Evolution of the US public health system

Public health activities stretch way back to antiquity, when people began living in larger groups and their garbage and waste attracted disease-spreading rodents and insects. Later, when the bubonic plague spread across Europe in the 14th century, the practice of quarantine emerged to protect coastal cities. Ships sailing from infected ports were made to sit at anchor for 40 days before docking in places like Venice and Milan.

Here are key moments that led to the US public health system as we know it today.

1701: Massachusetts mandated isolation of smallpox patients. Permanent councils were established to enforce quarantine and isolation rules in Philadelphia, New York and other cities by the end of the 18th century.

1799: Boston established the nation’s first board of health and health department to address a potential cholera outbreak. Paul Revere was the first health officer.

1850: Lemuel Shattuck, a Massachusetts bookseller and statistician, published a Report of the Massachusetts Sanitary Commission, documenting death and illness rates around the state. He concluded that citizens who tried to maintain “clean and decent homes” caught diseases due to the behavior of others. His report was “one of the most farsighted and influential documents in the history of the American public health system,” a 1988 Institute of Medicine report said.

1872: The American Public Health Association was established, marking the professionalization of the emerging field. One of its first actions: a public health survey, sent to every town with more than 5,000 residents, to gather information about the water supply, sewer systems and other community health topics.

1899–1900: When a plague outbreak hit Honolulu, health officials used a “cordon sanitaire,” roping off 14 blocks of the city and isolating 10,000 people.

1910: The federal Public Health Service started investigating poor working conditions and their effect on workers’ health. Among other things, it revealed unsanitary conditions and high rates of tuberculosis in the garment-making industry.

1912: When malaria eradication became important, Public Health Service workers used drip cans containing oil and kerosene to eliminate mosquito-breeding areas.

CREDIT: COURTESY OF THE ROCKEFELLER ARCHIVE CENTER

1916: The Johns Hopkins School of Hygiene and Public Health opened as the first permanent school of public health in the United States. It went on to establish the world’s first academic departments in immunology, epidemiology and public health administration.

1918–1919: The influenza pandemic — known as Spanish Flu or La Grippe — claimed more than 50 million lives worldwide. It is estimated to have infected 28 percent of all Americans — and killed 675,000. Half of the US soldiers who died in Europe fell to influenza rather than enemy troops. 

1948: The federal Malaria Control in War Areas program transitioned to become the Communicable Disease Center. After a series of name changes, the agency became known as the Centers for Disease Control and Prevention (CDC) in 1992. It is responsible for collecting health data, as well as supporting disease surveillance and population-based programs to prevent and control sickness, injury and disability.

1964: A US Surgeon General’s report on smoking, consolidating 15 years of growing evidence about the habit’s dangers, was a tipping point in public attitudes. Since then, the US adult smoking rate has fallen from more than 42 percent to less than 14 percent.

1981: The CDC made its first official report on the disease that would eventually become known as AIDS and formed a task force to investigate the previously unknown infectious disease. By 2007, more than 562,000 people in the US had died of AIDS.

1988: Public health advocates sounded an alarm, having watched the CDC’s financial support to local health departments continue to fall sharply since the early 1970s. The Institute of Medicine published a report on the US public health system, declaring that “this nation has lost sight of its public health goals and has allowed the system of public health activities to fall into disarray…. In our view, these problems reflect a lack of appreciation among the general public and policymakers for the crucial role that a strong public health capacity must play in maintaining and improving the health of the public.”

2020: On Jan. 9, the World Health Organization announced a new coronavirus-related pneumonia in Wuhan, China. Less than two weeks later, the CDC confirmed the first Covid-19 case in the US. Mistakes and politicization undermined the agency’s ability to limit the disease spread. As of Nov. 17, more than 11.3 million cases have been confirmed in the US and more than 248,000 people have died.

This article is part of Reset: The Science of Crisis & Recovery, an ongoing series exploring how the world is navigating the coronavirus pandemic, its consequences and the way forward. Reset is supported by a grant from the Alfred P. Sloan Foundation.