy's universal national health insurance bill. 
In December 1977, President Carter told Kennedy his bill must be changed to preserve a large role for private insurance companies, minimize federal spending (precluding payroll tax financing), and be phased-in so not to interfere with balancing the federal budget.   Kennedy and organized labor compromised and made the requested changes, but broke with Carter in July 1978 when he would not commit to pursuing a single bill with a fixed schedule for phasing-in comprehensive coverage.  
In May 1979, Kennedy proposed a new bipartisan universal national health insurance bill—choice of competing federally-regulated private health insurance plans with no cost sharing financed by income-based premiums via an employer mandate and individual mandate, replacement of Medicaid by government payment of premiums to private insurers, and enhancement of Medicare by adding prescription drug coverage and eliminating premiums and cost sharing.   In June 1979, Carter proposed more limited health insurance reform—an employer mandate to provide catastrophic private health insurance plus coverage without cost sharing for pregnant women and infants, federalization of Medicaid with extension to the very poor without dependent minor children, and enhancement of Medicare by adding catastrophic coverage.  In November 1979, Long led a bipartisan conservative majority of his Senate Finance Committee to support an employer mandate to provide catastrophic-only private health insurance and enhancement of Medicare by adding catastrophic coverage, but abandoned efforts in May 1980 due to budget constraints in the face of a deteriorating economy.    
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) amended the Employee Retirement Income Security Act of 1974 (ERISA) to give some employees the ability to continue health insurance coverage after leaving employment.
Clinton initiative Edit
Health care reform was a major concern of the Bill Clinton administration headed up by First Lady Hillary Clinton. The 1993 Clinton health care plan included mandatory enrollment in a health insurance plan, subsidies to guarantee affordability across all income ranges, and the establishment of health alliances in each state. Every citizen or permanent resident would thus be guaranteed medical care. The bill faced withering criticism by Republicans, led by William Kristol, who communicated his concern that a Democratic health care bill would "revive the reputation of. Democrats as the generous protector of middle-class interests. And it will at the same time strike a punishing blow against Republican claims to defend the middle class by restraining government."  The bill was not enacted into law.
The "Health Security Express," a cross-country tour by multiple buses carrying supporters of President Clinton's national health care reform, started at the end of July 1994. During each stop, the bus riders would talk about their personal experiences, health care disasters and why they felt it was important for all Americans to have health insurance. 
2000-2008: Bush era debates Edit
In 2000 the Health Insurance Association of America (HIAA) partnered with Families USA and the American Hospital Association (AHA) on a "strange bedfellows" proposal intended to seek common ground in expanding coverage for the uninsured.   
In 2001, a Patients' Bill of Rights was debated in Congress, which would have provided patients with an explicit list of rights concerning their health care. This initiative was essentially taking some of ideas found in the Consumers' Bill of Rights and applying it to the field of health care. It was undertaken in an effort to ensure the quality of care of all patients by preserving the integrity of the processes that occur in the health care industry.  Standardizing the nature of health care institutions in this manner proved rather provocative. In fact, many interest groups, including the American Medical Association (AMA) and the pharmaceutical industry came out vehemently against the congressional bill. Basically, providing emergency medical care to anyone, regardless of health insurance status, as well as the right of a patient to hold their health plan accountable for any and all harm done proved to be the biggest stumbling blocks for this bill.  As a result of this intense opposition, the Patients' Bill of Rights initiative eventually failed to pass Congress in 2002.
As president, Bush signed into law the Medicare Prescription Drug, Improvement, and Modernization Act which included a prescription drug plan for elderly and disabled Americans. 
During the 2004 presidential election, both the George Bush and John Kerry campaigns offered health care proposals. Bush's proposals for expanding health care coverage were more modest than those advanced by Senator Kerry.    Several estimates were made comparing the cost and impact of the Bush and Kerry proposals. While the estimates varied, they all indicated that the increase in coverage and the funding requirements of the Bush plan would both be lower than those of the more comprehensive Kerry plan.  
In 2006 the HIAA's successor organization, America's Health Insurance Plans (AHIP), issued another set of reform proposals. 
In January 2007 Rep. John Conyers, Jr. (D-MI) has introduced The United States National Health Care Act (HR 676) in the House of Representatives. As of October 2008, HR 676 has 93 co-sponsors.  Also in January 2007, Senator Ron Wyden introduced the Healthy Americans Act (S. 334) in the Senate. As of October 2008, S. 334 had 17 cosponsors. 
Also in 2007, AHIP issued a proposal for guaranteeing access to coverage in the individual health insurance market and a proposal for improving the quality and safety of the U.S. health care system.  
"Economic Survey of the United States 2008: Health Care Reform" by the Organisation for Economic Co-operation and Development, published in December 2008, said that: 
- Tax benefits of employer-based insurances should be abolished.
- The resulting tax revenues should be used to subsidize the purchase of insurance by individuals.
- These subsidies, "which could take many forms, such as direct subsidies or refundable tax credits, would improve the current situation in at least two ways: they would reach those who do not now receive the benefit of the tax exclusion and they would encourage more cost-conscious purchase of health insurance plans and health care services as, in contrast to the uncapped tax exclusion, such subsidies would reduce the incentive to purchase health plans with little cost sharing."
In December 2008, the Institute for America's Future, together with the chairman of the Ways and Means Health Subcommittee, Pete Stark, launched a proposal from Jacob Hacker, co-director of the U.C. Berkeley School of Law Center on Health, that in essence said that the government should offer a public health insurance plan to compete on a level playing field with private insurance plans.  This was said to be the basis of the Obama/Biden plan. The argument is based on three basic points. Firstly, public plans success at managing cost control (Medicare medical spending rose 4.6% p.a. compared 7.3% for private health insurance on a like-for-like basis in the 10 years from 1997 to 2006). Secondly, public insurance has better payment and quality-improvement methods because of its large databases, new payment approaches, and care-coordination strategies. Thirdly, it can set a standard against which private plans must compete, which would help unite the public around the principle of broadly shared risk while building greater confidence in government in the long term. 
Also in December 2008, America's Health Insurance Plans (AHIP) announced a set of proposals which included setting a national goal to reduce the projected growth in health care spending by 30%. AHIP said that if this goal were achieved, it would result in cumulative five-year savings of $500 billion. Among the proposals was the establishment of an independent comparative effectiveness entity that compares and evaluates the benefits, risks, and incremental costs of new drugs, devices, and biologics.  An earlier "Technical Memo" published by AHIP in June 2008 had estimated that a package of reforms involving comparative effectiveness research, health information technology (HIT), medical liability reform, "pay-for-performance" and disease management and prevention could reduce U.S. national health expenditures "by as much as 9 percent by the year 2025, compared with current baseline trends." 
Debate in the 2008 presidential election Edit
Although both candidates had a health care system that revolved around private insurance markets with help from public insurance programs, both had different opinions on how this system should operate when put in place. 
Senator John McCain proposed a plan that focused on making health care more affordable. The senator proposed to replace special tax breaks for persons with employer-based health care coverage with a universal system of tax credits. These credits, $2,500 for an individual and $5,000 for a family would be available to Americans regardless of income, employment or tax liability. In his plan, Senator McCain proposed the Guaranteed Access Plan which would provide federal assistance to the states to secure health insurance coverage through high-risk areas. 
Senator McCain also proposed the idea of an open-market competition system. This would give families the opportunity to go across state lines and buy health plans, expanding personal options for affordable coverage and force the health insurance companies to compete over the consumers’ money on an unprecedented scale. 
Barack Obama called for universal health care. His health care plan called for the creation of a National Health Insurance Exchange that would include both private insurance plans and a Medicare-like government run option. Coverage would be guaranteed regardless of health status, and premiums would not vary based on health status either. It would have required parents to cover their children, but did not require adults to buy insurance.
The Philadelphia Inquirer reported that the two plans had different philosophical focuses. They described the purpose of the McCain plan as to "make insurance more affordable," while the purpose of the Obama plan was for "more people to have health insurance."  The Des Moines Register characterized the plans similarly. 
A poll released in early November, 2008, found that voters supporting Obama listed health care as their second priority voters supporting McCain listed it as fourth, tied with the war in Iraq. Affordability was the primary health care priority among both sets of voters. Obama voters were more likely than McCain voters to believe government can do much about health care costs. 
2009 reform debate Edit
In March 2009 AHIP proposed a set of reforms intended to address waste and unsustainable growth in the current health care market. These reforms included:
- An individual insurance mandate with a financial penalty as a quid pro quo for guaranteed issue
- Updates to the Medicare physician fee schedule
- Setting standards and expectations for safety and quality of diagnostics
- Promoting care coordination and patient-centered care by designating a "medical home" that would replace fragmented care with a coordinated approach to care. Physicians would receive a periodic payment for a set of defined services, such as care coordination that integrates all treatment received by a patient throughout an illness or an acute event. This would promote ongoing comprehensive care management, optimizes patients’ health status and assist patients in navigating the health care system
- Linking payment to quality, adherence to guidelines, achieving better clinical outcomes, giving better patient experience and lowering the total cost of care. (instead of individual billing) for the management of chronic conditions in which providers would have shared accountability and responsibility for the management of chronic conditions such as coronary artery disease, diabetes, chronic obstructive pulmonary disease and asthma, and similarly
- A fixed rate all-inclusive average payment for acute care episodes which tend to follow a pattern (even though some acute care episodes may cost more or less than this). 
On May 5, 2009, US Senate Finance Committee held hearings on Health care reform. On the panel of the "invited stakeholder", no supporter of the Single-payer health care system was invited.  The panel featured Republican senators and industry panelists who argued against any kind of expanded health care coverage.  The preclusion of the single payer option from the discussion caused significant protest by doctors in the audience. 
There is one bill currently before Congress but others are expected to be presented soon. A merged single bill is the likely outcome. [ citation needed ] The Affordable Health Choices Act is currently before the House of Representatives and the main sticking points at the markup stage of the bill have been in two areas should the government provide a public insurance plan option to compete head to head with the private insurance sector, and secondly should comparative effectiveness research be used to contain costs met by the public providers of health care. [ citation needed ] Some Republicans have expressed opposition to the public insurance option believing that the government will not compete fairly with the private insurers. Republicans have also expressed opposition to the use of comparative effectiveness research to limit coverage in any public sector plan (including any public insurance scheme or any existing government scheme such as Medicare), which they regard as rationing by the back door. [ citation needed ] Democrats have claimed that the bill will not do this but are reluctant to introduce a clause that will prevent, arguing that it would limit the right of the DHHS to prevent payments for services that clearly do not work. [ citation needed ] America's Health Insurance Plans, the umbrella organization of the private health insurance providers in the United States has recently urged the use of CER to cut costs by restricting access to ineffective treatments and cost/benefit ineffective ones. Republican amendments to the bill would not prevent the private insurance sectors from citing CER to restrict coverage and apply rationing of their funds, a situation which would create a competition imbalance between the public and private sector insurers. [ citation needed ] A proposed but not yet enacted short bill with the same effect is the Republican sponsored Patients Act 2009. [ citation needed ]
On June 15, 2009, the U.S. Congressional Budget Office (CBO) issued a preliminary analysis of the major provisions of the Affordable Health Choices Act.  The CBO estimated the ten-year cost to the federal government of the major insurance-related provisions of the bill at approximately $1.0 trillion.  Over the same ten-year period from 2010 to 2019, the CBO estimated that the bill would reduce the number of uninsured Americans by approximately 16 million.  At about the same time, the Associated Press reported that the CBO had given Congressional officials an estimate of $1.6 trillion for the cost of a companion measure being developed by the Senate Finance Committee.  In response to these estimates, the Senate Finance Committee delayed action on its bill and began work on reducing the cost of the proposal to $1.0 trillion, and the debate over the Affordable Health Choices act became more acrimonious.   Congressional Democrats were surprised by the magnitude of the estimates, and the uncertainty created by the estimates has increased the confidence of Republicans who are critical of the Obama Administration's approach to health care.  
However, in a June New York Times editorial, economist Paul Krugman argued that despite these estimates universal health coverage is still affordable. "The fundamental fact is that we can afford universal health insurance—even those high estimates were less than the $1.8 trillion cost of the Bush tax cuts." 
In contrast to earlier advocacy of a publicly funded health care program, in August 2009 Obama administration officials announced they would support a health insurance cooperative in response to deep political unrest amongst Congressional Republicans and amongst citizens in town hall meetings held across America.    However, in a June 2009 NBC News/Wall Street Journal survey, 76% said it was either "extremely" or "quite" important to "give people a choice of both a public plan administered by the federal government and a private plan for their health insurance." 
During the summer of 2009, members of the "Tea Party" protested against proposed health care reforms.    Former insurance PR executive Wendell Potter of the Center for Media and Democracy- whose funding comes from groups such as the Tides Foundation-  argue that the hyperbole generated by this phenomenon is a form of corporate astroturfing, which he says that he used to write for CIGNA.  Opponents of more government involvement, such as Phil Kerpen of Americans for Prosperity- whose funding comes mainly from the Koch Industries corporation  counter-argue that those corporations oppose a public-plan, but some try to push for government actions that will unfairly benefit them, like employer mandates forcing private companies to buy health insurance.  Journalist Ben Smith has referred to mid-2009 as "The Summer of Astroturf" given the organizing and coordinating efforts made by various groups on both pro- and anti-reform sides. 
Healthcare debate, 2008–2010 Edit
Healthcare reform was a major topic of discussion during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, New York Senator Hillary Clinton and the eventual nominee, Illinois Senator Barack Obama. Each candidate proposed a plan to cover the approximately 45 million Americans estimated to not have health insurance at some point each year. Clinton's plan would have required all Americans obtain coverage (in effect, an individual health insurance mandate), while Obama's provided a subsidy but did not include a mandate. During the general election, Obama said that fixing healthcare would be one of his top four priorities if he won the presidency. 
After his inauguration, Obama announced to a joint session of Congress in February 2009 his intent to work with Congress to construct a plan for healthcare reform.   By July, a series of bills were approved by committees within the House of Representatives.  On the Senate side, from June through to September, the Senate Finance Committee held a series of 31 meetings to develop of a healthcare reform bill. This group – in particular, Senators Max Baucus (D-MT), Chuck Grassley (R-IA), Kent Conrad (D-ND), Olympia Snowe (R-ME), Jeff Bingaman (D-NM), and Mike Enzi (R-WY) – met for more than 60 hours, and the principles that they discussed, in conjunction with the other Committees, became the foundation of the Senate's healthcare reform bill.   
With universal healthcare as one of the stated goals of the Obama Administration, Congressional Democrats and health policy experts like Jonathan Gruber and David Cutler argued that guaranteed issue would require both a community rating and an individual mandate to prevent either adverse selection and/or free riding from creating an insurance death spiral  they convinced Obama that this was necessary, persuading him to accept Congressional proposals that included a mandate.  This approach was preferred because the President and Congressional leaders concluded that more liberal plans, such as Medicare-for-all, could not win filibuster-proof support in the Senate. By deliberately drawing on bipartisan ideas – the same basic outline was supported by former Senate Majority Leaders Howard Baker (R-TN), Bob Dole (R-KS), Tom Daschle (D-SD) and George Mitchell (D-ME) – the bill's drafters hoped to increase the chances of getting the necessary votes for passage.  
However, following the adoption of an individual mandate as a central component of the proposed reforms by Democrats, Republicans began to oppose the mandate and threaten to filibuster any bills that contained it.  Senate Minority Leader Mitch McConnell (R-KY), who lead the Republican Congressional strategy in responding to the bill, calculated that Republicans should not support the bill, and worked to keep party discipline and prevent defections: 
It was absolutely critical that everybody be together because if the proponents of the bill were able to say it was bipartisan, it tended to convey to the public that this is O.K., they must have figured it out. 
Republican Senators, including those who had supported previous bills with a similar mandate, began to describe the mandate as "unconstitutional". Writing in The New Yorker, Ezra Klein stated that "the end result was. a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."  The New York Times subsequently noted: "It can be difficult to remember now, given the ferocity with which many Republicans assail it as an attack on freedom, but the provision in President Obama's healthcare law requiring all Americans to buy health insurance has its roots in conservative thinking."  
The reform negotiations also attracted a great deal of attention from lobbyists,  including deals among certain lobbies and the advocates of the law to win the support of groups who had opposed past reform efforts, such as in 1993.   The Sunlight Foundation documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties. 
During the August 2009 summer congressional recess, many members went back to their districts and entertained town hall meetings to solicit public opinion on the proposals. Over the recess, the Tea Party movement organized protests and many conservative groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills.  There were also many threats made against members of Congress over the course of the Congressional debate, and many were assigned extra protection. 
To maintain the progress of the legislative process, when Congress returned from recess, in September 2009 President Obama delivered a speech to a joint session of Congress supporting the ongoing Congressional negotiations, to re-emphasize his commitment to reform and again outline his proposals.  In it he acknowledged the polarization of the debate, and quoted a letter from the late-Senator Ted Kennedy urging on reform: "what we face is above all a moral issue that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."  On November 7, the House of Representatives passed the Affordable Health Care for America Act on a 220–215 vote and forwarded it to the Senate for passage. 
The Senate began work on its own proposals while the House was still working on the Affordable Health Care for America Act. Instead, the Senate took up H.R. 3590, a bill regarding housing tax breaks for service members.  As the United States Constitution requires all revenue-related bills to originate in the House,  the Senate took up this bill since it was first passed by the House as a revenue-related modification to the Internal Revenue Code. The bill was then used as the Senate's vehicle for their healthcare reform proposal, completely revising the content of the bill.  The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate Health and Finance committees.
With the Republican minority in the Senate vowing to filibuster any bill that they did not support, requiring a cloture vote to end debate, 60 votes would be necessary to get passage in the Senate.  At the start of the 111th Congress, Democrats had only 58 votes the Senate seat in Minnesota that would be won by Al Franken was still undergoing a recount, and Arlen Specter was still a Republican.
To reach 60 votes, negotiations were undertaken to satisfy the demands of moderate Democrats, and to try to bring aboard several Republican Senators particular attention was given to Bob Bennett (R-UT), Chuck Grassley (R-IA), Mike Enzi (R-WY), and Olympia Snowe (R-ME). Negotiations continued even after July 7—when Al Franken was sworn into office, and by which time Arlen Specter had switched parties—because of disagreements over the substance of the bill, which was still being drafted in committee, and because moderate Democrats hoped to win bipartisan support. However, on August 25, before the bill could come up for a vote, Ted Kennedy—a long-time advocate for healthcare reform—died, depriving Democrats of their 60th vote. Before the seat was filled, attention was drawn to Senator Snowe because of her vote in favor of the draft bill in the Finance Committee on October 15, however she explicitly stated that this did not mean she would support the final bill.  Paul Kirk was appointed as Senator Kennedy's temporary replacement on September 24.
Following the Finance Committee vote, negotiations turned to the demands of moderate Democrats to finalize their support, whose votes would be necessary to break the Republican filibuster. Majority Leader Harry Reid focused on satisfying the centrist members of the Democratic caucus until the hold-outs narrowed down to Connecticut's Joe Lieberman, an independent who caucused with Democrats, and Nebraska's Ben Nelson. Lieberman, despite intense negotiations in search of a compromise by Reid, refused to support a public option a concession granted only after Lieberman agreed to commit to voting for the bill if the provision was not included,   even though it had majority support in Congress.  There was debate among supporters of the bill about the importance of the public option,  although the vast majority of supporters concluded that it was a minor part of the reform overall,  and that Congressional Democrats' fight for it won various concessions this included conditional waivers allowing states to set up state-based public options,  for example Vermont's Green Mountain Care. 
With every other Democrat now in favor and every other Republican now overtly opposed, the White House and Reid moved on to addressing Senator Nelson's concerns in order to win filibuster-proof support for the bill  they had by this point concluded that "it was a waste of time dealing with [Snowe]"  because, after her vote for the draft bill in the Finance Committee, Snowe had come under intense pressure from the Republican Senate Leadership who opposed reform.  (Snowe retired at the end of her term, citing partisanship and polarization).  After a final 13-hour negotiation, Nelson's support for the bill was won after two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges," which would require consumers to pay for the procedure out-of-pocket if the state so decided and an amendment to offer a higher rate of Medicaid reimbursement for Nebraska.   The latter half of the compromise was derisively referred to as the "Cornhusker Kickback"  and was later repealed by the subsequent reconciliation amendment bill.
On December 23, the Senate voted 60–39 to end debate on the bill: a cloture vote to end the filibuster by opponents. The bill then passed by a vote of 60–39 on December 24, 2009, with all Democrats and two independents voting for, and all Republicans voting against except one (Jim Bunning (R-KY), not voting).  The bill was endorsed by the AMA and AARP. 
Several weeks after the vote, on January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the late Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain filibusters, even signing autographs as "Scott 41."    The special election had become significant to the reform debate because of its effects on the legislative process. The first was a psychological one: the symbolic importance of losing the traditionally Democratic (‘blue’) Massachusetts seat formerly held by Ted Kennedy, a staunch support of reform, made many Congressional Democrats concerned about the political cost of passing a bill.   The second effect was more practical: the loss of the Democrat's supermajority complicated the legislative strategy of reform proponents. 
The election of Scott Brown meant Democrats could no longer break a filibuster in the Senate. In response, White House Chief of Staff Rahm Emanuel argued the Democrats should scale-back for a less ambitious bill House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care."   Obama also remained insistent on comprehensive reform, and the news that Anthem in California intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous Democrats after Scott Brown's win.   On February 22 Obama laid out a "Senate-leaning" proposal to consolidate the bills.  He also held a meeting, on February 25, with leaders of both parties urging passage of a reform bill.  The summit proved successful in shifting the political narrative away from the Massachusetts loss back to healthcare policy. 
With Democrats having lost a filibuster-proof supermajority in the Senate, but having already passed the Senate bill with 60 votes on December 24, the most viable option for the proponents of comprehensive reform was for the House to abandon its own health reform bill, the Affordable Health Care for America Act, and pass the Senate's bill, The Patient Protection and Affordable Care Act, instead. Various health policy experts encouraged the House to pass the Senate version of the bill.  However, House Democrats were not happy with the content of the Senate bill, and had expected to be able to negotiate changes in a House–Senate Conference before passing a final bill.  With that option off the table, as any bill that emerged from Conference that differed from the Senate bill would have to be passed in the Senate over another Republican filibuster most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill.  They drafted the Health Care and Education Reconciliation Act, which could be passed via the reconciliation process.    Unlike rules under regular order, as per the Congressional Budget Act of 1974 reconciliation cannot be subject to a filibuster, which requires 60 votes to break, but the process is limited to budget changes this is why the procedure was never able to be used to pass a comprehensive reform bill in the first place, such as the ACA, due to inherently non-budgetary regulations.   Whereas the already passed Senate bill could not have been put through reconciliation, most of House Democrats' demands were budgetary: "these changes – higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal – mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation." 
The remaining obstacle was a pivotal group of pro-life Democrats, initially reluctant to support the bill, led by Congressman Bart Stupak. The group found the possibility of federal funding for abortion would be substantive enough to warrant opposition. The Senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill, as it would be outside the scope of the process with its budgetary limits. Instead, President Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment.  This concession won the support of Stupak and members of his group and assured passage of the bill.   The House passed the Senate bill with a vote of 219 to 212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.  The following day, Republicans introduced legislation to repeal the bill.  Obama signed the ACA into law on March 23, 2010.  The amendment bill, The Health Care and Education Reconciliation Act, was also passed by the House on March 21, then by the Senate via reconciliation on March 25, and finally signed by President Obama on March 30.
A few states have taken steps toward universal health care coverage, most notably Minnesota, Massachusetts and Connecticut. Examples include the Massachusetts 2006 Health Reform Statute  and Connecticut's SustiNet plan to provide health care to state residents.  The influx of more than a quarter of a million newly insured residents has led to overcrowded waiting rooms and overworked primary-care physicians who were already in short supply in Massachusetts.  Other states, while not attempting to insure all of their residents, cover large numbers of people by reimbursing hospitals and other health care providers using what is generally characterized as a charity care scheme New Jersey is an example of a state that employs the latter strategy. [ citation needed ]
Several single payer referendums have been proposed at the state level, but so far all have failed to pass: California in 1994,  Massachusetts in 2000, and Oregon in 2002.  The state legislature of California twice passed SB 840, The Health Care for All Californians Act, a single-payer health care system. Both times, Governor Arnold Schwarzenegger (R) vetoed the bill, once in 2006 and again in 2008.   
The percentage of residents that are uninsured varies from state to state. In 2008 Texas had the highest percentage of residents without health insurance, 24%.  New Mexico had the second highest percentage of uninsured that year at 22%. 
States play a variety of roles in the health care system including purchasers of health care and regulators of providers and health plans,  which give them multiple opportunities to try to improve how it functions. While states are actively working to improve the system in a variety of ways, there remains room for them to do more. 
One municipality, San Francisco, California, has established a program to provide health care to all uninsured residents (Healthy San Francisco). [ citation needed ]
In July 2009, Connecticut passed into law a plan called SustiNet, with the goal of achieving health care coverage of 98% of its residents by 2014.  The SustiNet law establishes a nine-member board to recommend to the legislature, by January 1, 2011, the details of and implementation process for a self-insured health care plan called SustiNet. The recommendations must address (1) the phased-in offering of the SustiNet plan to state employees and retirees, HUSKY A and B beneficiaries, people without employer-sponsored insurance (ESI) or with unaffordable ESI, small and large employers, and others (2) establishing an entity that can contract with insurers and health care providers, set reimbursement rates, develop medical homes for patients, and encourage the use of health information technology (3) a model benefits package and (4) public outreach and ways to identify uninsured citizens.  The board must establish committees to make recommendations to it about health information technology, medical homes, clinical care and safety guidelines, and preventive care and improved health outcomes. The act also establishes an independent information clearinghouse to inform employers, consumers, and the public about SustiNet and private health care plans and creates task forces to address obesity, tobacco usage, and health care workforce issues. The effective date of the SustiNet law was July 1, 2009, for most provisions. 
In May 2011, the state of Vermont became the first state to pass legislation establishing a single-payer health care system. The legislation, known as Act 48, establishes health care in the state as a "human right" and lays the responsibility on the state to provide a health care system which best meets the needs of the citizens of Vermont. In December 2014, the governor of the state of Vermont suspended plans to implement this single-payer system because of its cost. [ citation needed ]
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Lesson at a glance
Suitable for: Key stage 4
Suggested inquiry questions: What do these documents reveal about attitudes concerning vaccination in the nineteenth century? How and why did laws concerning vaccination change in the Victorian era? Why was Edward Jenner a significant individual in the history of medicine?
Potential activities: Students design their own pro-vaccination leaflet from the perspective of a Local Board of Health in Victorian times. Students write their own anti-vaccination propaganda from the perspective of the Anti-compulsory Vaccination League in this period.
The Origins of Medical Statistics
Albert E. Mackay, M.D. established a bacteriology laboratory at the University Medical Department in 1889 and later directed the Portland Board of Health’s laboratory. (Historical Image Collection)
Medical statistics emerged as a distinct discipline in the mid-nineteenth century. Physicians in Western Europe became interested in statistics earlier than their American counterparts. They began using statistical analysis in the 1820s to study social problems produced by the Industrial Revolution, a transition that Europe experienced earlier than the United States. Statistics were seen as tools to address epidemic diseases, crime, urban poverty, and other issues arising in industrial societies. In 1834 the Royal Statistical Society was organized in London. It became a global leader in the application of statistical analysis in public health.
Five years later the American Statistical Society was established in Boston by Lemuel Shattuck and Edward Jarvis, M.D. Shattuck, a school teacher and publisher, realized the potential of statistics in analyzing public health problems and, in turn, influencing sanitary reform. He was largely responsible for starting the Massachusetts system of vital statistics collection and registration, which became a model for other states. While physicians had been collecting some statistics, particularly related to diseases, for decades, it was the involvement of laymen like Shattuck that helped make statistics a profession.
Public health practitioners wanting to help large populations could make a greater impact if they used data and statistics to their advantage. Data that was formatted and structured into tables made it easier for the reader to absorb and analyze information shared by authors. It also made it easier for colleagues to share and re-use data, especially for those who agreed to collect and present data in similar ways.
Louis Pasteur (late 1800)
Louis Pasteur was a French biologist and chemist who made enormous contributions to germ theory, to prevention of food spoilage, and to the control of disease. In 1853 Pasteur began studying fermentation in wine and beer and rapidly concluded that microorganisms were responsible. He also discovered that microbes in milk could be killed by heating to about 130 degrees Fahrenheit, a process which is now known as 'pasteurization'. He discovered that some microorganisms require oxygen (aerobic organisms), while others reproduce in the absence of oxygen (anaerobic).
Pasteur pioneered the idea of artificially generating weakened microorganisms as vaccines. Edward Jenner's work had demonstrated the principle with the naturally occurring cowpox, which could be used to vaccinate against smallpox. Pasteur was able to artificially weaken strains of anthrax and cholera in order to generate vaccines. It was, in fact, Pasteur who coined the term 'vaccine' in honor of Jenner's discovery. Pasteur developed vaccines against anthrax in sheep and cholera in chickens. In 1885 he developed a vaccine for rabies by growing it in rabbits and then drying the nerve tissue that had been infected with the virus. This vaccine was successfully used to save the life of a boy who had been bitten by a rabid dog.
During the past seven decades, China has made impressive strides in the development of public health system, despite experiencing twist and turns. Based on the analysis above, the study suggests:
(1) Strengthening the public health service delivery system, focusing on prevention and preemptive control of diseases, and highlighting public health functionality of rural and urban primary health facilities
Empowering community and the general population by setting up multi-department coordination mechanism for social mobilization and participation based on the experience of Patriotic Health Campaign and.
continuously improving the basic public health services, including higher quality of the services, better monitoring and in-flight adjustment of the Program, efficient and relevant training for more highly-skillful professionals, and more integrated IT systems, so that everyone has equitable access to quality basic public health services.
Public Health Reform in the 19th century (Commentary) - History
In The Healthy Body and Victorian Culture , Bruce Haley asserts that the Victorians were concerned with health over almost all, if not all, other issues. The following passages are excerpted from his book:
Nothing occupies a nation's mind with the subject of health like a general contagion. In the 1830s and the 1840s there were three massive waves of contagious disease: the first, from 1831 to 1833, included two influenza epidemics and the initial appearance of cholera the second, from 1836 to 1842, encompassed major epidemics of influenza, typhus, typhoid, and cholera. As F. H. Garrison has observed, epidemic eruptions in the eighteenth century had been "more scattered and isolated" than theretofore and in the early decades of the nineteenth century there had been a marked decline in such illnesses as diphtheria and influenza. Smallpox, the scourge of the eighteenth century, appeared to be controllable by the new practice of vaccination. Then, in the mid-twenties, England saw serious outbursts of smallpox and typhus, anticipating the pestilential turbulence of the next two decades.
The first outbreak of Asiatic cholera in Britain was at Sunderland on the Durham coast during the Autumn of 1831. From there the disease made its way northward into Scotland and southward toward London. Before it had run its course it claimed 52,000 lives. From its point of origin in Bengal it had taken five years to cross Europe, so that when it reached the course of Durham, British doctors were well aware of its nature, if not its cause.
The progress of the illness in a cholera victim was a frightening spectacle: two or three died of diarrhoea which increased in intensity and became accompanied by painful retching thirst and dehydration sever pain in the limbs, stomach, and abdominal muscles a change skin hue to a sort of bluish-grey. The disease was unlike anything then known. One doctor recalled: "Our other plagues were home-bred, and part of ourselves, as it were we had a habit of looking at them with a fatal indifference, indeed, inasmuch as it led us to believe that they could be effectually subdued. But the cholera was something outlandish, unknown, monstrous its tremendous ravages, so long foreseen and feared, so little to be explained, its insidious march over whole continents, its apparent defiance of all the known and conventional precautions against the spread of epidemic disease, invested it with a mystery and a terror which thoroughly took hold of the public mind, and seemed to recall the memory of the great epidemics of the middle ages."
The cholera subsided as enigmatically as it had flourished, but in the meantime another sort of devastation had taken hold. The previous June, following a particularly rainy spring, Britain was visited by the first of eight serious influenza epidemics in the space of sixteen years. In those days the disease was often fatal, and even when it did not kill, it left its victims weakened in their defenses against other diseases. Burials in London doubled during the first week of the 1833 outbreak in one two-week period they quadrupled. Whereas cholera, spread by contaminated water, affected mainly the poorer neighbourhoods, influenza was limited by no economic or geographic boundaries. Large numbers of public officials, especially in the Bank of England, died from it, as did many theater people.
At that time the term "fever" encompassed a number of different diseases, among them cholera and influenza. In the 1830s the "new fever," typhus, was isolated. During its worst outbreak, in 1837-38, most of the deaths from fever in London were attributed to typhus, and new cases averaged about sixteen thousand in England in each of the next four years. This happened to coincide with one of the worst smallpox contagions, which killed tens of thousands, mainly infants and children. Scarlet fever, or scarlatina as it was then called, was responsible for nearly twenty thousand deaths in 1840 alone.
Although mortality rates for specific diseases were not compiled for England and Wales between 1842 and 1846, we know that during this period there was a considerable decline in epidemics. It has been surmised that one reason was the expansion of railroad building, with the consequent increase in wage levels and a better standard of living. A hot, dry summer in 1846, however, was followed by a serious outbreak of typhoid in the fall of that year. Enteric fever, as it was then called, is a water-borne disease like cholera and tends to flourish when people are not particular about the source of their drinking water.* That same year, as the potato famine struck Ireland, a virulent form of typhus appeared, cutting down large numbers of even well-to-do families. As Irish workers moved to cities like Liverpool and Glasgow the "Irish fever" moved with them. By 1847 the contagion, not all of it connected with immigration, had spread throughout England and Wales, accounting for over thirty thousand deaths. As had happened a decade earlier, typhus occurred simultaneously with a severe influenza epidemic, one which carried off almost thirteen thousand. There was also a widespread dysentery, and as if all this were not enough, cholera returned in the autumn of 1848, assailing especially those parts of the island hardest hit by typhus and leaving about as many dead as it had in 1831. This was the epidemic which took the lives of one-fifth of the thousand children housed at the institution for the poor at Tooting.
Diseases like cholera, typhus, typhoid, and influenza were more or less endemic at the time, erupting into epidemics when the right climatic conditions coincided with periods of economic distress. The frequency of concurrent epidemics gave rise to the belief that one sort of disease brought on another indeed, it was widely believed that influenza was an early stage of cholera. There were other contagions, however, which yearly killed thousands without becoming epidemic. Taken together, measles and "hooping cough" accounted for fifty thousand deaths in England and Wales between 1838 and 1840, and about a quarter of all deaths during this general period have been attributed to tuberculosis or consumption.
It is not hard to see why the idea of disease had such an impact in the last century. In his Report on the Sanitary Condition of the Labouring Population of Gt. Britain , Edwin Chadwick included figures to show that in 1839 for every person who died of old age or violence, eight died of specific diseases. This helps explain why during the second and third decades of the nineteenth century nearly one infant in three in England failed to reach the age of five.
Generally throughout the 1830s and the 1840s trade was off and food prices were high. The poorer classes, being underfed, were less resistant to contagion. Also, during the more catastrophic years the weather was extremely variable, with heavy rains following prolonged droughts. Population, especially in the Midlands and in some seaport cities and towns, was growing rapidly without a concurrent expansion in new housing. Crowding contributed to the relatively fast spread of disease in these places. The Registrar General reported in 1841 that while mean life expectancy in Surrey was forty-five years, it was only thirty-seven in expectancy in London and twenty-six in Liverpool. The average age of "labourers, mechanics, and servants", at times of death was only fifteen. Mortality figures for crowded districts like Shoreditch, Whitechapel, and Bermondsey were typically half again or twice as high as those for middle-class areas of London.
Such statistics as these not only made Britons aware of the magnitude of disease in their own time, but served as effective weapons for sanitary reformers when they brought their case before Parliament. Two reports by the Poor Law Commission in 1838, one by Dr. Southwood Smith, the other by Drs. Neil Arnott and J. P. Kay (later Kay-Shuttleworth), outlined causes and probable means of preventing communicable disease in poverty areas like London's Bethnal Green and Whitechapel. Chadwick's Report broadened the scope of inquiry geographically, as did a Royal Commission document in 1845 on the Health of Towns and Populus Places. What we learn from these and other sources gives a depressing picture of early Victorian hygiene.
During the first decades of Victoria's reign, baths were virtually unknown in the poorer districts and uncommon anywhere. Most households of all economic classes still used "privy-pails" water closets were rare. Sewers had flat bottoms, and because drains were made out of stone, seepage was considerable. If, as was often the case in towns, streets were unpaved, they might remain ankle-deep in mud for weeks. For new middle-class homes in the growing manufacturing towns, elevated sites were usually chosen, with the result that sewage filtered or flowed down into the lower areas where the laboring populations dwelt. Some towns had special drainage problems. In Leeds the Aire River, fouled by the town's refuse, flooded periodically, sending noxious waters into the ground floors and basements of the low-lying houses.
As Chadwick later recalled, the new dwellings of the middle-class families were scarcely healthier, for the bricks tended to preserve moisture. Even picturesque old country houses often had a dungeonlike dampness, as an visitor could observe: "If he enters the house he finds the basement steaming with water-vapour walls constantly bedewed with moisture, cellars coated with fungus and mould drawing rooms and dining rooms always, except in the very heat of summer, oppressive from moisture bedrooms, the windows of which are, in winter, so frosted on their inner surface, from condensation of water in the air of the room, that all day they are coated with ice."
In some districts of London and the great towns the supply of water was irregular. Typically, a neighbourhood of twenty or thirty families on a particular square or street would draw their water from a singly pump two or three times a week. Sometimes, finding the pump not working, they were forced to reuse the same water. When a local supply became contaminated the results could be disastrous. In Soho's St. Anne's parish, for example, the faeces of an infant stricken with cholera washed down into the water reserve from which the local pump drew, and almost all those using the pump were infected. Millbank Prison, taking its water from the sewage-polluted Thames, suffered greatly during every epidemic of water-borne disease.
The Public Health Bill, passed in 1848 because of the efforts of reformers like Smith and Chadwick, empowered a central authority to set up local boards whose duty was to see that new homes had proper drainage and that local water supplies were dependable. The boards were also authorized to regulate the disposal of wastes and to supervise the construction of burial grounds. Simply bringing this last problem to public attention was a great service: the New Bunhill Fields burying ground in the Borough, less than an acre in size, was at that time the depository of over fifteen hundred bodies a year, though Chadwick estimated that only one hundred and ten could be "neutralized" per acre of ground. When more room was needed, the older skeletons and coffins were incinerated. The graveyard of St. Martin's, Ludgate, had long since filled, and hundreds more were interred in church vaults the resulting stench drove the regular worshippers from service.
Since it was widely believed that disease was generated spontaneously from filth (pythogenesis) and transmitted by noxious invisible gas or miasma, there was much alarm over the "Great Stink" of 1858 and 1859. The Thames had become so polluted with waste as to be almost unbearable during summer months. People refused to use the river-steamers and would walk miles to avoid crossing one of the city bridges. Parliament could carry on its business only by hanging disinfectant-soaked cloths over the windows. It should have been a blow to the theory of pythogenesis when no outbreak of fever ensued from this monstrous stench. As late as 1873, however, William Budd could reluctantly report in his important book on typhoid that "organic matter, and especially sewage in a state of decomposition, without any relation to antecedent fever, is still generally supposed to be the most fertile source."
Throughout most of the century, doctors can be said to have been conceptually helpless about the cause and treatment of the disease. A glance at the contents of a typical volume of the Lancet (1849) tells the melancholy story: "On the Advantage of Copious Bleeding in Inflammatory Diseases" "Report of a Case of Cholera Treated by Transfusion" "Treatment of Cholera by Small and Repeated Doses of Calomel" "On the Employment of Embrocations and Injections of Strong Liquid Ammonia in the Collapse Stage of Cholera." One title begins promisingly, "On the Production of Cholera by Insufficient Drainage", but continues, "with Remarks on the Hypothesis of an Altered Electrical State of the Atmosphere."
No doubt the resistance to the theory of polluted water as a source of infection contributed to the steady prevalence of typhoid in the second half of the century as well as to the high mortality rates from cholera in epidemics as late as 1854 or 1865-6. The general cleaning up of the cities and towns, however, produced a marked reduction in deaths from typhus, a disease, we now know, transmitted by lice. Although a systematic control of contagious disease had to await the introduction of preventive inoculation in the eighties and nineties, after mid-century the general health of the country measurably improved. In the 1850s and 1860s there came into common use such diagnostic aids as the stethoscope, the ophthalmoscope, and the short clinical thermometer. Meanwhile the employment of general anaesthesia and antiseptic surgery was reducing considerably the number of hospital deaths.
Improved hygiene, diagnosis, and treatment in the past century have given people a certain emotional security even in the face of serious disease. Throughout much of the Victorian period, however, with both the causes and the patterns of disease very much matters of speculation, it was difficult ever to feel comfortable about one's state of health. The behaviour of the sever contagions of the time had a special way of intensifying anxiety. They would appear, then perhaps subside for a month or two, only to reappear in the same locality or somewhere else. Also, the individual sufferer had no way of predicting the outcome of the disease in his own case. Influenza patients, observed the London Medical Gazette during the 1833 epidemic, "might linger for the space of two or three weeks and then get up well, or they might die in the same number of days." Just as frightening was the uncertain progress of typhoid. For the first week the victim would feel listless and suffer headaches, insomnia, and feverishness. His temperature would gradually increase over this period, though fluctuating between morning and evening hours. His stomach would be painful and distended. Probably he would have diarrhoea and perhaps red patches on his skin. Typically there would be an intensification of these symptoms for a few weeks. In most cases the patient would recover, but convalescence might take additional weeks. Depending on the severity of the attack, however, and the patient's ability to resist, he might die from exhaustion, internal haemorrhaging, or ulceration of the intestine.
The beginnings of such a disease as typhoid were so mild and gradual as to be subjectively indistinguishable from, say, a cold or a moderate case of influenza, of from any number of nonfatal complaints. Deficiency diseases, both glandular and dietary, were but dimly understood in those days. Proper diagnosis and effective treatment of goitre, diabetes, and the various vitamin deficiencies belong to the twentieth century, as is true with allergies, many of which must also have imitated the early symptoms of acute diseases. Thousands of sufferers from eczema, hives, or asthma not only were given superficial relief but were ignorant of the nature of their maladies.
The number of unknowing victims of chronic food poisoning must also have been great. Mineral poisons were often introduced into food and water form bottle stoppers, water pipes, wall paints, or equipment used to process food and beverages. Moreover, the deliberate adulteration of food was a common and, until 1860, virtually unrestricted practice. For example, because of the Englishman's dislike for brown bread, bakers regularly whitened their flour with alum. Conditions for the processing and sale of foods were unsanitary. An 1863 report to the Privy Council stated that one-fifth of the meat sold came from diseased cattle. In 1860 the first pure-food act was passed, but, as was often the case in these early regulatory measures, it provided no mandatory system of enforcement. In 1872 another act was passed, this time considerably strengthening penalties and inspection procedures. But in the meantime, and throughout most of the nineteenth century, Britons had little protection against unwholesome food and drink. We can only guess at how many tons of adulterated tea, rancid butter, and polluted meat were sold and consumed monthly throughout the kingdom.
Whenever Parliament debated some labor-reform bill, Victorians were reminded that the Industrial Revolution had brought as an unwelcome by-product the proliferation of occupational diseases. Testimony from medical investigators and workers alike included gruesome stories of "black-spittle" among miners, of grinder's rot and potter's asthma. Those looking into conditions among milliners and dressmakers found much higher than average rates of anaemia, deteriorating vision, and various lung diseases caused by breathing dust and fine particles of fiber. In many places of work, ten to twelve hours a day standing or sitting in one spot, often in an unnatural positions, damaged the spine, the digestion, and the circulation.
With the prevalence of these occupational ailments, as well as of contagions, deficiency diseases, and food poisonings, George Henry Lewe's remark that "few of us, after thirty, can boast of robust health" is understandable. Their correspondence reveals that many prominent Victorians were constantly afflicted. --Bruce Haley. The Healthy Body and Victorian Culture . Cambridge, Mass.: Harvard University Press, 1978.
What sort of insight does this information yield into the Victorian period, which was obviously a time of both medical progress and intense human suffering and physical pain?
Could it help to explain certain elegies, or a prevalence for grieving or ruminations on death, in poetry?
Snow was born on 15 March 1813 in York, England, the first of nine children born to William and Frances Snow in their North Street home, and was baptised at All Saints' Church, North Street, York. His father was a labourer  who worked at a local coal yard, by the Ouse, constantly replenished from the Yorkshire coalfield by barges, but later was a farmer in a small village to the north of York. 
The neighbourhood was one of the poorest in the city, and was frequently in danger of flooding because of its proximity to the River Ouse. Growing up, Snow experienced unsanitary conditions and contamination in his hometown. Most of the streets were unsanitary and the river was contaminated by runoff water from market squares, cemeteries and sewage. 
From a young age, Snow demonstrated an aptitude for mathematics. In 1827, when he was 14, he obtained a medical apprenticeship with William Hardcastle in the area of Newcastle-upon-Tyne. In 1832, during his time as a surgeon-apothecary apprentice, he encountered a cholera epidemic for the first time in Killingworth, a coal-mining village.  Snow treated many victims of the disease and thus gained experience. Eventually he adjusted to teetotalism and led a life characterized by abstinence, signing an abstinence pledge in 1835. Snow was also a vegetarian and tried to only drink distilled water that was “pure”.  Between 1832 and 1835 Snow worked as an assistant to a colliery surgeon, first in Burnopfield, County Durham, and then in Pateley Bridge, West Riding of Yorkshire. In October 1836 he enrolled at the Hunterian school of medicine on Great Windmill Street, London. 
In the 1830s, Snow's colleague at the Newcastle Infirmary was surgeon Thomas Michael Greenhow. The surgeons worked together conducting research on England's cholera epidemics, both continuing to do so for many years.    
In 1837, Snow began working at the Westminster Hospital. Admitted as a member of the Royal College of Surgeons of England on 2 May 1838, he graduated from the University of London in December 1844 and was admitted to the Royal College of Physicians in 1850. Snow was a founding member of the Epidemiological Society of London which was formed in May 1850 in response to the cholera outbreak of 1849. By 1856, Snow and Greenhow's nephew, Dr. E.H. Greenhow were some of a handful of esteemed medical men of the society who held discussions on this "dreadful scourge, the cholera".   
After finishing his medical studies in the University of London, he earned his MD in 1844. Snow set up his practice at 54 Frith Street in Soho as a surgeon and general practitioner. John Snow contributed to a wide range of medical concerns including anaesthesiology. He was a member of the Westminster Medical Society, an organisation dedicated to clinical and scientific demonstrations. Snow gained prestige and recognition all the while being able to experiment and pursue many of his scientific ideas. He was a speaker multiple times at the society's meetings and he also wrote and published articles. He was especially interested in patients with respiratory diseases and tested his hypothesis through animal studies. In 1841, he wrote, On Asphyxiation, and on the Resuscitation of Still-Born Children, which is an article that discusses his discoveries on the physiology of neonatal respiration, oxygen consumption and the effects of body temperature change. 
In 1857, Snow made an early and often overlooked  contribution to epidemiology in a pamphlet, On the adulteration of bread as a cause of rickets. 
Snow's interest in anaesthesia and breathing was evident from 1841 and beginning in 1843, he experimented with ether to see its effects on respiration.  Only a year after ether was introduced to Britain, in 1847, he published a short work titled, On the Inhalation of the Vapor of Ether, which served as a guide for its use. At the same time, he worked on various papers that reported his clinical experience with anaesthesia, noting reactions, procedures and experiments. Within two years of ether being introduced, Snow was the most accomplished anaesthetist in Britain. London's principal surgeons suddenly wanted his assistance. 
As well as ether, John Snow studied chloroform, which was introduced in 1847 by James Young Simpson, a Scottish obstetrician. He realised that chloroform was much more potent and required more attention and precision when administering it. Snow first realised this with Hannah Greener, a 15-year-old patient who died on 28 January 1848 after a surgical procedure that required the cutting of her toenail. She was administered chloroform by covering her face with a cloth dipped in the substance. However, she quickly lost pulse and died. After investigating her death and a couple of deaths that followed, he realized that chloroform had to be administered carefully and published his findings in a letter to The Lancet. 
John Snow was one of the first physicians to study and calculate dosages for the use of ether and chloroform as surgical anaesthetics, allowing patients to undergo surgical and obstetric procedures without the distress and pain they would otherwise experience. He designed the apparatus to safely administer ether to the patients and also designed a mask to administer chloroform.  Snow published an article on ether in 1847 entitled On the Inhalation of the Vapor of Ether.  A longer version entitled On Chloroform and Other Anaesthetics and Their Action and Administration was published posthumously in 1858. 
Although he thoroughly worked with ether as an anaesthetic, he never attempted to patent it instead, he continued to work and publish written works on his observations and research.
Snow's work and findings were related to both anaesthesia and the practice of childbirth. His experience with obstetric patients was extensive and used different substances including ether, amylene and chloroform to treat his patients. However, chloroform was the easiest drug to administer. He treated 77 obstetric patients with chloroform. He would apply the chloroform at the second stage of labour and controlled the amount without completely putting the patients to sleep. Once the patient was delivering the baby, they would only feel the first half of the contraction and be on the border of unconsciousness, but not fully there. Regarding administration of the anaesthetic, Snow believed that it would be safer if another person that was not the surgeon applied it. 
The use of chloroform as an anaesthetic for childbirth was seen as unethical by many physicians and even the Church of England. However, on 7 April 1853, Queen Victoria asked John Snow to administer chloroform during the delivery of her eighth child, Leopold. He then repeated the procedure for the delivery of her daughter Beatrice in 1857.  This led to wider acceptance of obstetrical anaesthesia. 
Achievements in Public Health, 1900-1999: Changes in the Public Health System
The 10 public health achievements highlighted in this MMWR series (see box) reflect the successful response of public health to the major causes of morbidity and mortality of the 20th century (1-11). In addition, these achievements demonstrate the ability of public health to meet an increasingly diverse array of public health challenges. This report highlights critical changes in the U.S. public health system this century.
In the early 1900s in the United States, many major health threats were infectious diseases associated with poor hygiene and poor sanitation (e.g., typhoid), diseases associated with poor nutrition (e.g., pellagra and goiter), poor maternal and infant health, and diseases or injuries associated with unsafe workplaces or hazardous occupations (4,5,7,8). The success of the early public health system to incorporate biomedical advances (e.g., vaccinations and antibiotics) and to develop interventions such as health education programs resulted in decreases in the impact in these diseases. However, as the incidence of these diseases decreased, chronic diseases (e.g., cardiovascular disease and cancer) increased (6,10). In the last half of the century, public health identified the risk factors for many chronic diseases and intervened to reduce mortality. Public efforts also led to reduced deaths attributed to a new technology, the motor vehicle (3). These successes demonstrated the value of community action to address public health issues and have fostered public support for the growth of institutions that are components of the public health infrastructure*. The focus of public health research and programs shifted to respond to the effects of chronic diseases on the public's health (12-17). While continuing to develop and refine interventions, enhanced morbidity and mortality surveillance helped to maintain these earlier successes. The shift in focus led to improved capacity of epidemiology and to changes in public health training and programs.
Quantitative Analytic Techniques
Epidemiology, the population-based study of disease and an important part of the scientific foundation of public health, acquired greater quantitative capacity during the 20th century. Improvements occurred in both study design and periodic standardized health surveys (12,18-21). Methods of data collection evolved from simple measures of disease prevalence (e.g., field surveys) to complex studies of precise analyses (e.g., cohort studies, case-control studies, and randomized clinical trials) (12). The first well-developed, longitudinal cohort study was conducted in 1947 among the 28,000 residents of Framingham, Massachusetts, many of whom volunteered to be followed over time to determine incidence of heart disease (12). The Framingham Heart Study served as the model for other longitudinal cohort studies and for the concept that biologic, environmental, and behavioral risk factors exist for disease (6,12).
In 1948, modern clinical trials began with publication of a clinical trial of streptomycin therapy for tuberculosis, which employed randomization, selection criteria, pre-determined evaluation criteria, and ethical considerations (19,21). In 1950, the case-control study gained prominence when this method provided the first solidly scientific evidence of an association between lung cancer and cigarette smoking (22). Subsequently, high-powered statistical tests and analytic computer programs enabled multiple variables collected in large-scale studies to be measured and to the development of tools for mathematical modeling. Advances in epidemiology permitted elucidation of risk factors for heart disease and other chronic diseases and the development of effective interventions.
Periodic Standardized Health Surveys
In 1921, periodic standardized health surveys began in Hagerstown, Maryland (12). In 1935, the first national health survey was conducted among U.S. residents (12,23). In 1956, these efforts resulted in the National Health Survey, a population-based survey that evolved from focusing on chronic disease to estimating disease prevalence for major causes of death, measuring the burden of infectious diseases, assessing exposure to environmental toxicants, and measuring the population's vaccination coverage. Other population-based surveys (e.g., Behavioral Risk Factor Surveillance System, Youth Risk Behavior Survey, and the National Survey of Family Growth) were developed to assess risk factors for chronic diseases and other conditions (24-26). Methods developed by social scientists and statisticians to address issues such as sampling and interviewing techniques have enhanced survey methods used in epidemiologic studies (12).
Morbidity and Mortality Surveillance
National disease monitoring was first conducted in the United States in 1850, when mortality statistics based on death registrations were first published by the federal government (23,27). During 1878-1902, Congress authorized the collection of morbidity reports on cholera, smallpox, plague, and yellow fever for use in quarantine measures, to provide funds to collect and disseminate these data, to expand authority for weekly reporting from states and municipal authorities, and to provide forms for collecting data and publishing reports (15,23,27). The first annual summary of The Notifiable Diseases in 1912 included reports of 10 diseases from 19 states, the District of Columbia, and Hawaii. By 1928, all states, the District of Columbia, Hawaii, and Puerto Rico were participating in the national reporting of 29 diseases. In 1950, state and territorial health officers authorized the Council of State and Territorial Epidemiologists (CSTE) to determine which diseases should be reported to the U.S. Public Health Service (PHS) (27). In 1961, the Centers for Disease Control and Prevention (CDC) assumed responsibility for collecting and publishing nationally notifiable diseases data. As of January 1, 1998, 52 infectious diseases were notifiable at the national level.
In the early 1900s, efforts at surveillance focused on tracking persons with disease by mid-century, the focus had changed to tracking trends in disease occurrence (28,29). In 1947, Alexander Langmuir at the newly formed Communicable Disease Center, the early name for CDC, began the first disease surveillance system (27). In 1955, surveillance data helped to determine the cause of poliomyelitis among children recently vaccinated with an inactivated vaccine (28). After the first polio cases were recognized, data from the national polio surveillance program confirmed that the cases were linked to one brand of vaccine contaminated with live wild poliovirus. The national vaccine program continued by using supplies from other polio vaccine manufacturers (28). Since these initial disease surveillance efforts, morbidity tracking has become a standard feature of public health infectious disease control (29).
In 1916, with the support of the Rockefeller Foundation, the Johns Hopkins School of Hygiene and Public Health was started (30,31). By 1922, Columbia, Harvard, and Yale universities had established schools of public health. In 1969, the number of schools of public health had increased to 12, and in 1999, 29 accredited schools of public health enrolled approximately 15,000 students (31,32). Besides the increase in the number of schools and students, the types of student in public health schools changed. Traditionally, students in public health training already had obtained a medical degree. However, increasing numbers of students entered public health training to obtain a primary postgraduate degree. In 1978, 3753 (69%) public health students enrolled with only baccalaureates. The proportion of students who were physicians declined from 35% in 1944-1945 to 11% in 1978 (28,31). Thus, public health training evolved from a second degree for medical professionals to a primary health discipline (33). Schools of public health initially emphasized the study of hygiene and sanitation subsequently, the study of public health has expanded into five core disciplines: biostatistics, epidemiology, health services administration, health education/ behavioral science, and environmental science (30,34).
Programs also were started to provide field training in epidemiology and public health. In 1948, a board was established to certify training of physicians in public health administration, and by 1951, approximately 40 local health departments had accredited preventive medicine and public residency programs. In 1951, CDC developed the Epidemic Intelligence Service (EIS) to guard against domestic acts of biologic warfare during the Korean conflict and to address common public health threats. Since 1951, more than 2000 EIS officers have responded to requests for epidemiologic assistance within the United States and throughout the world. In 1999, 149 EIS officers are on duty.
Nongovernment and Government Organizations
At the beginning of the century, many public health initiatives were started and supported by nongovernment organizations. However, as federal, state, and local public health infrastructure expanded, governments' role increased and assumed more responsibility for public health research and programs. Today, public health represents the work of both government and nongovernment organizations.
Nongovernment organizations. The Rockefeller Sanitary Committee's Hookworm Eradication Project conducted during 1910-1920 was one of the earliest voluntary efforts to engage in a campaign for a specific disease (35). During 1914-1933, the Rockefeller Foundation also provided $2.6 million to support county health departments and sponsored medical education reform. Other early efforts to promote community health include the National Tuberculosis Association work for TB treatment and prevention, the National Consumers League's support of maternal and infant health in the 1920s, the American Red Cross' sponsorship of nutrition programs in the 1930s, and the March of Dimes' support of research in the 1940s and 1950s that led to a successful polio vaccine. Mothers Against Drunk Driving started in 1980 by a group of women in California after a girl was killed by an intoxicated driver and grew into a national campaign for stronger laws against drunk driving.
Professional organizations and labor unions also worked to promote public heath. The American Medical Association advocated better vital statistics and safer foods and drugs (17). The American Dental Association endorsed water fluoridation despite the economic consequences to its members (9). Labor organizations worked for safer workplaces in industry (4). In the 1990s, nongovernment organizations sponsor diverse public health research projects and programs (e.g., family planning, human immunodeficiency virus prevention, vaccine development, and heart disease and cancer prevention).
State health departments. The 1850 Report of the Sanitary Commission of Massachusetts, authored by Lemuel Shattuck (13,14), outlined many elements of the modern public health infrastructure including a recommendation for establishing state and local health boards. Massachusetts formed the first state health department in 1889. By 1900, 40 states had health departments that made advances in sanitation and microbial sciences available to the public. Later, states also provided other public health interventions: personal health services (e.g., disabled children and maternal and child health care, and sexually transmitted disease treatment), environmental health (e.g., waste management and radiation control), and health resources (e.g., health planning, regulation of health care and emergency services, and health statistics). All states have public health laboratories that provide direct services and oversight functions (36).
County health departments. Although some cities had local public health boards in the early 1900s, no county health departments existed (33). During 1910-1911, the success of a county sanitation campaign to control a severe typhoid epidemic in Yakima County, Washington, created public support for a permanent health service, and a local health department was organized on July 1, 1911 (33). Concurrently, the Rockefeller Sanitary Commission began supporting county hookworm eradication efforts (17,35). By 1920, 131 county health departments had been established by 1931, 599 county health departments were providing services to one fifth of the U.S. population (33) in 1950, 86% of the U.S. population was served by a local health department, and 34,895 persons were employed full-time in public health agencies (37).
Local health departments. In 1945, the American Public Health Association proposed six minimum functions of local health departments (38). In 1988, the Institute of Medicine defined these functions as assessment, policy development, and assurance, and PHS has proposed 10 organizational practices to implement the three core functions (39,40). The national health objectives for 2000, released in 1990, provided a framework to monitor the progress of local health departments (41). In 1993, 2888 local health departments**, representing county, city, and district health organizations operated in 3042 U.S. counties. Of the 2079 local health departments surveyed in 1993, nearly all provided vaccination services (96%) and tuberculosis treatment (86%) fewer provided family planning (68%) and cancer prevention programs (54%) (42).
Federal government. In 1798, the federal government established the Marine Hospital Service to provide health services to seamen (15). To recognize its expanding quarantine duties, in 1902, Congress changed the service's name to the Public Health and Marine Hospital Service and, in 1912, to the Public Health Service. In 1917, PHS' support of state and local public health activities began with a small grant to study rural health (35). During World War I, PHS received resources from Congress to assist states in treating venereal diseases. The Social Security Act of 1935, which authorized health grants to states, and a second Federal Venereal Diseases Control Act in 1938 (13,14), expanded the federal government's role in public health (15,35). In 1939, PHS and other health, education, and welfare agencies were combined in the Federal Security Agency, forerunner of the Department of Health and Human Services. In the 1930s, the federal government began to provide resources for specific conditions, beginning with care for crippled children. After World War II, the federal role in public health continued to expand with the Hospital Services and Construction Act (Hill-Burton) of 1946*** (15). In 1930, Congress established the National Institutes of Health [formerly the Hygiene Laboratories of the Public Health Service] and the Food and Drug Administration. CDC was established in 1946 (29). Legislation to form Medicare and Medicaid was enacted in 1965, and the Occupational Safety and Health Administration and the Environmental Protection Agency were organized in 1970.
Although federal, state, and local health agencies and services have increased throughout the century, public health resources represent a small proportion of overall health-care costs. In 1993, federal, state, and local health agencies spent an estimated $14. 4 billion on core public health functions, 1%-2% of the $903 billion in total health-care expenditure (43).
The public health infrastructure changed to provide the elements necessary for successful public health interventions: organized and systematic observations through morbidity and mortality surveillance, well-designed epidemiologic studies and other data to facilitate the decision-making process, and individuals and organizations to advocate for resources and to ensure that effective policies and programs were implemented and conducted properly. In 1999, public health is a complex partnership among federal agencies, state and local governments, nongovernment organizations, academia, and community members. In the 21st century, the success of the U.S. public health system will depend on its ability to change to meet new threats to the public's health.
Reported by: Epidemiology Program Office, Office of the Director, CDC.
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* The government, community, professional, voluntary, and academic institutions and organizations that support or conduct public health research or programs.
** A local health department is an administrative or service unit of local or state government responsible for the health of a jurisdiction smaller than the state.