I chose a career in public health because of its power to improve lives, as the field did in the United States in the late 19th and early 20th centuries by controlling infectious diseases such as cholera and tuberculosis. I was fortunate to begin my career as a program analyst at the National Institutes of Health working to streamline funding allocation decisions. Over the past few weeks, it has been painful to witness the White House issuing directives curtailing federal funding, communications disparaging public health leaders, and directives to fire staff at numerous federal public health agencies, including NIH. Like many public health professionals, I fear what will happen next.
These attacks on public health efforts — and the feelings of anger and frustration from Covid-19 policy failures — have sent me searching for how the field fell from its glory years over a century ago. Where exactly did we go wrong?
U.S. public health efforts began in a vastly different era. In 19th century New York City, for example, diarrhea was a larger health threat than cancer or heart disease. And across the U.S., it was common for families to lose multiple children before their fifth birthday. Medicine offered little reprieve. Doctors’ orders could be more harmful than beneficial, and hospitals were only for the lower classes, while the wealthy received medical care at home.
In the period after the Civil War, many states and cities founded public health departments with an objective to prevent disease, especially because medical treatments were so ineffective. Boosted by the discovery of germ theory in the mid-1800s, these departments prevented disease through large-scale projects. They supported implementing water sanitation, trash removal services, housing regulations, and plumbing standards, along with distributing pasteurized milk to poor families and educating the public about personal hygiene.
The enormous success of this work changed patterns of disease — a process now known as the epidemiological transition. Though national metrics are unavailable, data from New York City show that the death rate fell 60 percent between 1875 and 1925. And from 1880 to 1920, life expectancy increased from 36 to 53 years. If the same proportional rise had occurred in the last 40 years, U.S. life expectancy in 2025 would be 110. The era was described as the “golden age” of public health. The improvements were due primarily to decreasing deaths from communicable diseases — at least one of which declined by 99 percent. However, as fewer people died from communicable diseases, more deaths were due to chronic diseases such as cancer and cardiovascular disease — the same health issues we see today.
Public health of the time was not equipped to address chronic disease. Early germ theory did not point to solutions, and the interventions used to control communicable diseases — clean water, clean cities, and vaccinations — were not effective. The idea of risk factors and the importance of diet and exercise were still being developed and not widely understood. Public health professionals needed to find new solutions.
In 1926, Charles-Edward Amory Winslow, a professor of public health at Yale and president of the American Public Health Association, envisioned a new approach in his speech at the society’s annual meeting. Winslow said public health was at a “crossroads,” noting that “the major problems of public health have fundamentally changed in 50 years,” and told the association “we must adopt new methods if we are to meet it with any measure of success.” According to Winslow: “Future progress in the reduction of mortality and in the promotion of health and efficiency depends chiefly upon the application of medical science to the early diagnosis and preventive treatment of disease.” Winslow saw a way forward if public health could work with health care providers to improve preventative interventions.
Public health went wrong when it failed to integrate medical services to address the new rise in chronic disease between the 1930s and early 1950s.
However, he noted that medical services had not reached a “wholly ideal status,” saying problems were caused by physicians who were too individualistic, lack of access in some areas, and people hesitating to seek preventative services because of the cost. Winslow told public health officers that it was their “primary responsibility to work out in cooperation with the medical profession a wise solution of this problem,” and said it was their duty to ensure their communities have access to appropriate medical care.
Unfortunately, Winslow’s hopes were never achieved. Public health went wrong when it failed to integrate medical services to address the new rise in chronic disease between the 1930s and early 1950s.
Serious attempts were made, mainly by Thomas Parran Jr., U.S. Surgeon General from 1936 to 1948, whose most heinous failure, however, was support for the infamous Tuskegee Experiment and equally horrific research in Guatemala. Parran had served in the U.S. Public Health Service since 1917 and was a confidante of President Franklin D. Roosevelt. A bit of a national celebrity, he was one of the most well-known surgeons general due to writing a bestselling book on syphilis and having a speech pulled from the radio for insisting on saying “syphilis.”
Parran saw medicine and public health as “two facets of a unit problem” and pushed for their integration like Winslow recommended. During negotiations for New Deal legislation in the mid-1930s, a national health insurance program was under intense discussion, and Parran made a last-second push to add funding for public health departments. While insurance was kept out of the final draft of what would become the 1935 Social Security Act, due to opposition from the American Medical Association, Parran’s advocacy won an increase federal funding for state and local health departments.
A few years later, in July 1938, Roosevelt’s health staff organized a conference to discuss health insurance policy options and laid out a five-point National Health Program that included federal grants for state public health departments, hospital construction, medical care for the needy, general medical care programs, and disability insurance. Parran spoke at the conference about the need to think beyond “the separateness of preventative and curative efforts to reduce death and disease” because all health efforts “are parts of the same entity.” Sen. Robert Wagner from New York introduced a bill modeled on the program in 1939, but Germany’s invasion of Poland pushed it off the agenda.
President Harry Truman, however, resurrected a version of the National Health Program in a policy announcement to Congress in November 1945 and added provisions for funding medical education and medical research. Parran was so enthusiastic that he instructed his staff to treat Truman’s plan as official policy and made speeches in support. Three members of Congress introduced a new version of a previous bill, based on Truman’s idea, but again, it faced strong opposition from the AMA over national health insurance. While one point in the bill — federal funding for hospital construction — became law in 1946, Truman’s hopes for systemic health reform fell apart for good after a midterm elections loss.
By the 1950s, public health advocates shrunk their goals to only one part of the original five-point plan: funding for state and local public health departments. Hugh R. Leavell, chair of the APHA executive board, testified before a House committee in 1951 in support of “local health units,” an idea that had been developing since at least 1945. However, a draft of the bill would only provide funding to departments that did not provide medical care. Leavell sought to remove this requirement, but the issue split support, and despite the APHA’s efforts, the bill failed again.
It is a tragic irony that the current anger and frustration at public health stems from a communicable disease response — the basis for our original success.
Public health struggled after the failures to integrate medical services and guarantee federal funding. In 1926, Winslow told APHA that they were at a “crossroads,” yet 30 years later the APHA conference was still debating, “Where Are We Going in Public Health?” Federal funding for state public health departments declined through the 1950s, while money was poured into the newly reorganized NIH to find out how to curtail chronic disease. Health care and public health drifted further apart. The major advances in health care policy in the 1960s, Medicare and Medicaid, bypassed state public health departments. Efforts in the 1970s to use public health departments as a centralized health planner failed.
By the 1980s, the public health system was in “disarray” by admission of its own internal experts in a major national report. Although there have been small wins since then, there have never been reform efforts as large as under Parran. Data show the significance of these failures: Life expectancy in the U.S. increased by 22 years between 1900 and 1952 (from 47 to 69 years) but by only eight years since then, and it has consistently lagged behind many other countries since 1980.
Things could have been different. Had the National Health Program passed, our response to Covid-19 would have been improved by more access to care, better clinical data, better health care resource sharing, and perhaps more trust. It is a tragic irony that the current anger and frustration at public health stems from a communicable disease response — the basis for our original success.
As we enter an era when archetypical public health efforts, such as vaccines and pasteurized milk, are questioned, how we got here matters. As activist Rebeca Solnit wrote, citing her friend Julian Aguon, “Hope does not come from knowing the future; it comes from knowing the past.” The past shows that the way to a healthier nation is more, not fewer, public health initiatives. I hope we learn that lesson.
Eric Coles, DrPH, is the Tribal Public Health Officer on the Tule River Indian Reservation and is writing a book about the rise and fall of public health in the United States.