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The rising costs of health care in the United States have spawned a national debate about whether or not health care, especially as manifested by health insurance, is a right or a privilege. In twenty-first century America, as in previous centuries, the very poor suffer the most from disease because of squalid living conditions, inadequate diet, ignorance about health issues, and insufficient funds to pay for care. Federal programs such as Medicare and Medicaid, in place since the 1960s, provide some relief for the poor, although such relief is rarely adequate to meet the costs of prescription drugs, lab results, surgery, and extended hospital stays.
Although status and wealth have always had an impact on disease and health, the rich and poor in colonial America, compared to today, tended to be more equal in respect to health care. Colonial America had no medical schools and few trained physicians. Health care was usually the domain of the amateur practitioner—the barber surgeon, chirurgeon, midwife, pastor, master, or parent. Books such as John Tennent’s Every Man his own Doctor: Or The Poor Planter’s Physician (1734) provided common sense, traditional, and Native American remedies for ailments ranging from the common cold to cancer. The seemingly unlimited botanical resources: of America encouraged amateur botanists to treat themselves and others with a variety of folk remedies. The ability to collect herbs in a forest or garden did not depend on personal wealth and status. Such ad hoc medical treatment explains in part the mortality rate of colonial children. On average, one in ten children in New England died in infancy—although the percentage increased during epidemics. Only 50 percent of Chesapeake youth made it to adulthood during the colonial period. Children, especially of the poor, were struck down by smallpox, diphtheria, yellow fever, and malaria; intestinal complaints caused by worms were all too common.
From the beginning, Americans have felt an obligation to care for the unfortunate physically or mentally ill members of the community. The earliest cities, such as Boston, remunerated local physicians who cared for impoverished townspeople. In 1731 Boston appointed a physician whose sole task was to treat the city’s poor. Towns such as Portsmouth, New Hampshire, paid physicians to inoculate the poor for smallpox. New Hampshire in 1680 passed a law requiring that medical expenses generated by the care of the poor be passed on to the town of the poor person’s origin. Townspeople were paid to care for sick or mentally ill poor. In the eighteenth century, the impoverished mentally and physically ill were increasingly placed in almshouses with the sane and well. Benevolent physicians sometimes treated the inmates of the almshouse for no charge. The institutionalization of the poor took a different turn (for the better) with the creation of hospitals to care for the sick poor. Of early signiicance was the Pennsylvania Hospital, opened in Philadelphia in 1752. Founded in part by Benjamin Franklin and consistent with his beliefs in the practice of charity and benevolence toward the downtrodden, the Pennsylvania
Hospital initially treated the sick poor, especially those with terminal illnesses who had nowhere to go to suffer through their final illnesses and die. Philadelphia physicians who practiced at the Pennsylvania Hospital treated their poor charges for free. Franklin’s promotional tract, Some Account of the Pennsylvania Hospital (1754), brought early notoriety to the institution. From the beginning, the Pennsylvania Hospital practiced the “reception and cure of lunaticks”; such treatment and care of the impoverished mentally ill became a trademark for late eighteenth- and early nineteenth-century American physicians. Benjamin Rush, for example, America’s most famous physician, was also one of the first to study “diseases of the mind,” recording his insights in the 1812 book Medical Inquiries and Observations upon the Diseases of the Mind.
Another early American institution that housed the impoverished sick was the pesthouse, which was a place, usually on a secluded island, where those who were ill with deadly diseases, such as smallpox, were quarantined from the rest of the population. Sick servants, redemptioners, and convicts arriving from England and Europe often had to wait aboard ship for their illness to mitigate unless local authorities had already whisked them away to the pesthouse. The eighteenth-century medical technique to prevent smallpox epidemics was inoculation, which involved taking the blood or tissue of a person who was ill with smallpox and purposely transposing it to a well person; the inoculated person, it was hoped, would develop a less virulent form of the disease that would make them forever immune. Because the inoculated person was contagious, he or she was quarantined at the pesthouse. During the Revolutionary War, inoculation was practiced widely and sometimes administered to the poor for free, as a public health measure. Boston’s pesthouse was at Spectacle Island; Newport’s pesthouse was at Coaster’s Harbor Island; Philadelphia’s pesthouse was at Province Island. “As Christians and men,” wrote a Philadelphian in 1738, referring to those redemptioners awaiting aboard ship for admission to the city, “we are obliged to make a charitable provision for the sick stranger, and not by confining him to a ship, inhumanly expose him to fresh miseries when he hopes that his sufferings are soon to be mitigated.”
During the 1800s scientists and physicians in America and Europe made important discoveries in public health and in understanding how disease occurs and is spread. Scientists realized that the increasing population of American cities led to unhealthy conditions. They had learned that microorganisms are the cause of contagious disease and that disease-causing microorganisms thrive in certain environments. Increasing awareness of the causes and contagion of disease resulted in the continuation of some practices directed toward the sick poor, such as the quarantine system, as well as the development of sanitary commissions directed toward bettering public health.
American public health advocates worked in the wake of the publication of Edwin Chadwick’s Report on the Sanitary Condition of the Labouring Population of Great Britain in 1842. Chadwick argued that poor sanitation led to the spread of disease through densely populated areas. He was an advocate of the standard medical theory of the time (before the discoveries of Louis Pasteur)—that miasmic air, caused by rotting organic filth, resulted in disease. At the same time, cities such as New York were experiencing a dramatic increase in population that included impoverished neighborhoods exuding physical and moral filth, which inspired the City Inspector of New York, Dr. John Griscom, to publish The Sanitary Condition of the Laboring Population of New York in 1845. In the words of Alexander Von Hoffman, Griscom argued that “when applied to the urban poor . . . the physical disorder and dilapidation of the shabby residential districts determined, or helped to determine, the physical and moral conditions of their inhabitants.” Robert Hartley, a founder of the New York Association for Improving the Condition of the Poor (AICP), argued for the presence of “miasmatic air” as a cause of immorality and disease in crowded New York neighborhoods. The AICP declared in 1847 that the poor “suffer from sickness and premature mortality; their ability for self-maintenance is thereby destroyed; social habits and morals are debased, and a vast amount of wretchedness, pauperism, and crime is produced.”
Other mid- to late nineteenth-century reformers advocated altering the physical environment to produce important social, moral, and emotional results, thus breaking from the cycle of poverty. Charles Loring Brace was a minister and missionary who worked for the AICP and founded the Children’s Aid Society in 1853, which provided children with a host of services, ranging from medical care to education to direct relief. Noteworthy was Brace’s implementation of the orphan trains, which brought thousands of children from the East Coast to the West, where they lived in foster homes until they reached majority. Dorothea Dix was a mental health reformer who investigated the vile treatment of the poor and criminal insane in prisons, almshouses, and asylums. She tirelessly lobbied state and federal government for reforms, including the opening of mental hospitals to treat the insane. Julia Lathrop also worked for the care and support of poor children with mental illnesses. Lathrop was involved with Hull House, the Chicago United Charities, and the U.S. Children’s Bureau. Lillian Wald of Ohio, who was similarly involved in child health issues, opened the Henry Street Settlement among the poor of New York and, as a nurse, offered care to indigent children.
Advances in knowledge about the causes and spread of disease in the late nineteenth into the twentieth centuries resulted in commensurate developments for the prevention and treatment of disease in the poor. Understanding of infectious disease and contagion—as well as the development of antibiotics and vaccinations, particularly to treat and prevent cholera, diphtheria, polio scarlet fever, tetanus, tuberculosis, whooping cough, and yellow fever—resulted in a decline in child mortality rates, even as urban population grew. Hospitals, once the domain of the dying pauper, were, by the twentieth century, on the forefront of treatment and prevention; the numbers of hospitals grew from hundreds in the nineteenth century to more than 6,000 by the end of the twentieth century.
From the late nineteenth to the twentieth centuries, the federal government increasingly took the lead in health care for the poor. Federal involvement was instigated because of cholera and yellow fever epidemics in the 1870s, which led to the creation of the National Board of Health. Local, state, and federal public health officials worked to alleviate the problems, such as inadequate plumbing and sewage, unsanitary public venues (such as restaurants), and air and water pollution, causing poor public health, especially among the poor. Federal agencies created during the twentieth century that directly or indirectly affected health care and the poor include the Food and Drug Administration, the National Institutes of Health (NIH), and the Centers for Disease Control, all organized under the executive office of the Department of Health and Human Services. At the close of World War II, the Hill-Burton Act (1946) was passed by Congress, authorizing the federal government to sponsor the erection of hospitals in rural America. During the 1960s, Lyndon Johnson’s Great Society program created Medicare, a program to provide health care for the elderly poor.
Despite government involvement and programs such as Medicaid that help the disadvantaged, the United States has no universal health care program. At the beginning of the twenty-first century, 40,000,000 Americans, mostly the poor, lack health insurance, even as the costs of health care skyrocket. Minority groups are at a higher risk for obesity, cancer, low birth weight, and infant mortality. According to the National Institute of Child Health and Human Development, one in four African American children live in poverty, with consequent health risks. The NIH reports that African Americans have a 25 percent higher cancer mortality rate compared to the overall population. The NIH also reports that diabetes has grown to become a serious illness (four to eight times greater than in the overall population) for Native Americans, who traditionally have high poverty rates as well; Native Americans also have a higher rate of dependency on tobacco than the general population.
- Bridenbaugh, Carl, Cities in Revolt (New York: Oxford, 1955);
- Bridenbaugh, Carl, Cities in the Wilderness (New York: Oxford, 1938);
- Grob, Gerald N., The Deadly Truth: A History of Disease in America (Cambridge, MA: Harvard University Press, 2002);
- Hoffman, Alexander von, “The Origins of American Housing Reform.” Joint Center for Housing Studies, Harvard University (1998);
- Hofstadter, Richard, America in 1750: A Social Portrait (New York: Random House, 1971);
- Mazzari, Louis, “Child Health” in Encyclopedia of New England (New Haven: Yale University Press, 2005);
- National Institute of Health (www.nih.gov);
- Rosen, George, A History of Public Health (Baltimore: Johns Hopkins University Press, 1993);
- Stevens, Rosemary, In Sickness and Wealth: American Hospitals in the Twentieth Century (Baltimore: Johns Hopkins University Press, 1999).
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