Five Turning Points in 250 Years of American Public Health History
Since its founding, the United States of America has repeatedly confronted threats to life, health, and well-being, and over the last 250 years, Americans have often enthusiastically embraced policies to protect public health at scale. The most obvious fruit of those efforts is a doubling of life expectancy since the signing of the Declaration of Independence.
At the same time, the history of public health is entwined with the country’s social and political struggles, and progress has not always been linear or equally distributed. Even today, in the aggregate, Black Americans have shorter life expectancy compared to White Americans, as a result of racist policies on housing, education, and access to health care decades ago.
Nor does progress happen automatically. According to public health historian James Colgrove, PhD, MPH ’01, professor and interim chair of Sociomedical Sciences at Columbia Mailman School, “Public health action often happens in the face of opposition from powerful political and economic interests, like 19th-century tenement owners who profited from unhealthy living conditions, and the tobacco industry, which knowingly marketed deadly products since the early 20th century.”
Colgrove, who has taught public health history to undergraduate and graduate students at Columbia for 20 years and is a member of the celebrated Center for the History and Ethics of Public Health, shared five transformative moments that help tell the story of public health in the United States.
1. 1777: George Washington, Smallpox Inoculation, and Vaccinations
During the Revolutionary War, George Washington required all of the troops in the Continental Army to be inoculated against smallpox. “The disease had had a devastating effect on troop mortality, and inoculation dramatically reduced the number of cases, which almost certainly played a part in our winning the war,” Colgrove notes. Two hundred years later, in 1977, the last naturally occurring smallpox case in the world was observed in Somalia, an achievement made possible by a smallpox eradication program started by the Centers for Disease Control and Prevention in the 1960s.
In the early years after the country’s founding, Americans embraced vaccines and recognized the value of laws requiring their use. In 1855, Massachusetts was the first state to mandate vaccination for all children statewide, and in 1905, the Supreme Court upheld states’ authority to enforce vaccine mandates. In the middle decades of the 20th Century, American scientists developed vaccines for many diseases, most famously polio, which saved millions of lives. According to Colgrove, this period was a high point in Americans’ trust in public health. Unfortunately, vaccine hesitancy has grown in the 21st Century. After the first COVID-19 vaccine was developed with unprecedented speed, the reaction was politically polarized. Nevertheless, that vaccine, too, saved millions of lives.
2. 1801: The Philadelphia Water Works and Public Health Infrastructure
When rapidly growing cities relied on wells for water, waves of yellow fever spread by mosquitoes killed thousands of Americans. In response, Philadelphia built the Fairmont Water Works, the country’s first large-scale municipal water system. At a larger scale, in 1842, New York City built the Croton Aqueduct, a 41-mile system that brought fresh water from upstate into Manhattan. In the 1850s, sewer systems were introduced in Chicago and Brooklyn. “Contaminated water was responsible for some of the most devastating diseases of the 19th century, including cholera, typhoid, and dysentery, so it’s hard to overstate the importance of cities creating clean water supplies,” Colgrove observes.
The formal administrative apparatus for regulating public health was established with the creation of New York City’s Metropolitan Board of Health in 1866. Public health authorities in cities, states, and at the federal level followed, with overlapping jurisdictions. At the same time, driven by demand for public health scientists, the Rockefeller Foundation sponsored a conference in 1913 to formalize public health education, ultimately leading to the creation in 1922 of what became a school of public health at Columbia. In the 1960s, the U.S. introduced public health insurance for the elderly and destitute; while that system was expanded in 2010, millions of Americans remain uninsured.
3. 1892: Ellis Island Medical Screenings, Xenophobia, and Eugenics
Between 1892 and 1954, more than 12 million immigrants disembarked at Ellis Island in New York Harbor before reaching the mainland. Every new arrival was subject to a medical inspection. Those with disease or signs of physical or mental weakness could be subject to quarantine or deportation. These stringent inspections took place in an environment where some Americans blamed immigrants for urban unrest, overcrowding, and disease.
Concurrently, the eugenics movement promulgated the erroneous idea of the genetic superiority of Nordic, Germanic, and Anglo-Saxon people. Its adherents—some of whom included advocates for public health and progressive reforms from reproductive justice to housing reform—supported strict immigration and anti-miscegenation laws, as well as the forcible sterilization of poor, disabled, and “immoral” people. According to Colgrove, “The history of public health isn’t just a story of triumph over disease. It also shows that public health professionals are influenced by societal biases and prejudices. The doctors from the U.S. Public Health Service who conducted the Tuskegee Syphilis Study are one of the most egregious examples of that. Studying our history can teach us to be more self-aware and to guard against hubris.”
4. 1964: The Surgeon General’s Report on Smoking and Lung Cancer
Based on rigorous public health science, the Surgeon General’s 1964 Smoking and Health report estimated that smokers had a nine- to ten-fold risk of developing lung cancer compared to non-smokers. The bombshell findings, the culmination of more than a decade of epidemiological investigation, contributed to a sea change in attitudes around smoking and a sharp decline in the use of tobacco. In 1998, in the largest civil litigation settlement in U.S. history, tobacco companies agreed to pay billions in restitution for treating smoking-related illnesses. “Tragically, tobacco companies continue to lie about the deadly effects of their products, resulting in millions of preventable deaths and illnesses,” says Colgrove.
As with tobacco, public health research on the health dangers of asbestos, DDT, and lead was instrumental in the development of regulations limiting people’s exposure to these industrial products. Columbia Mailman scientists’ studies on air pollution, the insecticide chlorpyrifos, and endocrine-disrupting chemicals in beauty products led to local- and state-level legislation limiting their use. Yet, Americans continue to be exposed to hundreds of largely unregulated industrial chemicals, each with potentially adverse health impacts.
5. 1987: ACT UP and Community Advocacy
In the 1980s, as HIV/AIDS rapidly spread across the U.S., ACT UP (AIDS Coalition to Unleash Power), founded in 1987, was created to advocate for improved medical research and treatment for people with AIDS, as well as preventive strategies. Among other accomplishments, ACT UP forced the National Institutes of Health and pharmaceutical companies to include women and people of color in clinical trials and advocated abandoning unethical, double-blind placebo trials when alternative treatments were available.
The strategies and goals of ACT UP drew upon decades of community advocacy growing out of the Civil Rights movement. Since the 1960s, individual advocates like Rachel Carson and Ralph Nader and advocacy groups like the Black Panther Party, the Disability Rights Education and Defense Fund, Mothers Against Drunk Driving, and the National Organization for Women have successfully pushed for policies that protect public health. Since the early 2000s, Columbia Mailman environmental health scientists have partnered with WE ACT for Environmental Justice to identify and address community health risks, including air pollution from city buses. “Many of the landmark accomplishments in the history of public health come not from scientists or academics, but from affected communities. For schools of public health, learning from these examples and working in true partnership with community members, activists, and advocates is essential to having the greatest impact,” Colgrove says.
