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War, Tropical Disease, and the Emergence of National Public Health Capacity in the United States

  • Daniel Sledge (a1)
Abstract

This article analyzes the emergence of national public health capacity in the United States. Tracing the transformation of the federal government's role in public health from the 1910s through the emergence of the CDC during World War II, I argue that national public health capacity emerged, to a great extent, out of the attempts of government officials to deal with the problem of tropical disease within the southern United States during periods of mobilization for war.

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danielsledge@gmail.com
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1. See Hunt, Michael H., The American Ascendancy: How the United States Gained and Wielded Global Dominance (Chapel Hill: University of North Carolina Press, 2007), 47.

2. This account follows Espinosa, Mariola, Epidemic Invasions: Yellow Fever and the Limits of Cuban Independence, 1878–1930 (Chicago: University of Chicago Press, 2009). Espinosa argues persuasively that the ongoing threat of yellow fever in Havana to health in the United States was an important source of tension between the United States and Spain.

3. Ibid., 15, 34.

4. See Ibid., 57–63.

5. Ibid., 57, 59.

6. On the development of mosquito control techniques in Cuba, see particularly LePrince, Joseph A. and Orenstein, A.J., Mosquito Control in Panama: The Eradication of Malaria and Yellow Fever in Cuba and Panama (New York: G.P. Putnam's Sons, 1916).

7. President William Howard Taft speaking in Augusta, Georgia, in 1909, noted that “We pride ourselves on having done something that France was not able to do . . . but we must remember that she did not then have at her command the knowledge which we have had in the suppression of the disease that made life on that Isthmus so dangerous to every one who attempted to live there. The consequence is that to-day we have less malaria, or certainly not more on the Isthmus of Panama than you have in your Southern States.” See Taft, William Howard, “Sanitation and Health of the South, Remarks at the Georgia-Carolina Fair, Augusta, Ga., November 8, 1909,” in Presidential Addresses and State Papers of William Howard Taft, from March 4, 1909, to March 4, 1910 (New York: Doubleday, Page & Company, 1910), 421.

8. Gostin, Lawrence O., Public Health Law: Power, Duty, Restraint, Second ed. (Berkeley: University of California Press, 2008), 121.

9. Quoted in Gostin, Public Health Law, 121. Harlan wrote specifically about the power of the Commonwealth of Massachusetts to pass legislation enabling local boards of health to compel vaccination for diseases such as smallpox.

10. Proposed Department of Public Health: Hearings before the Committee on Public Health and National Quarantine, United States Senate, on the Bill, S. 6049, to Establish a Department of Health and for Other Purposes (Washington, DC: GPO, 1910), 48, quoted in Waserman, Manfred, “The Quest for a National Health Department in the Progressive Era,” Bulletin of the History of Medicine 49, no. 3 (1975):364.

11. Political scientists have long recognized the role of war in political and institutional development. See particularly Tilly, Charles, Coercion, Capital, and European States, AD 990–1992 (Cambridge, MA: B. Blackwell, 1992); Tilly, Charles, ed., The Formation of National States in Western Europe (Princeton: Princeton University Press, 1975); Porter, Bruce D., War and the Rise of the State (New York: The Free Press, 1994); Saldin, Robert P., War, the American State, and Politics since 1898 (New York: Cambridge University Press, 2011); Bensel, Richard, Yankee Leviathan: The Origins of Central State Authority in America, 1859–1877 (New York: Cambridge University Press, 1990).

12. For a particularly thoughtful and broad analysis of the potential impacts of war on governing structures (which include wholesale destruction), see Porter, War and the Rise of the State.

13. Focusing events (crises or disasters that draw the attention or can be used to draw the attention of political actors capable of enacting, altering, or expanding policies) have long played a role in analyses of public policy. See particularly Kingdon, John, Agendas, Alternatives, and Public Policies, 2nd ed. (New York: Longman Classics in Political Science, 2003); Baumgartner, Frank R. and Jones, Bryan D., Agendas and Instability in American Politics, 2nd ed. (Chicago: University of Chicago Press, 2009); Carpenter, Daniel and Sin, Gisela, “Policy Tragedy and the Emergence of Regulation: The Food, Drug, and Cosmetic Act of 1938,” Studies in American Political Development 21(2007).

14. On health insurance and the federal government, see particularly Hacker, Jacob S., The Divided Welfare State: The Battle over Public and Private Social Benefits in the United States (New York: Cambridge University Press, 2002); Hacker, Jacob S., “The Historical Logic of National Health Insurance: Structure and Sequence in the Development and British, Canadian, and U.S. Medical Policy,” Studies in American Political Development 12(1998); Mettler, Suzanne, The Submerged State: How Invisible Government Policies Undermine American Democracy (Chicago: University of Chicago Press, 2011); Blumenthal, David and Morone, James A., The Heart of Power: Health and Politics in the Oval Office (Berkeley: University of California Press, 2009); Skocpol, Theda, Boomerang: Health Care Reform and the Turn against Government (New York: W.W. Norton and Company, 1997); Starr, Paul, Remedy and Reaction: The Peculiar American Struggle over Health Care Reform (New Haven, CT: Yale University Press, 2011). On Medicare, see Oberlander, Jonathan, The Political Life of Medicare (Chicago: University of Chicago Press, 2003); Marmor, Theodore R., The Politics of Medicare, 2nd ed. (Hawthorne, NY: Aldine De Gruyter, 2000); Oberlander, Jonathan, “Through the Looking Glass: The Politics of the Medicare Prescription Drug, Improvement, and Modernization Act,” Journal of Health Politics, Policy, and Law 32, no. 2 (2007). On Medicaid, see Olson, Laura Katz, The Politics of Medicaid (New York: Columbia Univeristy Press, 2010).

15. John Ettling, for instance, has written an authoritative account of the Rockefeller Sanitary Commission's 1910–1915 campaign against hookworm disease. In addition to detailing the work of the Sanitary Commission in the United States, Ettling's Germ of Laziness is impressively attentive to the impact of international factors (particularly the campaign against hookworm in Puerto Rico) on domestic developments. Because of its focus on the period ending in 1915, however, Ettling's work does not address the work of the Rockefeller International Health Board in the United States or the later institutionalization of public health work in the South. See Ettling, John, The Germ of Laziness (Cambridge, MA: Harvard University Press, 1981). William Link's Paradox of Southern Progressivism offers a thorough discussion of the Sanitary Commission and also contains an excellent account of the early role of the International Health Board in stimulating the development of systematic public health work in the South. In focusing on the Progressive Era, however, Link cuts his narrative short before the crucial 1930s. In addition, Link largely ignores international influences on domestic public health policy. He does not deal with the impact of World War I and is for the most part unconcerned with the role of the Public Health Service. See Link, William A., The Paradox of Southern Progressivism, 1880–1930, The Fred W. Morrison Series in Southern Studies (Chapel Hill: University of North Carolina Press, 1992). This article is greatly influenced by Link's work, which, particularly in its consideration of the relationship between public health workers and the communities in which they attempted to operate, has had a significant impact on my approach to understanding public health interventions.

16. Carpenter, Daniel, “Is Health Politics Different?The Annual Review of Political Science 15 (2012).

17. Starr, Paul, The Social Transformation of American Medicine (New York: Basic Books, 1982), 180.

18. On the potential expansiveness of health interventions, see also Kersh, Rogan and Morone, James, “How the Personal Becomes Political: Prohibitions, Public Health, and Obesity,” Studies in American Political Development 16 (2002).

19. Quoted in Starr, Social Transformation of American Medicine, 180.

20. Institute of Medicine Committee for the Study of the Future of Public Health, The Future of Public Health (Washington, DC: National Academy Press, 1988), 7.

21. This definition of health capacity is based on the Institute of Medicine's enumeration of core public health functions. See The Future of Public Health. The IOM's core functions are: 1) assessment (the ability to assess the nature and extent of health problems); 2) policy development; and 3) assurance (the ability to implement public health interventions).

22. Ashford, Bailey K. and Igaravidez, Pedro Gutierrez, Uncinariasis (Hookworm Disease) in Porto Rico, Senate Document No. 808 (Washington, DC: GPO, 1911), 35.

23. Stiles worked for the U.S. Department of Agriculture prior to 1902, when he accepted a post with the Public Health and Marine Hospital Service. In large part, he appears to have done so because of his interest in hookworm and belief that it was likely present in the United States.

24. Stiles, Charles Wardell, Report Upon the Prevalence and Geographic Distribution of Hookworm Diseases (Uncinariasis or Anchylostomiasis) in the United States (Washington, DC: GPO, 1903), 97.

25. Stiles, Charles Wardell, “Hook-Worm Disease in the South- Frequency of Infection by the Parasite (Uncinaria Americana) in Rural Districts,” Public Health Reports 17, no. 43 (1902).

26. Tobey, James A., The National Government and Public Health (Baltimore, MD: Johns Hopkins University Press, 1926), 8889.

27. Ibid., 90.

28. Ibid., 91; Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1915 (Washington, DC: GPO, 1915), 127; “Government Plans Control: Will Take Over Quarantine Station, Says Report,” New York Times, February 15, 1921. “While this act did not undertake to prohibit states or municipalities from maintaining quarantine stations,” James Tobey wrote of the 1893 quarantine law, “it provided that state officers might surrender local stations to the Secretary of the Treasury, who was authorized to receive and pay for them if he considered them necessary to the United States. It would probably have been impossible to pass a law prohibiting states from maintaining quarantine stations, and the best results were thus obtained by allowing the states to surrender their quarantine functions from time to time as they realized the advantages of the national system.”

29. Waserman, “The Quest for a National Health Department in the Progressive Era.”

30. Ibid.

31. Quoted in Furman, Bess, A Profile of the United States Public Health Service, 1798–1948 (Washington, DC: U.S. Department of Health Education, and Welfare, National Institutes of Health, National Library of Medicine, 1973), 279. The Wyman associate was Milton Rosenau, who played an important early role in the service's Hygienic Laboratory, the precursor of the National Institutes of Health.

32. From 1912 until the creation of the Department of Labor in 1913, the bureau was a part of the Department of Commerce. See Tobey, National Government and Public Health, 233.

33. See Waserman, “The Quest for a National Health Department in the Progressive Era,” 377–78.

34. “Walter Wyman Dead: Surgeon General of the Public Health and Marine Hospital Service,” New York Times, November 21, 1911.

35. Furman, Profile of the United States Public Health Service, 286.

36. Tobey, National Government and Public Health, 102; Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1912 (Washington, DC: GPO, 1913), 9.

37. See Campaign against Plague-Infected Squirrels in California,” Public Health Reports 26, no. 16 (1911).

38. Furman, Profile of the United States Public Health Service, 288; Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1912, 317, 30.

39. Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1912, 36.

40. Gostin, Public Health Law, 151.

41. Scott, James C., Seeing Like a State: How Certain Schemes to Improve the Human Condition Have Failed (New Haven, CT: Yale University Press, 1998), 77.

42. Bureau, U.S. Census, Mortality Statistics (Washington, DC: GPO), 1909.

43. Troesken, Werner, Water, Race, and Disease (Cambridge, MA: MIT Press, 2004).

44. Lieberman, Evan, Boundaries of Contagion: How Ethnic Politics Have Shaped Government Responses to Aids (Princeton, NJ: Princeton Universtiy Press, 2009), 3.

45. Troesken, Water, Race, and Disease. Indeed, Troesken finds that “blacks benefited more than whites, in terms of disease reduction, from investments in water and sewer lines and water purification systems” during this period. See Troesken, Water, Race, and Disease, 204.

46. Troesken, Water, Race, and Disease. See also Doyle, Don H., New Cities, New Men, New South: Atlanta, Nashville, Charleston, Mobile, 1860–1910 (Chapel Hill: University of North Carolina Press, 1990), 280–81. Doyle argues that the “democracy of disease” in urban areas caused white reformers to favor public health measures for blacks.

47. 1910 Census, 55. The Census “North” is made up of the Missouri plus all areas where slavery had been outlawed prior to the Civil War from Maine in the east to the line of plains states stretching south from North Dakota to Kansas in the west. The West is comprised of all states west of and including the line of states that stretches from Montana in the North to New Mexico in the South.

48. 1910 Census, 55.

49. The Rockefeller Sanitary Commission for the Eradication of Hookworm, Fifth Annual Report (1915),14.

50. Brooker, Simon, Hotez, Peter J., Bethony, Jeffrey M., Bottazzi, Maria Elena, et al., “Current Concepts: Hookworm Disease,” The New England Journal of Medicine 351, no. 8 (2004): 802.

51. The eleven states were those of the former Confederacy, with the exception of Florida, and the border state of Kentucky.

52. Contemporary studies of the “American” hookworm (Necator americanus) have suggested that the disease's prevalence tends to be higher among teenagers and adults than among young children. As a result, it is possible to use the RSC's surveys of children ages 6–18 as a proxy for the entire population of a county. See Crompton, D.W.T., “The Public Health Importance of Hookworm Disease,” Parasitology 121(2000): S41. Surveys were compiled from The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease, Second, Third, Fourth, and Fifth Annual Reports (Washington, DC: 1911, 1912, 1913, 1914). The missing infection rates for counties that were not surveyed have been derived from neighboring counties with similar characteristics through the use of State Economic Area groups, following the SEA descriptions in Ruggles, Steven; Alexander, J. Trent; Genadek, Katie; Goeken, Ronald; Schroeder, Matthew B.; Sobek, Matthew, Integrated Public Use Microdata Series: Version 5.0. [Machine-Readable Database] (Minneapolis: University of Minnesota, 2010). County population data was accessed through Minnesota Population Center, National Historical Geographic Information System: Version 2.0. (Minneapolis: University of Minnesota 2011). The URL for NHGIS is http://www.nhgis.org.

53. Ferrell, John and Mead, Pauline, Public Health Bulletin No. 222: History of County Health Organizations in the United States, 1908–33 (Washington, DC: GPO, 1936).

54. “Crusade to Transform the South's ‘Poor Whites’ into Industrious Citizens,” Washington Post, September 27, 1908.

55. Stiles, Charles Wardell, “The Medical Influence of the Negro in Connection with Anemia in the White, Address Given to the North Carolina Board of Health and State Medical Society, June 17, 1908,” in Biennial Report of the North Carolina Board of Health, 1907–1908 (Raleigh, NC: 1909), 28. See also Marion Hamilton Carter, “The Vampire of the South,” McClure's Magazine, October 1909, 631. Marion Hamilton Carter, relying on Stiles's work, advised the readers of McClure's that “The one real hope of curing the white man lies in curing the black man.”

56. Stiles, “The Medical Influence of the Negro,” 28.

57. An influential account of the malaria problem in the southern United States may be found in Humphreys, Margaret, Malaria: Poverty, Race, and Public Health in the United States (Baltimore, MD: Johns Hopkins University Press, 2001). Humphreys adopts a broad time horizon, encompassing the period discussed in this article, and makes frequent mention of the U.S. Public Health Service. Nonetheless, her analysis of public health efforts aimed at limiting malaria in the United States overlooks both the intervention of the federal government against malaria during World War I and the subsequent development of federally backed local public health infrastructure in the South. These are substantial oversights. As I argue below, the federal government played a central role in the demise of malaria in the United States. Quantitative support for the argument that federal public health interventions played a key role in the demise of southern malaria may be found in Mohler, George and Sledge, Daniel, “Eliminating Malaria in the American South: An Analysis of the Decline of Malaria in 1930s Alabama,” American Journal of Public Health (forthcoming).

58. Trask, John W., “Malaria: A Public Health and Economic Problem in the United States,” Public Health Reports 31, no. 51 (1916): 3445–46.

59. Ibid.

60. See Gallup, John Luke and Sachs, Jeffrey D., “The Economic Burden of Malaria,” American Journal of Tropical Medicine 64, nos. 1, 2 (2001); Sachs, Jeffrey and Malaney, Pia, “The Economic and Social Burden of Malaria,” Nature 415 (2002).

61. See, for instance, Malaria in Alabama: Prevalence and Geographic Distribution—1915 and 1916,” Public Health Reports 32, no. 51 (1917); Malaria in North Carolina: Prevalence and Geographic Distribution,” Public Health Reports 32, no. 29 (1917); von Ezdorf, R.H., “Malarial Fevers: Prevalence and Geographic Distribution in South Carolina, Georgia, and Florida,” Public Health Reports 29, no. 11 (1914); Malaria in Eastern Texas: Prevalence and Geographic Distribution,” Public Health Reports 32, no. 33 (1917).

62. Maxcy, Kenneth F., “The Distribution of Malaria in the United States as Indicated by Mortality Reports,” Public Health Reports 38, no. 21 (1923).

63. See Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1918 (Washington, DC: GPO, 1918), 103; Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1919, (Washington, DC: GPO, 1919), 8687. This quotation is from PHS Officer J.A. Watkins's description of the Camp Shelby Extra-Cantonment Zone in Mississippi. Watkins, J.A., “Extra-Cantonment Zone Sanitation, Camp Shelby, near Hattiesburg, Miss,” Public Health Reports 32, no. 51 (1917): 2149.

64. Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1918, 323.

65. Warren, Benjamin S. and Bolduan, Charles F., “War Activities of the United States Public Health Service,” Public Health Reports 34, no. 23 (1919): 1247–48. The South is defined here as the eleven former states of the Confederacy plus Kentucky and Oklahoma. The extra-cantonment zone around Washington, D.C., included parts of Virginia and is counted as southern.

66. For a summary of PHS work in all extra-cantonment zones, see Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1918, 103–60; Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1919, 86–106. See also Rupert Blue, “Conserving the Nation's Man Power: Disease Weakens Armies, Cripples Industry, Reduces Production. How the Government Is Sanitating the Civil Zones around Cantonment Areas. A Nation-Wide Campaign for Health,” National Geographic, September 1917.

67. Watkins, “Extra-Cantonment Zone Sanitation, Camp Shelby, near Hattiesburg, Miss,” 2149.

68. Ibid., 2153.

69. Ibid; Report of the Board of Health of the State of Mississippi June 1–30, 1915 (Jackson, MS/ Nashville, TN), 17, 36, 43, 47.

70. Watkins, “Extra-Cantonment Zone Sanitation, Camp Shelby, near Hattiesburg, Miss,” 2153.

71. Ibid., 2151.

72. Ibid., 2153.

73. Ibid., 2149.

74. See Grubbs, Samuel B., By Order of the Surgeon General (Greenfield, INWilliam Mitchell Printing Company, 1943), 287.

75. Watkins, “Extra-Cantonment Zone Sanitation, Camp Shelby, near Hattiesburg, Miss,” 2155.

76. Bolduan, “War Activities of the United States Public Health Service,” 1246.

77. Watkins, “Extra-Cantonment Zone Sanitation, Camp Shelby, near Hattiesburg, Miss,” 2155.

78. Ibid., 2163.

79. Ibid., 2154.

80. Ibid., 2155.

81. Ibid.

82. Prior to the war, PHS personnel had surveyed mosquito-breeding conditions in a few areas (often suggesting control measures) and advised physicians employed by cotton and lumber mill owners who were interested in malaria control. See Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1915, 21–22.

83. All biographical information is from Griffitts, T.H.D., “Henry Rose Carter: The Scientist and the Man,” Southern Medical Journal 32, no. 8 (1939). Griffitts, who knew Carter, reports that Carter (born in 1852) was shot in the leg during the Civil War after grabbing a gun and becoming briefly involved in an engagement with Union troops.

84. The “right hand” quotation is from the introduction, by the Department of Agriculture's L.O. Howard, of LePrince's book. See Orenstein, Mosquito Control in Panama. On LePrince's wide-ranging career, which spanned antimalaria work from the aftermath of the Spanish-American War through the Tennessee Valley Authority, see Leprince, Malaria Fighter,” Public Health Reports 71, no. 8 (1956).

85. LePrince, J.A., “Mosquito Control About Cantonments and Shipyards,” Public Health Reports 34, no. 12 (1919): 548.

86. Ibid., 552.

87. Watkins, “Extra-Cantonment Zone Sanitation, Camp Shelby, near Hattiesburg, Miss,” 2157.

88. Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1919, 92.

89. Bolduan, “War Activities of the United States Public Health Service,” 1248–49. A description of the PHS's wartime antimalaria work may be found in LePrince, “Mosquito Control About Cantonments and Shipyards.”

90. LePrince, “Mosquito Control About Cantonments and Shipyards,” 552.

91. Ibid., 553. “The President of a large association of cotton-mill interests,” LePrince continued, “has stated that the elimination of mosquitoes near the mill properties has paid a higher return on the money expended than any other investment that the corporation has ever made.”

92. LePrince, J.A., “The Aftermath of Malaria Control in Extra-Cantonment Areas,” Southern Medical Journal 13, no. 6 (1920): 414–15.

93. Porter, War and the Rise of the State, 269.

94. Ibid., 270, 274; Saldin, War, the American State, and Politics since 1898, 69–70, 78.

95. The first quotation is from Tobey, National Government and Public Health, 136. The second quotation is from Pierce, C.C., “Public Health Service Program for Nation-Wide Conrol of Venereal Disease,” Public Health Reports 34, no. 20 (1919): 1057.

96. Tobey, National Government and Public Health, 136.

97. Furman, Profile of the United States Public Health Service, 345.

98. Economic Security Act: Hearings before the Committee on Ways and Means, House of Representatives, Seventy-Fourth Congress, First Session, on H.R. 4120, a Bill to Alleviate the Hazards of Old Age, Unemployment, Illness, and Dependency, to Establish a Social Insurance Board in the Department of Labor, to Raise Revenue, and for Other Purposes (Washington, DC: GPO, 1935), 329.

99. Warren, B.S., “Coordination and Expansion of Federal Health Activities,” Public Health Reports 34, no. 49 (1919): 2772, reprint of letter from Secretary McAdoo to President Wilson, originally sent November 21, 1918.

100. Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1919, 18.

101. See Rural Sanitation: Hearings before the Committee on Agriculture of the House of Representatives, Sixty-Fifth Congress, Third Session, February 17, 1919 (Washington, DC: GPO, 1919); Warren, “Coordination and Expansion of Federal Health Activities,” 2767; Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1919, 18. The Lever Bill was introduced on December 12, 1918.

102. This description of the Smith-Lever Act is from Sanders, Elizabeth, Roots of Reform: Farmers, Workers, and the American State, 1877–1917 (Chicago: University of Chicago Press, 1999), 392. Lever's attitude toward federal power and money is neatly summarized in a statement quoted by Sanders: “When there is a great general good to be accomplished by legislation, I am not so squeamish about the Constitution.”

103. Rural Sanitation: Hearings before the Committee on Agriculture of the House of Representatives, Sixty-Fifth Congress, Third Session, February 17, 1919, 8.

104. Warren, B.S., “A Unified Health Service,” Public Health Reports 34, no. 9 (1919): 378.

105. Ibid., 381. See also, for example, Rural Sanitation: Hearings before the Committee on Agriculture of the House of Representatives, Sixty-Fifth Congress, Third Session, February 17, 1919, “Statement of Dr. J.W. Schereschewsky, Assistant Surgeon General of the United States Public Health Service,” 11–12; Malaria: A Serious Health Problem of Nation-Wide Concern,” Public Health Reports 34, no. 12 (1919): 544; Testimony of Lumsden, Dr. Leslie, Rural Sanitation: Hearings before the Committee on Interstate and Foreign Commerce of the House of Representatives, Sixty-Fifth Congress, Third Session, on H.R. 3549, December 10, 1918 (Washington, DC: GPO, 1918), 28; Lumsden, L.L., Public Health Bulletin No. 94: Rural Sanitation: A Report on Special Studies Made in 15 Counties in 1914, 1915, 1916 (Washington, DC: GPO, 1918), 1718; Warren, “Coordination and Expansion of Federal Health Activities,” 2769.

106. Rural Sanitation: Hearings before the Committee on Agriculture of the House of Representatives, Sixty-Fifth Congress, Third Session, February 17, 1919, 11–12.

107. Warren, “A Unified Health Service,” 379.

108. Blue, Rupert, “Urgent Public Health Needs of the Nation,” American Journal of Public Health 9, no. 2 (1919): 98.

109. Ibid., 102.

110. Rural Sanitation: Hearings before the Committee on Agriculture of the House of Representatives, Sixty-Fifth Congress, Third Session, February 17, 1919, 31.

111. Ibid.

112. “Malaria: A Serious Health Problem of Nation-Wide Concern,” 545.

113. Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1919, 17. On hookworm disease and the draft, see also The Rockefeller Foundation International Health Board, Fifth Annual Report, January 1, 1918- December 31, 1918 (New York, 1919).

114. Printed version of lecture delivered May 22, 1919, in New York City.

115. “Program for each state health officer for assisting in the enactment of bill providing for rural health work,” included with form letter to state health officials from W.S. Rankin, January 21, 1919. National Archives, College Park, MD. Records of the Public Health Service (RG 90), Central File, 1897–1923. 2240 (January 1918–January 1919), Box 219.

116. “Statement,” included with form letter to state health officials from W.S. Rankin, January 21, 1919. National Archives, College Park, MD. Records of the Public Health Service (RG 90), Central File, 1897–1923. 2240 (January 1918–January 1919), Box 219.

117. Oscar Dowling, President of Louisiana State Board of Health, to Surgeon General Rupert Blue, January 21, 1919. See also for instance W.H. Kellogg, Secretary of the California State Board of Health, to Rupert Blue, January 24, 1919; S.J. Crumbine, Secretary of the Kansas State Board of Health, to Rupert Blue, January 24, 1919. All in Records of the Public Health Service (RG 90), Central File, 1897–1923. 2240 (January 1918-January 1919), Box 219.

118. See Hearings before Subcommittee of House Committee on Appropriations in Charge of Sundry Civil Bill for 1919 (Washington, DC: GPO, 1918), 248.

119. W.H. Slaughter to Surgeon General, In Re: Appropriation for Rural Sanitation Work, Charleston County, February 1, 1919; “At the Chamber: To A County Fund For Health Work,” Charleston Evening Post, January 31, 1919. National Archives, College Park, MD. Records of the Public Health Service (RG 90), Central File, 1897–1923. 2240 (January 1918–January 1919), Box 219.

120. M.V. Ziegler, Medical Officer in Charge, to the Surgeon General, April 16, 1919. National Archives, College Park, MD. Records of the Public Health Service (RG 90), Central File, 1897–1923. 2240 (January 1918–January 1919), Box 219.

121. L.L. Lumsden to Surgeon General (requesting that a qualified officer be detailed to assist Draper), April 19, 1919. Records of the Public Health Service (RG 90), Central File, 1897–1923. 2240 (January 1918–January 1919), Box 219.

122. Leslie C. Frank to Surgeon General, February 10, 1919. National Archives, College Park, MD. Records of the Public Health Service (RG 90), Central File, 1897–1923. 2240 (January 1918–January 1919), Box 219.

123. Undated letter (December 1918) from Leslie C. Frank, Director of Sanitation, Mississippi Coastal District, United States Public Health Service. National Archives, College Park, MD. Records of the Public Health Service (RG 90), Central File, 1897–1923. 2240 (January 1918–January 1919), Box 219. “WHAT GUARANTEE HAVE YOU,” Frank wrote in capital letters, “of the length of stay of the Public Health Service in its constructive and policing capacity?”

124. Leslie C. Frank to Surgeon General, February 10, 1919. National Archives, College Park, MD. Records of the Public Health Service (RG 90), Central File, 1897–1923. 2240 (January 1918-January 1919), Box 219. Lumsden, L.L., “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1920,” Public Health Reports 35, no. 40 (1920): 2330.

125. If the Public Health Service and State Boards of Health did not “take hold of this matter and direct,” he warned them, “it is going to come through some other channel; and it is going to be our fault if some other organization—the Department of Agriculture, for example . . . the Red Cross, or some other organization- takes hold of this matter and drives it through and fixes it up according to its own ideas.” Public Health Bulletin No. 105: Transactions of the Seventeenth Annual Conference of State and Territorial Health Officers with the United States Public Health Service, Held at Washington, D.C. June 4 and 5, 1919, (Washington, DC: GPO, 1920), 14.

126. Ibid., 16, 23. “The other way to get immediate action on a reasonably adequate scale,” Dr. Lumsden told the assembled health officers, “is to get enacted or appropriated the item for rural sanitation contained in the sundry civil bill.”

127. Ibid., 16.

128. Proceedings of the Thirty-Fourth Annual Meeting of the Conference of State and Provincial Health Authorities of North America, Held at Atlantic City, N.J., June 6–7, 1919 (Concord, NH: The Rumford Press, 1919), 17.

129. Resignation of Herbert Quick from Federal Farm Loan Board- Representative Lever Named as Successor,” The Commercial and Financial Chronicle, a Weekly Newspaper Representing the Industrial Interests of the United States, vol. 109, July 19, 1919, 224; Official Congressional Directory, for the Use of the United States Congress, 66th Congress, 2nd Session, Begining December 1, 1919 (Washington, DC), iii. Lever was appointed to the position on July 17, 1919, and officially resigned from Congress on August 1.

130. Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1919, 52; Lumsden, “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1920,” 2334. On June 24, 1919, only a few days before the end of the fiscal year, Surgeon General Rupert Blue and Assistant Surgeon General J.W. Schereschewsky appeared before the Senate Appropriations Committee, requesting $150,000 for rural sanitation rather than the $50,000 allowed by the House. The committee appeared indifferent. After being warned that “we have a list of engagements and ask you to be as brief as possible,” Blue and Schereschewsky made extremely brief statements, although Schereschewsky managed to mention both the interconnection between rural communities and the rest of the nation and the economic impact of malaria. They received only one question, from Senator Reed Smoot, a well-known opponent of federal expansion in the field of public health: “You want $150,000 instead of $50,000?” See Hearings before the Subcommittee on Appropriations, United States Senate, Sixty-Sixth Congress, First Session, on H.R. 6176, a Bill Making Appropriations for Sundry Civil Expenses of the Government for the Fiscal Year Ending June 30, 1920 and for Other Purposes (Washington, DC: GPO, 1919), 2526.

131. Lumsden, “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1920,” 2334.

132. The appropriation was $25,000 for the 1917 fiscal year (beginning July 1, 1916). See Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1917 (Washington, DC. GPO, 1917), 335.

133. Counties were surveyed in Alabama (2), Georgia (1), Illinois (1), Indiana (1), Iowa (1), Kansas (1), Maryland (2), Mississippi (1), Missouri (1), North Carolina (1), South Carolina (1), Tennessee (1), and West Virginia (1). See Lumsden, Report on Special Studies in 15 Counties.

134. Annual Report of the Surgeon General of the Public Health and Marine Hospital Service of the United States for the Fiscal Year 1911 (Washington, DC: GPO, 1911), 27.

135. On the significance of the work in Yakima from the perspective of Lumsden, see Mead, Public Health Bulletin No. 222: History of County Health Organizations in the United States, 1908–33, 2–4.

136. Roberts, Norman, Lumsden, L.L., and Stiles, Charles Wardell, “Preliminary Note on a Simple and Inexpensive Apparatus for Use in Safe Disposal of Night Soil,” Public Health Reports 25, no. 45 (1910).

137. The only nonsouthern “rural sanitation” cooperative program undertaken during the war was in Polk County, Iowa, during the 1918 fiscal year. A cooperative effort was also initiated in Mason County, Kentucky, which was not within an extra-cantonment zone. See Rural Sanitation: Hearings before the Committee on Agriculture of the House of Representatives, Sixty-Fifth Congress, Third Session, February 17, 1919, 14, 15. Questioning Surgeon General Rupert Blue and Assistant Surgeon General J.W. Schereschewsky in the summer of 1918, South Carolina Representative James Byrnes noted that the appropriation for rural sanitation did not appear to be being used for its original purpose: “Then, you have really abandoned the idea of investigating the questions of rural sanitation, and have been using this fund in extra-cantonment work?” See Hearings before Subcommittee of House Committee on Appropriations in Charge of Sundry Civil Bill for 1919, 248.

138. Jasper County, MO, Cherokee County, KS, and Ottawa County, OK, were part of a “tri-state” sanitary district.

139. Lumsden, “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1920,” 2334.

140. In 1927, for instance, both organizations contributed toward full-time health departments in eighty-eight counties, fifty-eight of which were dominated by PHS money. Following the 1930–1931 drought, the PHS eclipsed the IHB as the leading organization in development of county public health infrastructure. See Figure 6.

141. Furman, Profile of the United States Public Health Service, 349.

142. Ibid., 350; Skocpol, Theda, Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States (Belknap Press of Harvard University Press: Cambridge, MA, 1992), 517.

143. Lumsden, L.L., “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1930,” Public Health Reports 45, no. 43 (1930): 2619–20. Lumsden's comments are specifically in reference to the Red Cross, Rockefeller Foundation, and the Children's Bureau. His general point is that public health work should not be divided into separated categories such as “typhoid fever prevention, hookworm control, tuberculosis prevention, trachoma control, malaria control, venereal disease prevention, school hygiene, or advancement of child and maternity hygiene.”

144. Mead, Public Health Bulletin No. 222: History of County Health Organizations in the United States, 1908–33.

145. Public Health Bulletin No. 105: Transactions of the Seventeenth Annual Conference of State and Territorial Health Officers with the United States Public Health Service, Held at Washington, D.C., June 4 and 5, 1919, 26–27.

146. Lumsden, “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1920,” 2335; Lumsden, L.L., “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1921,”Public Health Reports 36, no. 40 (1921): 2481.

147. See, for example, Mustard, H.S., “Outline of Rural Health Administration in Rock-Bridge County, Virginia,” Public Health Reports 35, no. 40 (1920).

148. In most counties, the health officer was a physician. In some counties, however, the health officer was not a physician, but rather a trained sanitarian.

149. Lumsden, “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1920,” 2335.

150. W.K. Sharp (Office of Field Investigations, Rural Sanitation) to Surgeon General, July 10, 1919. Records of the Public Health Service, Central File, 1897–1923. 2240 (February-May 1919) Box 220. Lumsden describes the use of franking by “field agents” in a 1926 memo to the Surgeon General written following the objection of an Alabama postmaster to Field Agent J.A. Hill's furnishing of “penalty envelopes or labels to private physicians for the purpose of enabling the latter to transmit in the mails free of postage” bacteriological specimens. See J.H. Hill to L.L. Lumsden, June 21, 1926, L.L. Lumsden to Surgeon General via W.F. Draper, June 26, 1926. Records of the Public Health Service. General Subject File, 1924–1935. State Boards of Health. Alabama 0620–2323, Box 377, NC-34, E-10, NWCH, HM 1999.

151. Lumsden, L.L., “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1927,” Public Health Reports 42, no. 42 (1927). The Cape Cod project, wrote Lumsden, “is of especial interest in that it furnishes a test of the applicability of the general plan of cooperative rural health work to the conditions of local government by town units obtaining in Massachusetts and other New England States.” See Lumsden, L.L., “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1922,” Public Health Reports 37, no. 39 (1922): 2362.

152. See Furman, Profile of the United States Public Health Service, 370.

153. Lumsden, L.L., “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1929,” Public Health Reports 44, no. 49 (1929): 2987.

154. Lumsden, “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1920,” 2383–84.

155. See, for instance, Van Dine, D.L., “The Destruction of Anopheles in Screened Dwellings,” Southern Medical Journal XIV, no. 4 (1921): 20.

156. James Agee offers a telling description of an Alabama tenant home: “The walls, and shutters, and floors, are not by any means solid: indeed, and beyond and aside from any amount of laborious caulking, they let in light in many dozens of places. There are screens for no windows but one, in the rear bedroom. Because in half the year the fever mosquitoes are thick and there are strong rainstorms, and in the other half it is cold and wet for weeks on end with violent slanted winds and sometimes snow, the right front room is not used to live in at all and the left front room is used only dubiously and irregularly . . . .” See Agee, James and Evans, Walker, Let Us Now Praise Famous Men (New York: Houghton Miflin, 1988, originally published 1941), 153.

157. See, for instance, the comments of D.L. Van Dine and J.A. LePrince at the 1920 meeting of the Southern Medical Association, contained in Dine, “The Destruction of Anopheles in Screened Dwellings.”

158. Coogle, C.P., “Preliminary Report of Screening Studies in Leflore County, Miss.,” Public Health Reports 42, no. 15 (1927). See also Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1925 (Washington, DC: GPO, 1925), 23.

159. Coogle, “Preliminary Report of Screening Studies in Leflore County, Miss.,” 1105.

160. Ibid., 1107.

161. Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1925, 24.

162. Barry, John M., Rising Tide: The Great Mississippi Flood of 1927 and How It Changed America (New York: Simon and Schuster, 1997), 285.

163. One function of these camps was to ensure that local black laborers would not leave for work elsewhere. Writes James Cobb: “The national guardsmen charged with camp security appeared to have the dual mission of keeping refugees in and others—particularly labor agents—out.” Cobb, James C., The Most Southern Place on Earth: The Mississippi Delta and the Roots of Regional Identity (New York: Oxford University Press, 1992), 123. See also Dulles, Foster Rhea, The American Red Cross: A History (New York: Harper & Brothers, 1953), 272.

164. Townsend, J.G., “The Full-Time County Health Program Developed in the Mississippi Valley Following the Flood,” Public Health Reports 43, no. 20 (1928): 1200–1.

165. J.A. LePrince, “Suggested Plan for Sanitary Control at Flood Area Plantations and Farm Tenant Homes,” Records of the Public Health Service. General Subject File, 1924–1935. Closed Stations: Virginia. Richmond Malaria Investigation—Richmond Relief Station. Box 354, NC 34, E-10, NWCH, HM 1999.

166. J.A. LePrince to L.L. Williams, Jr., May 19, 1927. Records of the Public Health Service. General Subject File, 1924–1935. Closed Stations: Virginia. Richmond Malaria Investigation—Richmond Relief Station. Box 354, NC 34, E-10, NWCH, HM 1999.

167. Townsend, “The Full-Time County Health Program Developed in the Mississippi Valley Following the Flood,” 1200–1. See also Deklein, William, “Recent Health Observations in the Mississippi Flood Area,” American Journal of Public Health 18, no. 2 (1928): 148.

168. Annual Report of the Surgeon General of the Public Health Service of the United States for the Fiscal Year 1927 (Washington, DC: GPO, 1927), 39. See also Coogle, C.P., “Methods and Costs of Screening Farm Tenant Homes in Mississippi: Post Flood Malaria Control,” Southern Medical Journal (1928). On the significance of Coogle's work, see also L.L. Williams, Medical Officer in Charge, Office of Malaria Investigations, to Dr. Felix J. Underwood, Mississippi State Health Officer, May 27, 1929. Records of the Public Health Service, General Subject File, 1924–1935. State Boards of Health. Mississippi, 0115–1340, Box 416, NC-34, B-10, NWCH, HM 1999. “We have seen his results spread into many of the counties of the South where identical work is being done very successfully,” wrote Williams, “we saw most of the past flood emergency malaria control work carried on exactly according to the results of Dr. Coogle's work in LeFlore County.”

169. DeKruif, Paul, Hunger Fighters (New York: Harcourt, Brace and Company, 1928), 365–66; Townsend, “The Full-Time County Health Program Developed in the Mississippi Valley Following the Flood,” 1206.

170. Lumsden, “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1927,” 2594–95.

171. O'Neill, J.H., “Relief Measures During and Following the Mississippi Valley Flood,” American Journal of Public Health 18, no. 2 (1928): 159.

172. Townsend, “The Full-Time County Health Program Developed in the Mississippi Valley Following the Flood,” 1202. “In view of the preventable-disease disaster with which every populated county in the United States not provided with efficient health service is frequently visited,” wrote Leslie Lumsden, “there appears sufficient reason why there should be an increased rate of development of efficient whole-time county health service in every section of the United States.” Lumsden, “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1927,” 2595.

173. Townsend, “The Full-Time County Health Program Developed in the Mississippi Valley Following the Flood,” 1202.

174. Ibid., 1202–3. See also The Rockefeller Foundation, Annual Report for 1927 (New York: The Rockefeller Foundation, 1927), 145; O'Neill, “Relief Measures During and Following the Mississippi Valley Flood,” 159.

175. Townsend, “The Full-Time County Health Program Developed in the Mississippi Valley Following the Flood,” 1203.

176. First Deficiency Appropriation Bill, 1928: Hearing before the Subcommittee of House Committee on Appropriations in Charge of Deficiency Appropriations, Seventieth Congress, First Session (Washington, DC: GPO, 1927), 631; Flood Control: Hearings before the Committee on Flood Control, House of Representatives, Seventieth Congress, First Session, on the Control of the Destructive Flood Waters of the United States (Washington, DC: GPO, 1928), 3074; Mead, Public Health Bulletin No. 222: History of County Health Organizations in the United States, 1908–33, 5. The amount of $180,740 was released from the “epidemic fund” for the development of county health departments in the flood zone. The use of this money was authorized by Secretary of the Treasury Andrew Mellon and by President Coolidge.

177. Lumsden, L.L., “Cooperative Rural Health Work of the Public Health Service in the Fiscal Year 1928,” Public Health Reports 43, no. 48 (1928): 3154.

178. Townsend, “The Full-Time County Health Program Developed in the Mississippi Valley Following the Flood,” 1207. Testifying before the House Committee on Flood Control, Surgeon General Hugh Cumming suggested that “largely due to the action taken there has been actually in many respects an improved health condition.” In response to Cumming's enthusiasm, Chairman Frank Reid felt it necessary to caution Cumming that he had not intended to prompt the Surgeon General “to give the impression that the flood was good for the health of the people there.” See Flood Control: Hearings before the Committee on Flood Control, House of Representatives, Seventieth Congress, First Session, on the Control of the Destructive Flood Waters of the United States, 3074–75.

179. Second Deficiency Appropriation Bill, 1928: Hearing before the Subcommittee of House Committee on Appropriations in Charge of Deficiency Appropriations, Seventh Congress, First Session (Washington, DC: GPO, 1928), 466.

180. Ibid., 469.

181. Ibid.

182. Eisenhower, Milton E., ed. United States Department of Agriculture, Yearbook of Agriculture 1931 (Washington, DC: GPO, 1931), 1.

183. Emergency Appropriation for Cooperation with State Health Departments in Rural Sanitation, Etc., Hearing before the Committee on Agriculture and Forestry, United States Senate, Seventy-First Congress, Third Session, on S. 5440, a Bill to Authorize an Emergency Appropriation for Special Study of, and Demonstration Work in, Rural Sanitation (Washington, DC: GPO, 1931), “Statement of Dr. A.T. McCormack,” 2. The apparent contrast between Hoover's role during 1927 as Secretary of Commerce and his administration's restrained approach to the 1930–1931 drought crisis was often referenced by the proponents of a more vigorous federal response. “If the President of the United States could be fully informed as to conditions,” Joseph Robinson said in a statement taking issue with the chairman of the Red Cross's assertion that the agency could handle the situation in the drought area, “if the Secretary of Agriculture would do what President Hoover did as Secretary of Commerce in 1927—go in person to the regions, visit the homes of the people, confer with those familiar with conditions—we wouldn't be disputing in the Senate and conflicts would not arise between the two houses of Congress as to what means are desirable for relief.” See “Robinson Pleads for Drought Area,” New York Times, January 8, 1931.

184. Emergency Appropriation for Cooperation with State Health Departments in Rural Sanitation, Etc., Hearing before the Committee on Agriculture and Forestry, United States Senate, 6.

185. Ibid., 16.

186. Ibid., “Letter from James M. Smith to Dr. C.W. Garrison, dated December 28, 1930,” 165. In addition to being submitted and reprinted along with the other letters from local public health officials, Smith's letter was read aloud by C.W. Garrison during his testimony.

187. “House May Delay Relief Bill Action,” New York Times, January 23, 1931; “Senate Democrats End Congress Truce as House Kills $25,000,000 for Relief,” New York Times, January 31, 1931; “Senate Foes Compromise on $24,000,000 Drought Aid,” New York Times, February 6, 1931.

188. As signed, the appropriations bill was the outcome of a conference committee. There were no roll-call votes on the public health provisions of the bill.

189. Mead, Public Health Bulletin No. 222: History of County Health Organizations in the United States, 1908–33, 5.

190. Annual Report of the Surgeon General of the Public Health Service for the Fiscal Year 1931 (Washington, DC: GPO, 1932), 8788.

191. Demonstration Work in Rural Sanitation: Hearings before the Committee on Agriculture and Forestry, United States Senate, Seventy-Second Congress, First Session, on S. 1234, a Bill to Authorize an Emergency Appropriation for Special Study of and Demonstration Work in Rural Sanitation (Washington, DC: GPO, 1932), 808.

192. Mead, Public Health Bulletin No. 222: History of County Health Organizations in the United States, 1908–33.

193. Lumsden, L.L., “Public Health Perspective,” American Journal of Public Health 9, no. 12 (1919): 931.

194. Ibid., 933.

195. “Memorandum for the Surgeon General—Regarding the public health situation in Louisiana, with especial reference to the detail of Doctor Akin,” May 23, 1929. Records of the Public Health Service, General Subject File, 1924–1935. State Boards of Health. Louisiana- Cities and Counties (A-T) 0665–2323. Box 409, NC-34, E-10, NWCH, HM 1999.

196. C.V. Akin to Warren Draper, May 28, 1928. Records of the Public Health Service, General Subject File, 1924–1935. State Boards of Health. Louisiana—Cities and Counties (A-T) 0665–2323. Box 409, NC-34, E-10, NWCH, HM 1999.

197. C.V. Akin to Warren Draper, May 22, 1928. Records of the Public Health Service, General Subject File, 1924–1935. State Boards of Health. Louisiana—Cities and Counties (A-T) 0665–2323. Box 409, NC-34, E-10, NWCH, HM 1999.

198. Louisiana House Concurrent Resolution No. 14, By Dr. Drouth, Adopted by the House of Representatives and concurred in by the Senate June 12th, 1930. Records of the Public Health Service, General Subject File, 1924–1935. State Boards of Health. Louisiana—Cities and Counties (A-T) 0665–2323. Box 409, NC-34, E-10, NWCH, HM 1999.

199. Felix J. Underwood, Executive Officer, Mississippi State Board of Health, to Dr. L.L. Williams, PHS Office of Malaria Investigations, May 21, 1929. Records of the Public Health Service, General Subject File, 1924–1935. State Boards of Health, Mississippi, 0115–1340, Box 416, NC-34, E-10, NWCH, HM 1999.

200. L.L. Williams, Medical Officer in Charge, Office of Malaria Investigations, to Dr. Felix Underwood, May 27, 1929. Records of the Public Health Service, General Subject File, 1924–1935. State Boards of Health, Mississippi, 0115–1340, Box 416, NC-34, E-10, NWCH, HM 1999.

201. See Public Health Service Act, 1944,” Public Health Reports 59, no. 28 (1944); Willard, William R., “Fifteen Years of Public Health Administration,” Public Administration Review 10, no. 2 (1950).

202. For Underwood's comments on Title VI, see Economic Security Act: Hearings before the Committee on Finance, United States Senate, Seventy-Fourth Congress, First Session, on S. 1130, a Bill to Alleviate the Hazards of Old Age, Unemployment, Illness, and Dependency, to Establish a Social Insurance Board in the Department of Labor, to Raise Revenue, and for Other Purposes (Washington, DC: GPO, 1935), 415; Bridgforth, Lucie Robertson, “The Politics of Public Health Reform: Felix J. Underwood and the Mississippi State Board of Health, 1924–58,” The Public Historian 6, no. 3 (1984).

203. During his testimony before Congress, the PHS's C.E. Waller, who had succeeded Warren Draper as head of the Division of Domestic Quarantine, repeatedly appeared to suggest under questioning from Republican Allen Treadway of Massachusetts that the proposed public health grant-in-aid title would essentially change nothing about the PHS's existing work. Congressman Fred Vinson (D-KY) ultimately interrupted Waller to note that the work would indeed be different, since “this [funding] will be extended not only to the work in rural sections, but in small cities and large cities, too.” See Economic Security Act: Hearings before the Committee on Ways and Means, House of Representatives, 319.

204. See Witte, Edwin E., The Development of the Social Security Act: A Memorandum on the History of the Committee on Economic Security and Drafting and Legislative History of the Social Security Act (Madison: University of Wisconsin Press, 1962), 172–73n. According to Witte, the opponents of national health insurance supported an expanded public health program as a means of diffusing calls for an insurance program.

205. Ibid., 171.

206. Economic Security Act: Hearings before the Committee on Finance, United States Senate, 408.

207. Economic Security Act: Hearings before the Committee on Ways and Means, House of Representatives, 312.

208. Ibid., 315. Later in the hearing, Vinson told Waller that he did “not see any logical connection between the marine hospital appropriation and the Public Health Service appropriation.” See Economic Security Act: Hearings before the Committee on Ways and Means, House of Representatives, 321.

209. Economic Security Act: Hearings before the Committee on Ways and Means, House of Representatives, 316.

210. Witte, Development of the Social Security Act, 171.

211. Ibid., 173.

212. Ibid.

213. Sullivan, E.C. and Wiley, J.S., “Sanitation Activities in the Southeastern States in Connection with National Defense,” Public Health Reports 57, no. 17 (1942).

214. Annual Reports of the United States Public Health Service, 1941–42, 1942–43 (Washington, DC: U.S. GPO, 1943), 60.

215. Tetzlaff, Frank, “Operation of the United States Public Health Service Malaria Control Program,” Public Health Reports 63, no. 18 (1948): 557.

216. Ibid. See also Malaria Control in War Areas, 1942–43 (Atlanta, GA: U.S. Public Health Service, 1943), 34.

217. Margaret Humphreys has argued that the decline of malaria in the southern United States was a consequence of rural depopulation following implementation of the 1933 Agricultural Adjustment Act. See Humphreys, Malaria; Humphreys, Margaret, “How Four Once Common Diseases Were Eliminated from the American South,” Health Affairs 28, no. 6 (2009). An analysis of the decline of malaria in Alabama (relying on mathematical modeling of the disease and a novel data set including information on weather, rural and urban population, malaria mortality at the county level, number of tenant farms, and WPA drainage projects), however, shows that 1) high malaria mortality areas gained, rather than lost, population during the period of malaria's decline; 2) decreases in the number of farms operated by tenants did not result in depopulation and were not a cause of declining malaria mortality; 3) after weather, cumulative drainage was the variable most associated with declining malaria rates; 4) the release of Title VI funding during 1936 resulted in higher quality and more effective drainage work. This analysis may be found in Mohler, George and Sledge, Daniel, “Eliminating Malaria in the American South: An Analysis of the Decline of Malaria in 1930s Alabama,” American Journal of Public Health (forthcoming).

218. Andrews, Justin and Grant, Jean, “Experience in the United States,” in Preventive Medicine in World War Ii, Volume Vi, Communicable Diseases: Malaria (Washington, DC: Office of the Surgeon General, Department of the Army, 1963), 68.

219. The methodology used to determine these rates and the number of states (forty-eight) within the Death Registration Area remained consistent throughout this period. Texas, the final state to join the Death Registration Area, was first included in 1933. See Mortality Statistics, 1933: Thirty-Fourth Annual Report, (Washington, DC: GPO, 1936), 37; Vital Statistics of the United States, Part I, (Washington, DC: GPO, 1939), 24.

220. See Grant, “Experience in the United States.”

221. Williams, L.L., “The Extended Malaria Control Program,” Public Health Reports 60, no. 17 (1945):464.

222. Annual Report of the Federal Security Agency, Section Four: United States Public Health Service, 1946 (Washington, DC: GPO, 1946), 337.

223. Etheridge, Elizabeth W., Sentinel for Health: A History of the Centers for Disease Control (Berkley: University of California Press, 1992), 1617; Parran, Thomas, “A Career in Public Health,” Public Health Reports 67, no. 10 (1952): 935. Etheridge provides a thorough account of MCWA.

224. See Etheridge, Sentinel for Health, 24; Tisdale, Ellis S., “A National Program for Training Public Health Personnel,” Public Health Reports 66, no. 42 (1951); Stubbs, Trawick H., Boyd, William S., Weinstein, Paul P., “The Tropical Disease Education Program of the United States Public Health Service,” Public Health Reports 61, no. 20 (1946).

225. “Highlights from the 1959 Report of the Communicable Disease Center,” Public Health Reports 75, no. 12.

226. See Etheridge, Sentinel for Health, 115.

227. Congressional Record, Proceedings and Debates of the First Session of the Sixty-Eighth Congress of the United States of America, and index, Volume LXV-Part 3, House, February 9, 1924, 2200.

228. Grants-in-aid are, of course, one of the central means through which the federal government attempts to influence state and local policy. Notable examples include the use of federal funds to compel school and hospital desegregation, to lower speed limits during the 1970s–90s, and various attempts (such as “No Child Left Behind”) to influence state and local educational policy. On the use of the Commerce Clause by the CDC to compel quarantine and isologation, see, for instance, Parmet, Wendy, “Legal Power and Legal Rights—Isolation and Quarantine in the Case of Drug-Resistant Tuberculosis,” New England Journal of Medicine 357, no. 5 (2007). The limitations on the federal government's ability to induce states to act through the use of grants-in-aid are not fully clear. As it stands, the Supreme Court has articulated the standard that grants-in-aid may not exceed the point at which the financial inducement offered by Congress turns from “pressure” into “coercion.” In 2012, this standard led the Supreme Court to declare some provisions of the 2010 Patient Protection and Affordable Care Act unconstitutional. As enacted, the law allowed the Secretary of Health and Human Services to discontinue Medicaid funding to states that failed to expand their Medicaid programs to include all individuals with incomes up to 133 percent of the poverty line. Writing for the majority, Chief Justice John Roberts argued that such a denial of Medicaid funds was impermissibly coercive. Since the states had agreed to participate in Medicaid under the assumption that its pool of beneficiaries would be limited to certain categories of individuals and could not now opt out of the program without foregoing substantial portions of their budgets, the new Medicaid requirements represented “a gun to the head.” See National Federation of Independent Business v. Sebelius, 567 U.S. (2012), 51.

I thank Richard Bensel, Theodore Lowi, Elizabeth Sanders, two anonymous reviewers, and the editors of Studies in American Political Development for their input and feedback. Thanks to Jenna Green for her ongoing help and also to George, David, and Carolyn Sledge for reading various drafts.

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