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Public Health in Modern America, 1890-1970 offers researchers a rich array of primary sources documenting the history of public health as it relates to infants and children. Most significantly, the collection includes files from the United States Children’s Bureau from 1912 to 1969 related to maternal and child health research and to programs that the Bureau administered under Title V of the Social Security Act of 1935. Those records, along with published and unpublished primary sources in other parts of the collection, detail the engagement of public health officials and voluntary organizations in many of the major health challenges that confronted and medical advances that improved the overall health of the nation’s children, from the infant mortality crisis of the early twentieth century to the vaccination campaigns of the 1950s and 1960s.
PUBLIC HEALTH DEFINED
In 1920, Charles-Edward A. Winslow (1877-1957), a faculty member at the Yale School of Medicine, penned his “classic definition” of public health as “organized community efforts” to prevent disease and promote health through sanitary measures, health education, and preventive medicine, as well as “the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health” (Berridge 2; Winslow 30). Almost 40 years later, George Rosen, pioneer historian of public health, echoed Winslow when he attributed the decline in mortality from infectious diseases that occurred over the first half of the twentieth century to the willingness of Western nations “to invest accumulated wealth in the improvement of community health” (Rosen xvii). But how did men, women, private organizations, and American governmental institutions come to identify child health as a community concern that required “the development of social machinery” and the investment of tax dollars for its protection and “improvement”?
CHILD SAVING: PUBLIC HEALTH REFORM AND REFORMERS
Public health originated in the efforts of nineteenth-century sanitary reformers to address the living conditions of the working classes and to respond to epidemic diseases (Rosen 105). The first public health entity, New York City’s Metropolitan Board of Health, formed in 1866 in the wake of a third major cholera epidemic in 35 years (Rosen 139). Those early sanitarians’ efforts ran parallel to important developments in the history of children and child welfare that were essential to the later development of children’s public health in the Progressive Era.
Over the course of the nineteenth century, a gradual transformation of attitudes toward children occurred. Viviana Zelizer has argued that, early in the century, children usually contributed to the family economy largely because children’s roles in their families were similar to those of other adult members. By the mid-nineteenth century, as birth rates declined and wealth increased, the middle and upper classes began to focus on the “sentimental value” of children and childhood. Children, in their view, became “economically ‘worthless’ but emotionally ‘priceless’” (Zelizer 3). The industrializing economy’s insatiable demand for labor, however, meant that “the economic value of the working-class child increased rather than decreased” (Zelizer 5-6). The conditions of childhood among the nation’s impoverished city dwellers were increasingly at odds with the sentimental views of children and childhood held by the middle and upper classes. As early as the 1850s, the plight of children in urban tenement districts drew the attention of those social reformers who came to be known as “child savers.”
Reformers became increasingly anxious about the corrosive influence of urban slums on the physical and moral wellbeing of the children who inhabited them. “Child saving” (cf. child welfare) efforts first arose among the children of New York City’s tenements. Reformers sought to improve the material conditions of children from the poorest ranks of society, many of whom were immigrants or the children of immigrants. Several charities had established dispensaries (neighborhood clinics) throughout the city, but reformers concerned with children’s health viewed those efforts as inadequate. Many of the city’s poor children had health problems that reformers believed could only be addressed by removing the children from their “unhealthy” homes to places where they could receive proper nutrition and medical care in a clean environment with “good” moral influences (King 61-68).
CHILDREN’S HOSPITALS AND THE BIRTH OF PEDIATRICS
General hospitals and infirmaries had been founded to provide charity care; New York’s first hospital was established in 1791, and by 1872 the city had 21 such institutions (Richmond xiv-xv). Those hospitals, however, made no special provision for children and, indeed, often refused to admit them. When children were admitted, it was to adult wards (King 61). By mid-century, “physicians and reformers increasingly wondered whether a general hospital was a suitable moral place for a child,” reflecting the belief that childhood was a unique and special time, and that children were not simply small adults (Sloane). In response, those physicians and reformers collaborated to establish in 1854 the first children’s hospital in the United States, New York’s Nursery and Child’s Hospital. Children’s Hospital of Philadelphia opened in 1855, and Boston Children’s Hospital followed in 1869. By 1890, the nation had at least 30 free-standing children’s hospitals (Sloane). Children's hospitals were thus among the many institutions developed to accomplish the goals of child saving. They were also among the earliest indicators of a growing conviction that communities bore some collective responsibility for the health of children.
The emergence of children’s hospitals in the mid-nineteenth century coincided with the development of pediatrics as a medical specialty under the leadership of New York’s Dr. Abraham Jacobi (1830-1919) from the 1850s to 1870s. In 1880, Jacobi led in organizing the Pediatric Section of the American Medical Association; in 1888, he helped organized the American Pediatric Society. Pediatrics as Jacobi envisioned it was inherently a public health discipline, as concerned with nutrition and disease prevention (cf. preventive medicine) as with the diagnosis and treatment of illnesses. Nevertheless, pediatricians saw affiliations with children’s hospitals as a way to establish their medical authority and gain professional status (Sloane, paragraphs 3 & 4). Women physicians often trained in children’s hospitals in the late nineteenth century and became leaders in public health initiatives for children during the Progressive Era. New York’s S. Josephine Baker (1873-1945) is a prime example. She graduated from the Women’s Medical College of the New York Infirmary in 1898 and then spent a year as an intern at the New England Hospital for Women and Children in Boston. While trying to establish a private practice in New York City, she took a part-time position as a city medical inspector. By 1907, she was Assistant Commissioner of Health and the following year she became Director of Bureau of Child Hygiene, a newly formed division within the City Health Department and an innovation in American public health. In that role, she became an influential figure in the promotion of child health (Perry 621).
In addition to founding children’s hospitals, pediatricians and public health reformers collaborated to form voluntary organizations dedicated to promoting child health. S. Josephine Baker, for example, helped found the American Child Hygiene Association (cf. American Child Health Association) in 1909 to spearhead the effort to combat infant mortality. In 1918, renowned pediatrician L. Emmett Holt (1855-1924) founded and led the Child Health Organization of America, whose mission was to promote the health of school children by fostering health education. Perhaps the most famous of their publications was the Child Health Alphabet (1920), which is included in this collection. In 1923, The American Child Hygiene Association and the Child Health Organization joined forces to form the American Child Health Association, which for twelve years significantly influenced the work of public health for children. The ACHA published two popular magazines, Mother and Child and the Child Health Bulletin, and many well-regarded pamphlets and books. The organization was most well-known for establishing Child Health Day (cf. May Day) as May 1 each year beginning in 1924 and continuing until 1960, twenty-five years after the ACHA itself ceased operations. Child Health Day raised awareness about the importance of protecting and nurturing children’s physical and mental health and promoted health education (Goldberg). That day is extensively documented in this collection.
“SOCIAL MACHINERY”: LEGISLATION AND GOVERNMENT ACTION
Beginning in the 1890s, “child saving” entered a new phase as Progressive Era reformers set out to rescue children from poverty, exploitation, and disease through protective legislation and a wide variety of social and medical services. From the 1890s to the 1920s, Progressive reformers addressed the social problems posed by childhood disease and disability by applying the tenets of science and pro-active good government—Winslow’s “social machinery” (Holt 177). “At the turn of the century,” Zelizer notes, “the protection of children’s life and health emerged as a national priority” (Zelizer 12).
Two renowned reformers laid the groundwork for what became the United States Children’s Bureau. Lillian D. Wald (1867-1940), who originated the concept of the public health nurse and founded New York City’s Henry Street Settlement, had a special interest in the health of women and children. Florence Kelley (1859-1832), founder and General Secretary of the National Consumers’ League, had already devoted years to the important labor questions of the day, among them the crusade to outlaw child labor. The two women began meeting in 1903 to discuss the plight of the nation’s working-class children and came up with the idea of a federal agency, much like the Department of Agriculture, only devoted to “’the Nation’s crop of children’” (Oettinger). Backed by President Theodore Roosevelt (1858-1818), they launched a seven-year effort to secure legislation establishing the agency. In 1909, to garner public support, Roosevelt called the White House Conference on the Care of Dependent Children, a seminal event for making the health of children a matter of government concern. Attended by eminent professionals and reformers in the field of child welfare, the Conference enthusiastically endorsed the creation of a Federal Children’s Bureau. Three more years of lobbying finally yielded the desired result and in 1912, the United States Children’s Bureau came into being.
THE WAR ON INFANT MORTALITY
Under the broad umbrella of “the welfare of children and child life,” the Children’s Bureau was charged, among other things, with investigating the “accidents and diseases of children” (Lathrop 30). Led by Julia Lathrop (1858-1932) for its first decade, the Bureau made the investigation of infant mortality a top priority.
Over the second half of the nineteenth century, anywhere from 15% to 30% of American infants died before their first birthday, depending on location (Meckel 1, 106). In the mid-nineteenth century, physicians and child welfare reformers considered high infant mortality rates an indicator that sanitary reform measures were needed in a given locale. As a result, they threw their support behind sanitarians’ campaigns to clean up cities—the first manifestations of public health concern in the United States. After 1880, those concerned about infant mortality began to home in on poor nutrition as the chief culprit. Influenced by the emerging science of bacteriology, they crusaded to clean up the urban milk supply (Meckel, 5-6). Reformers aimed not only to reduce infant mortality but to remove milk contaminated by bovine tuberculosis, a source of bone and joint tuberculosis resulting in the disability or death of children. From 1924 to 1927, funded by a grant from the Children’s Bureau, Dr. Martha Eliot conducted research on the efficacy of community health programs for preventing rickets in children. Partly as a result of that research, the Bureau added Vitamin D fortification to their pure milk campaigns in the early 1930s. The Children’s Bureau devoted significant resources to the campaign for pure milk in its first three decades, as evidenced by the extensive documentation contained in the Records of the Children’s Bureau.
Not content to stop with the pure milk campaigns, staff of the Children’s Bureau quickly launched research projects on maternal and child health in order to identify other measures that could be implemented in the crusade against infant mortality. Out of that initial research grew the Bureau’s first organized nationwide public health campaign aimed at improving the health of children—the Campaign for Better Babies, launched in 1915. The Better Babies Campaign aimed to educate mothers, reduce infant mortality, and identify and neutralize threats to children’s health. Children’s Bureau staff promoted the use of statistical norms to measure physical and mental development; those measurements became criteria for judging Better Baby competitions. Public health officials implementing the campaigns used traveling health exhibits and mobile clinics to promote routine physical examinations. Those examinations often resulted in medical interventions, such as surgery to remove tonsils and adenoids (Holt 176-179).
American involvement in World War I interrupted the Better Babies Campaigns and other outreach and research initiatives at the Children’s Bureau. After the war, the campaigns shifted to the “social context of county and state fairs” (Holt 182). These campaigns took place alongside “Fitter Families” contests and became more overtly influenced by the eugenics movement (Holt 184).
At the conclusion of the war in 1918, the Bureau’s staff set out to regain public and legislative attention by declaring 1918-1919 the Children’s Year. They generated research data demonstrating that poverty and limited access to prenatal care resulted in the nation’s relatively high rates of maternal and infant mortality. Using that data, Bureau staff and some 11 million volunteers nationwide lobbied state governments to establish agencies or programs focused on child health and welfare, with the overarching goal of reducing infant mortality. The volunteers also carried out activities to promote three additional objectives: first, record the measurements of infants and toddlers, thereby educating mothers about proper nutrition; second, promote safe and healthy recreation and play in their communities; and third, do everything possible to keep children in school and out of the work force (“Centennial Series: The Children’s Year, 1918-1919”).
During the Children’s Year, Children’s Bureau Chief Julia Lathrop enlisted the help of Congressional representative Jeannette Rankin (R-Montana) (1880-1973) in securing legislation to fund through the Children’s Bureau state-level programs for maternal and infant hygiene. Although Rankin’s bill did not gain traction in 1918, it laid the groundwork for what ultimately became the Sheppard-Towner Act of 1921 (Lemons 777; Holt 181). Supporters of the Act pointed to Children’s Bureau research on the role of poverty in the nation’s abysmal maternal and infant mortality rates to convince lawmakers to pass it (Lemons 776). The League of Women Voters and the Women’s Joint Congressional Committee led a broad campaign to persuade newly enfranchised women to support the legislation (Lemons 778). Other highly visible proponents included the Medical Women’s National Association and Dr. S. Josephine Baker, the New York public health physician who had achieved renown for her work resulting in a 50% decline in infant mortality in New York City (Lemons 781). The years that the Sheppard-Towner Act were in effect (1921-1929) saw infant mortality drop by 15%, while maternal mortality dropped by 8%—small but significant declines (Lemons 785-786). When the Sheppard-Towner Act came up for renewal in 1929, it was defeated largely as a result of opposition by the American Medical Association, which considered it a form of “state medicine” that infringed upon the prerogatives of physicians (Lindenmeyer 101).
SERVING DISABLED CHILDREN
During the course of their work with the states under the Sheppard-Towner Act, officials at the Children’s Bureau began fielding inquiries regarding aid for physically disabled children. In response, the Bureau undertook a nationwide study into the ways that states responded to those needs, including methods of identifying disabled children, methods of preventing disabling conditions, and, reflecting their determined emphasis on the “whole child,” the provision of medical care, education, and vocational training. The findings of this study, together with reports that emerged from the 1930 White House Conference on Child Health and Protection, formed the basis for the Bureau’s subsequent recommendation that the Social Security Act of 1935 provide grants-in-aid to the states for establishing programs and services for maternal and child health and for physically disabled (“crippled”) children (Bradbury 20, 39). The Children’s Bureau then served as the parent agency for both the Maternal and Child Health Program and the Crippled Children’s Program. The Children’s Bureau oversaw and disbursed federal funds for state-level implementations of both programs that were created as the result of Title V of the Social Security Act of 1935.
As a temporary expansion of the Children’s Bureau’s Maternal and Child Health Program, Congress enacted legislation in 1943 creating the Emergency Maternity and Infant Care Program (cf. EMIC). Funded by grants-in-aid to the states and territories, the program provided maternity care for the wives of servicemen in the four lowest pay grades of the armed forces and medical care for their infants. Both Congress and the Children’s Bureau viewed EMIC as a part of the national defense in a time of war because it improved and sustained the morale of servicemen who might otherwise be distracted by worry for their wives and children (Eliot, 833). During the time of its existence from 1943 to 1949, EMIC provided maternity care for about 15% of all births in the United States (Ward and Warren 115). The creation and implementation of EMIC is well-documented in the collection, as is the American Medical Association’s opposition to the program as an example of state-controlled medicine.
Another important influence on child health in the late nineteenth century was the emergence of the science of bacteriology and the identification of germs as the cause of diseases. George Rosen maintains that the development of vaccination, beginning with smallpox, was one of the most important contributions to public health in American (and indeed, world) history (Rosen 101). The promise of the bacteriological revolution that began when Robert Koch discovered the tubercle bacillus in 1881 went largely unfulfilled until the development of antibiotics and new vaccines in the 1940s and 1950s. But one early product of that revolution had a profound impact on the health of children in the 1890s and after—the development of diphtheria anti-toxin to treat that deadliest of childhood diseases (Holt 174). A diphtheria vaccine became available in 1923. Other communicable diseases, such as measles, scarlet fever, rheumatic fever, and whooping cough also contributed to high rates of morbidity and mortality for the nation’s children, with effective treatments and vaccines for those common ailments not becoming available until mid-century. Until then—and even sometime afterwards--childhood diseases caused loss and grief to families, and some diseases, when they did not kill, left a toll in the form of permanent physical and intellectual disability (Holt 176).
During World War II, the War Department sponsored research into antibiotics as part of the American defense effort. The development and mass production of penicillin and streptomycin had a profound impact on the health of children, greatly reducing some causes of disability and death from such ailments as tuberculosis and rheumatic heart disease. The combination diphtheria-tetanus-pertussis (cf. whooping cough) vaccine came on the market in 1948. More widely publicized and celebrated, however, was Jonas Salk’s development of the poliomyelitis vaccine, which became available in 1955. Vaccines for measles, mumps, and rubella became available in 1963, 1967, and 1969, respectively; the combined MMR vaccine appeared in 1971 (Baker and Katz 347). The history of these vaccines and of vaccination in general is richly documented in this collection.
Pruitt, Lisa: ““The Welfare of Children and Child Life”: Public Health and America’s Children”, Public Health Archives: Gale, A Cengage Company (2020).
Abbott, Grace. Ten Years’ Work for Children. Washington, D.C.: Government Printing Office, 1923.
Baker, Jeffrey P., and Samuel L. Katz. “Childhood Vaccine Development: An Overview.” Pediatric Research 55, no. 2 (2004): 347-356.
Berridge, Virginia. Public Health: A Very Short Introduction. Oxford, UK: Oxford University Press, 2016.
Bradbury, Dorothy. Five Decades of Action for Children: A History of the Children’s Bureau. Washington, D. C.: Government Printing Office, 1962.
“Centennial Series: The Children’s Year, 1918-1919.” Children’s Bureau Express, https://cbexpress.acf.hhs.gov/index.cfm?event=website.viewArticles&issueid=135§ionid=1&articleid=3495. Accessed April 13, 2020.
“Dr. S. Josephine Baker.” In “Changing the Face of Medicine,” https://cfmedicine.nlm.nih.gov/physicians/biography_19.html. Accessed April 12, 2020.
Eliot, Martha M. “Emergency Maternity and Infant Care Program for the Wives and Infants of Men in the Armed Forces.” JAMA 124 (March 25, 1944): 833-838.
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Holt, Marilyn Irvin. “Children’s Health and the Campaign for Better Babies.” Kansas History: A Journal of the Central Plains 28 (Autumn 2005): 174-187.
King, Charles R. Children’s Health in America. New York: Twayne, 1991.
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Lindenmeyer, Kriste. “A Right to Childhood”: The U. S. Children’s Bureau and Child Welfare, 1912-1946. Urbana, IL: University of Illinois Press, 1997.
Oettinger, Katherine B. “It’s Your Children’s Bureau.” https://www.ssa.gov/history/childb2.html - Accessed April 13, 2020.
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Zelizer, Viviana. Pricing the Priceless Child: The Changing Social Value of Children. New York: Basic Books, 1985.