1.10: Twentieth Century Public Health

In the 20th century, public health grew through several distinct phases (Seabert, McKenzie, & Pinzer, 2022). The focus of public health departments and laws expanded from an initial phase of expanding healthcare infrastructure, to expanding access to healthcare through public insurance programs and other social benefits, to addressing health behaviors and healthy environments, reaching beyond healthcare.

• Health Resources Development Period (1900 to 1960)
  • Training more doctors, nurses and health professionals
  • Building more hospitals and clinics
  • Developing the basic resources for health
• Period of Social Engineering (1960-1973)
  • Major health programs thru public policy like Medicare and Medicaid
  • The "war on poverty" and other social programs and benefits
  • Ensuring that more people have access to healthcare, Head Start, and other services
• Period of Health Promotion (1974-Present)
  • Addressing rising chronic disease through changing health behaviors
  • Promoting healthy environments (physical and social environments)
  • Addressing the roots of poor health

The tabbed content below summarizes key aspects of this period

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Health Resources Development Period (1900-1960)Social Engineering (1960-1973)Health Promotion (1974-present)

Health Resources Development Period (1900-1960)

Because of the growth of health care facilities and providers (doctors, nurses, etc.) in this period, the first 60 years of the 20th century are called the "health resources development period." The early part of this period in particular (1900-1920, the Reform Phase) was also marked by many social advances with large impacts on health. For example, this period saw changes in occupational health, union organizing, immigration, and women's right to vote. As a response to the Great Depression, the Social Security Act of 1935 marked the beginning of the federal government's major involvement in social issues, including health. This law supported health facilities and public health programs. The Centers for Disease Control (CDC) began in the 1940's. After WWII, the Hill-Burton Act led to new hospital construction and attention to expanding access to healthcare across the country. The development of the polio vaccine and the heart attack of President Eisenhower further drew attention to the role of public health in prevention. In Geneva, Switzerland, the World Health Organization (WHO) was also established shortly after WWII, alongside the launch of the United Nations.

Social Engineering (1960-1973)

The federal government became more active in health matters in the 1960's and 1970's, with the establishment of Medicaid and Medicare in 1965. The picture shows then-President Lyndon Johnson signing the Medicaid and Medicare law, with former President Harry Truman by his side. Like the Affordable Care Act today, this law was very controversial when it was signed, but became popular and expanded coverage to reach most of the elderly and many of the poor living in the US. As the ICPH textbook notes, healthcare costs grew rapidly after this law came into place -- although there were many factors that influenced that increase in costs, not only the involvement of the federal government. Many countries that had greater government involvement in healthcare did not experience the same rise in healthcare costs.

Health Promotion (1974-present)

Because expanding access to doctors and hospitals wasn't enough to improve the public's health, starting in the mid-1970's public health began to focus on health promotion. The first Healthy People report came out in 1979. Public health departments began to focus more seriously on changing health behaviors (smoking tobacco, eating poorly, etc.). Increasingly, there is a recognition that behavior change is not only about educating the public, but also changing the conditions that people live in -- so public health went after the tobacco companies, not only individual smokers. Similar approaches are now used to reduce consumption of sugary drinks and to make it easier for people to fit physical activity into their day. The National Prevention Strategy (see Figure 1.9 and discussion on pp. 18-19) recognizes this complex approach to promoting the public's health.

Changes in Life Expectancy

Life expectancy at the start of the 20th century was under 50 years of age -- and by the end of the century was approaching 80. Early deaths among vulnerable populations such as children and women in childbirth declined. Would you be surprised to know that less than 25% of the increase in life expectancy is due to medical advancements -- even though antibiotics and heart surgeries and other medical innovations have been important? Most of the gain in life expectancy is due to public health measures -- basic things like clean water and safer working conditions, as well as population-based interventions like vaccinations.

Look at the list of public health achievements in Box 1.1 (page 4 of ICPH -- a summary from the CDC's list).

• Which key accomplishments in the 20th century (the 1900's) stand out for you?
• Which ones are familiar and which ones are surprising?
• Which ones seem most important?
• What might be missing from the list?

Since 2014, the US has seen a new decline in life expectancy -- after decades of life expectancy increasing, then leveling off. This decline -- like the gains in early decades -- has more to do with public health conditions than changes in medicine. Some of the reasons for the decline include rising drug overdoses, rising suicide rates, and increases in diabetes and other chronic conditions associated with poor diet and physical inactivity. Deepening inequality in the US adds to the problem. If you are interested in reading more about the decline in life expectancy, this optional article from Our World In Data is rather good. Since 2020, Covid-19 has been a major cause of shortened life expectancy. However, the effect is not nearly as dramatic as the Influenza Epidemic of 1918 was -- look at that big dip in life expectancy in the chart above! The 1918 Influenza was both more deadly than Covid-19, and it tended to kill younger people instead of older people -- so its impact on life expectancy was extreme.

References

Seabert, D.M., McKenzie, J.F., & Pinger, R.R. (2022). An introduction to community and public health, 10th ed. Jones & Bartlett.