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From the US Congress, 1837

Mr. L. insisted that the same reasons which had been urged by the gentleman from Louisiana (Mr. Johnson), in support of his amendment, applied with equal force to Mobile. That city was known to be increasing in population, wealth and business, with great rapidity. It was situated in a climate regarded as somewhat unhealthy at certain seasons, but its immense trade required the employment of seamen and boatmen at all seasons of the year, and if hospitals were to be provided for sick seamen and boatmen at the expense of the Government at any points, he regarded the southern cities as the places most entitled to notice. The amount he had proposed was small, and he hoped his amendment would not be rejected. The amendment prevailed without a division.

The last sentence seems sort of quaint today, doesn’t it. This was the discussion that ensued when the Marine Hospital in Mobile Alabama was funded in 1837. This bill funded hospitals in New Orleans, Mobile, Portland, Newport, and Wilmington, North Carolina, at a cost of $115,000 each.

Why were these hospitals needed? Most illness and death at the time was due to infectious disease. Most sick folks were treated in their homes;  physicians (or other healers) were in attendance, but the nursing was done by family members. In port cities, merchant seamen were necessary to transport goods  from America to Europe (here in Mobile, it was transporting cotton to Liverpool, England). To quote from the National Library of Medicine:

These seamen traveled widely, often became sick at sea, and then, away from their homes and families, could not find adequate health care in the port cities they visited or would overburden the meager public hospitals then in existence. Since they came from all the new states and former colonies, and could get sick anywhere, their health care became a national or Federal problem.

What began as a loose network of hospitals eventually became the US Public Health Service.

In the 1870s, when the Marine Hospital Service was federalized, the city of Mobile saw the need to provide these types of services for her citizens, and the Board of Health was created (by Alabama constitutional mandate). The duties included:

  • Examine all cases of malignant, pestilential, infectious, or epidemic disease
  • Exercise general supervision over sanitary regulation
  • Supervise all matters pertaining to quarantine
  • Supervise all measures of detention, disinfection, and purification of vessels from ports against which quarantine is proclaimed

The county health officer was employed by the Board to oversee the above. In addition, he was required to maintain vaccine and vaccinate all indigent people free of charge (that would be smallpox and rabies in 1873). He was also directed to maintain a dispensary where poor, sick people could receive care.

Fast forward to today. The traditional “health department” is performing roughly the same tasks as outlined in the 1870s, immunizations, control of infectious illnesses (in Mobile, mosquito control is a big part of this), and care of the  sick who happen to be poor. They are, it seems, victims of their own success. Malaria is unheard of in Mobile except when it arrives in a person who has traveled here with the parasite already incubating in his or her bloodstream. Vaccination has moved to the physician’s office with the Vaccines for Children program. Community Health Centers have taken over care of the poor sick. The public health focus needs to be on prevention and early detection of chronic illnesses. These account for 70% of American deaths and most of our disability. Many chronic illnesses are a consequence of tobacco use, poor diet, sedentary lifestyle, and risky behavior.

In Louisville, Kentucky, the “Board of Health” is now the Louisville Metro Department of Public Health and Wellness. Not only do they do they perform the traditional health department role but they

  • provide education regarding health behaviors that affect health, such as tobacco use
  • distribute condoms to prevent STIs
  • work to combat childhood obesity through physical activity
  • work to eliminate food deserts through food justice
  • sponsor a health equity speaker series

They do this in a belief that they can address the root causes of health disparities by supporting projects, policies and research working to change the correlation between health and longevity and socioeconomic status.

A far cry from running the quarantine station, is it not?

We have a professionalism exercise within the Health Sciences division at the University of South Alabama of which I play a small part. This exercise places students from nursing, allied health, pharmacy, and medicine together in a room and they are given a case scenario with no correct answer but one in which a difficult decision will almost certainly need to be made by the treating clinician. The case that I want to bring to your attention today is one not involving a breast mass. In this case, the patient reports that she has a lot of fear and concern about cancer and requests that her clinician order a mammogram to assuage her fears. The only problem is that her insurance will not pay for a “screening” mammogram, only for one in which a breast mass is detected on physical exam. In the educational exercise, students are assigned to either defend “lying” about a mass to get a mammogram paid for or “denying” the patient access to a mammogram paid for by her insurance. At the end of the exercise, the students vote on what they would do (mostly stick it to the insurance company) and then we all go home to wonder what we will really do when the time comes.

Susan Reverby has a new book out about the Tuskegee Syphilis Study and she happened to be in Mobile this past week to lecture about it. The study itself was a longitudinal prospective study in which African-American men from rural Alabama who had been identified as having latent syphilis during a previous study and were not treated adequately (because there were questions about the need for treatment and no money for treating these gentlemen) were identified. They were then followed over time to see what happened to them by the Public Health Service. The Public Health Service attempted, over the intervening 40 years, to withhold or deny treatment to the subjects even after penicillin was in widespread use. The study was made public in 1972 and created a scandal ultimately resulting in an apology offered by President Clinton to the survivors on behalf of the United States in 1997. The study has had a lasting impact on the black community with a profound impact on HIV/AIDS detection and treatment. In Bad Blood, another book about the Study, it is reported that community workers report mistrust of public health institutions within the African-American community. Alpha Thomas of the Dallas Urban League testified before the National Commission on AIDS: “So many African-American people I work with do not trust hospitals or any of the other community health care service providers because of that Tuskegee Experiment”

What does this have to do with health care reform and people doing what they can to get tests paid for? Dr Reverby’s review of the medical records, the writings and oral histories of the time and subsequently by the “subjects” and the investigators has led her to another conclusion as well. She has found that “the men thought of themselves as patients obtaining needed medical care for what was known as “bad blood” from the government’s doctors. The PHS physicians never told these men they were actually research subjects being followed in a “no treatment” study. Instead, the researchers explained that the aspirins, tonics, and diagnostic spinal taps given were “free treatment.” In a county with only 16 doctors whose prices the men could rarely afford, a government program of free care enticed them. The study’s nurse kept visiting the men’s homes and helping them to get medical care for other ills. The study’s subjects and controls were also promised money for decent burials in exchange for the use of their bodies for autopsy after their deaths.” She also believes it is likely that many of the “investigators” such as Dr Reginald James and Nurse Rivers may have helped to get these gentlemen needed care under the guise of the “study.”

 Her findings are that “these men living in rural Alabama came forward for treatment not because they were uneducated and easily duped by their government, but because they needed health care for themselves and their families. They (as with increasing numbers of Americans today)  had no real access to the medical care they required, could not pay for what was available, and had to find it where possible.

She and I both feel that this study is as much an object lesson on the lengths people will go and the harm they will expose themselves to as they seek out adequate health care as it is a lesson in the ethics of research. When President Obama argues for affordable and accountable health care, it is in the hopes of creating a system which will keep people from having to sell their health in order to afford health care. When medical bills account for 62% of bankruptcies, it is clear that people will endanger their long-term physical and financial wellbeing to acquire good health. Government almost certainly should play a role in helping its citizens obtain and keep quality health care (as even Bill Kristol admits it can do).

I am training for the marathon here in Mobile and this is the end of my first 60 mile week. Although I don’t define myself as a runner, I guess running 60 miles in a week would be dumb for a non-runner. Here in Mobile,we  runners can pursue our avocation outside almost every day of the year. I am further blessed by living just north of a large, antebellum cemetary (Magnolia Cemetary) where a circuit is about 1.8 miles or, put another way, it takes 2 1/2 laps over 45 minutes to run 5 miles

Running for several hours gives one a lot of reflecting time. While running today I reflected on being called a socialist by our medical students for pointing out that the Democrats had won the election and would probably dictate changes in health care policy (being right doesn’t make one especially popular) and the results of the cloture vote which proved my point. After that my thoughts turned to the cemetary and the monuments contained within. Many of the private graves have clustered dates which coincide with outbreaks of yellow fever or influenza but my attention today was drawn to the monuments  with labels such as Woodmen of the World, Watermen’s Association, and Fire Department Association among others .These were put up by benevolent societies.

In an article about benevolent societies at the turn of the last century, C. A. Spencer identifies these as “any local voluntary or incorporated non-profit association organized with or without capital stock providing mutual assistance for its members in the form of services or payments.” These organizations were designed to offer protection to their members at cost with the organizations constitution specifying the benefits to be provided such as sickness, disability, burial, and occasionally survivor. The as many (if not all of the members) belonged to the labor class, services usually provided by family members and servants to upper class folks were provided by the society which was an incentive for membership. These services included “watching” the sick and providing a physician who was kept on retainer. The members when not sick got to (and still get to) wear some great costumes and have a lot of fun. For example, the Mobile (Alabama) Turner’s Association celebrated the thirtieth anniversary of its founding in 1868, according to the Mobile Daily Register, with a parade, an address, and a song and dance exercise followed by fireworks.  As white workers became more prosperous, their societies tended to become less important to the provision of services (they were able to pay cash or their workplace provided doctors) but because of the economic precariousness of blacks in the early 20th century (most men were laborers), their societies were more likely to have survived. Interestingly, some of these societies have evolved into insurance companies.

Benevolent Societies were an important way to aggregate resources among African-Americans, recent immigrants, and members of common crafts (particularly if there was an element of physical risk). They became less important to the provision of healthcare in the 1950’s with the rise of employer based insurance and government-funded coverage to the poor and the elderly in the 1960’s. Perhaps if we all still had a vested interest in our own health as well as that of our immediate neighbor-in-the-funnny-hat then the debate over paying for health care reform would be a little more civil.