Successes and Missed Opportunities in Protecting Our Children's Health: Critical Junctures in the History of Children's Health Policy in the
http://www.100md.com
《小儿科》
Center for the History of Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan
Department of History, Rutgers University, Camden, New Jersey
ABSTRACT
This article revisits several turning points in the history of child health policy for the purpose of understanding why many current health needs of children have not been addressed. We demonstrate how the rupture of ties between child medical and child welfare leaders, as well as the fault lines between various health care professionals, led to difficulties in establishing programs for children in the early 20th century. We note how wartime mobilizations helped to make the needs of the nation's youth apparent to political leaders and observe that programs begun in response to these discoveries often were ended in peacetime. Finally, we discuss how politics shaped the situation wherein maternal and child health programs, including Medicaid, are need based, severely underfunded, and administered by the states, whereas benefit programs for the elderly, including Medicare and Social Security, are general entitlements administered at the federal level.
Key Words: medical history child health health policy politics child welfare Progressive Era Sheppard-Towner Maternity and Infancy Act New Deal Social Security Act Great Society Medicaid
Abbreviations: AMA, American Medical Association APS, American Pediatric Society SSA, Social Security Act
As we settle into the 21st century, many child health care professionals and scholars take for granted the essential partnerships among local, state, and federal governments and health care professionals, hospitals, clinics, and other institutions or associations. Developed over the past century, such alliances have improved the health of our nation's children despite some unresolved systematic problems. Medicaid, for example, is the major federal health insurance program for children today. Yet, access to that funding often is thwarted by extensive paperwork for billing and documentation, low reimbursement rates, and regulations at odds with the provision of needed services. These hindrances have led many practicing pediatricians to withdraw from the program entirely and declare the current situation unworkable. More troubling from a public health standpoint are potential patients who often are confronted with enrollment barriers. Even families who do succeed in gaining admission to the program must endure ongoing cuts in state funding that limit the kinds of care they can receive.
Policy experts, economists, and political officials have offered important assessments of the shortcomings of Medicaid. Proposed solutions range from higher reimbursement rates to a single-payer national health system. As historians, we take a different approach. We see the problem of provision of child health services rooted in ongoing debates of whether the health needs of poor children constitute a medical or social problem and whether such needs are a matter for states or the federal government. These debates raged several times over the course of the 20th century. The failure to resolve them at critical historical junctures has contributed significantly to our present failures in optimizing the health of every child in the United States.
PEDIATRICS: A SHORT HISTORY
Pediatrics is a relatively new development in the history of medicine, not having taken root until the late 19th century.1 Although the American Medical Association (AMA) established a Section on Diseases of Children in 1880 (which became the Section on Pediatrics in 1933) and the independent American Pediatric Society (APS) was founded by 43 nascent pediatricians in 1888, the profession of pediatrics remained a limited medical enterprise, at best, for much of this time. Beginning in the mid-1800s, a handful of the largest US cities established freestanding hospitals devoted almost exclusively to childhood surgical conditions such as orthopedic anomalies. Although at the close of the 19th century 50 physicians established practices with a focus on children, none practiced pediatrics exclusively.2 Indeed, the leading US pediatrician, Abraham Jacobi, admitted in 1880 that if he restricted his practice solely to the diseases of infancy and childhood, he "would make himself ridiculous."3
During the early decades of the 20th century, the field expanded, as did the places in which pediatricians plied their trade. Children's hospitals, orphan asylums, specialized clinics, and dispensaries sprang up; at special "milk stations," clean milk was provided to poor children in concert with what most pediatricians would recognize today as the well-child examination. However, a critical and more universal theme running through this focused work for child health had to do with social factors. In an era in which child labor was still all too common and many young people grew up in slum housing or impoverished rural communities, activists were inspired to attack the causes and consequences of child poverty and ill health. Among their goals were increasing the income of the workingman or breadwinner so that he could better accommodate the needs of his family; providing widows with aid so that they could rear their children at home rather than placing them in institutions; improving institutional care for orphaned or abandoned children; and cleaning up neighborhoods and improving tenement housing. These income- and environment-focused measures typically overshadowed those aimed specifically at the medical needs of children, but they were seen as ultimately providing for a healthier childhood.
CHILD MEDICAL CARE AND CHILD WELFARE: AN UNEASY PARTNERSHIP
An emerging, albeit tentative partnership among physicians, child activists, female reformers, and journalists was evident at the White House Conference on Dependent Children in 1909. Spearheaded by James H. West, a Washington lawyer, close friend of President Theodore Roosevelt, and later a founder of the Boy Scouts of America, and Theodore Dreiser, the novelist and then-editor of the women's magazine The Delineator, the conference brought together experts from many fields related to children's medical and welfare needs. The meeting proved so successful that White House conferences focused on children's medical and social needs were held every decade thereafter (and continue to be held).
1909 proved to be a pivotal year in child health, marking not only the inauguration of the White House conferences but also the first national AMA conference on infant mortality. This meeting led directly to the founding of the American Association for the Study and Prevention of Infant Mortality. The association encouraged studies of the causes and extent of infant mortality, worked to publicize the findings, encouraged philanthropic and health associations in their efforts to promote pregnant women's health, lobbied for child health bureaus, and held annual meetings at which experts shared the findings of their research and information about programs that succeeded in lowering infant mortality rates.4
The alliance that emerged between pediatricians, public health officials, and infant social-needs advocates in the Progressive Era rested on a shared zeal in reducing unacceptable high infant mortality rates in the United States; for a brief time, the alliance obscured underlying divisions. Pediatricians were just beginning to solidify their position as medical specialists in the diseases of infancy and childhood. On the eve of World War I, only 879 US physicians had the training and qualifications to legitimately call themselves pediatricians.5 Nervous about their professional status, many physicians worried about potential competition from what Samuel McClintock Hamill, MD, the president of the APS in 1914, identified as the "charitably and philanthropically inclined reformer and the sociologist." Dr Hamill, therefore, encouraged his fellow pediatricians to seize control of all programs relating to children. However, there were dissenting voices. Other specialists such as the leading clinician, researcher, and pediatrics textbook author Isaac A. Abt, MD, argued that it was best for pediatricians to focus exclusively on health issues that resided within the domain of medical practice, leaving broader social issues such as child labor and school reform to other child advocates.6,7 This division between reformers and physicians would be mirrored in many local, state, and federal programs, which maintained a division between social and medical programs.
It is difficult for a 21st century reader to imagine the extent of child labor in the early 20th century. In 1910, 12% of children aged 10 to 13 years worked, as did 31% of those aged 14 to 15 years. The majority of these children engaged in long hours of farm labor or worked alongside parents harvesting seasonal crops. Alarmed reformers, however, focused their concern on children working in extractive industries such as mining or industrial jobs such as those working alongside family members in southern textile mills and most especially on children earning income in the streets selling newspapers and delivering goods or messages and in more nefarious activities including prostitution and procuring narcotics. The health effects of the long workdays for the poorest children ranged from psychological difficulties and injuries to death on the job. Eliminating child labor proved to be a particularly vexing issue, because it did not solve underlying problems. Households headed by women were those most likely to include child workers. Paradoxically, state laws passed to protect children tended to force poor mothers into the labor force to make ends meet, often at the expense of their young children and with potential health consequences for themselves. Relatively few states passed laws to keep young children out of the labor force. Among the most famous was New York, at the urging of then-assemblyman and soon-to-be Governor Al Smith, in which a law was passed in 1903 banning child labor in factories, on farms, in sweatshops, and in the street trades. The federal government later passed the Keating-Owen Act of 1916, which banned articles produced by children from being sold in interstate commerce but was overturned by the Supreme Court in 1918. Not until the passage of the Fair Labor Standards Act of 1938 were children <16 years old excluded from full-time labor and those <18 years old kept from hazardous occupations. Many children, of course, continued to labor on family farms; over the course of the 20th century, the health concerns of rural children gained increased attention.8,9
THE SHEPPARD-TOWNER MATERNITY AND INFANCY ACT
The nascent infant and child health movement that united public health officials, philanthropists, health care professionals, and social workers in a crusade to lower the infant mortality rates quickly matured into an effective political organization. A major victory came in 1912 when the US Congress created the Children's Bureau, an agency within the Department of Labor, and gave it a mandate to "investigate and report on all matters pertaining to the welfare of children." The Children's Bureau had long been a dream of groups such as the National Consumers' League, the General Federation of Women's Clubs, and the National Congress of Mothers. Among its early efforts were programs to help communities improve sanitation and milk supplies; the creation of child hygiene divisions in state-run public health agencies; the production and distribution of 2 influential, instructional pamphlets ("Prenatal Care" and "Infant Care"); and campaigns involving free diagnostic evaluations by health care professionals.
These efforts helped to decrease infant mortality in large urban centers in the United States during the opening decades of the 20th century. Nevertheless, infant mortality remained high at 131 deaths per 1000 live births, prompting the Children's Bureau leaders to make combating infant mortality a top priority.10 Early investigative reports documented the effects of poverty on child health and pointed particularly to the problem of maternal employment. The findings led reformers to propose maternity benefits in the form of medical services to pregnant women and compensation for lost wages that would permit them to stay home and breastfeed their infants. Modeled on similar programs in other industrialized nations, the proposals met with vehement opposition from the AMA (which objected to federal intervention in the distribution of medical care) and others who feared that cash payments to low-income households might limit the supply of workers and cause wages to rise. Forced to find another solution, reformers turned to a more constrained program of maternal education and infant child care carefully designed to avoid antagonizing private physicians; the Sheppard-Towner Maternity and Infancy Act, first proposed in 1918, was signed into law in 1921. The act authorized the federal government to grant funds for maternal and infant welfare to each state, provided the individual states passed their own "enabling legislation." The federal government supplied approximately $1.25 million a year to the states, which used the funds for child health and prenatal centers, instructional home visits by nurses, and distribution of educational materials. The funds went only to education and child care; infants and children needing medical care were referred to private physicians or, if unable to afford such services, municipally supported providers.11
Congressional debate over the Sheppard-Towner Act was shaped in part by recent wartime experiences. The poor health of many World War I draftees, with 29.1% judged unfit for service, surprised many who were unfamiliar with the health problems of younger, poorer US citizens. In Michigan alone, >30% of all registrants for the draft in 1918 were rejected because of thyroid enlargements that were the direct result of iodine-poor diets, an indication of the types (and variety) of health challenges facing the nation's youngest citizens. One result was that office-based pediatricians increased their attention to weight, growth, and overall preventive health measures.12,13
Reform organizations used the findings about draftees to press for programs that would facilitate the health of the nation's poor in general and their children in particular. In 1919, the American Association for the Study and Prevention of Infant Mortality became the American Child Hygiene Association, demonstrating its expanded commitment and mission. Under the leadership of Herbert Hoover, the organization merged with the Child Health Organization to become the American Child Health Association. Hoover served as its president for most of the 1920s, while he was Secretary of Commerce in the Harding Administration, until his election to the presidency in 1928. During this period, the Sheppard-Towner Act was passed and implemented.
Efforts to pass federal legislation for maternal and child health, however, divided the medical profession, putting pediatricians at odds with other physicians and the leadership of the AMA. During the 1920s, as pediatrics became one of the fastest growing specialties, anxieties about the relationship between pediatricians and social reformers eased somewhat, but in their place new conflicts emerged. The Sheppard-Towner Act provoked the biggest fight of all. The majority of pediatricians supported the act, as did a number of influential women's groups and social activist societies. Still, although the Sheppard-Towner Act explicitly avoided the free dispensation of clinical care, it sparked the ire of many in the medical establishment. Many opponents invoked the specter of the recent Bolshevik revolution, suggesting it was "inspired by foreign experiments in Communism and backed by the radical forces of this country."14
Most vociferous in its condemnation was the AMA, which claimed that the law would harm the public and mark an unprecedented intrusion onto states' rights.15 While the AMA governing House of Delegates was busy condemning the Sheppard-Towner Act, its Section on Diseases of Children voiced its support. The resulting schism, which culminated with the AMA formally chastising the members of the Section on Diseases of Children, motivated many pediatricians, already estranged from the more elite and research-driven APS, to form a new professional group, the American Academy of Pediatrics, in 1930. Devoted principally to advocacy, education, and primary care, its motto was "For the Welfare of Children."16,17
The Sheppard-Towner Act proved to be short-lived. The political clout and antipathy of the AMA and conservative women's groups such as the Daughters of the American Revolution brought a swift end to the legislation. The law was not renewed by Congress in 1927 and was virtually defunded by 1929. In its absence, a system emerged that decidedly separated the provision of medical care for needy children from children whose parents were working or had financial resources; the former provision was labeled "welfare," and the latter was called "fee-for-service" or private medicine.
The rapid demise of the Sheppard-Towner Act should not be read as a sign of failure. The 7 years that the act was in force saw a significant decline in maternal and infant mortality in regions where it concentrated its efforts.10 The Sheppard-Towner Act also facilitated the routine practice of US mothers bringing their infants to pediatricians for regular checkups.18 Finally, the act established an important precedent: it was the first time that the federal government provided funds earmarked for children's health needs.19
In the wake of growing support for children's health needs and the long shadow cast by the termination of Sheppard-Towner, President Herbert Hoover convened the 1930 White House Conference on Child Health and Protection. From this summit came a seminal document, the Children's Charter, which spelled out the rights of children. Among them were: "For every child full preparation for his birth; his mother receiving prenatal, natal and post natal care" and "For every child health protection from birth through adolescence." Sadly, these noble goals would not be met. Faced with unprecedented fiscal demands during the Great Depression, President Hoover proved unable to marshal the aggressive measures needed to respond to the growing medical and social needs of children or adults. His successor, President Franklin Roosevelt, had far greater success in acting on these pressing needs; it is ironic that his most important effort on behalf of child health, Title V of the Social Security Act (SSA), ultimately would set in stone the divisions between medical care and social welfare and between social insurance entitlements managed by the federal government and public assistance entitlements managed by the states.
SOCIAL SECURITY AND CHILD HEALTH
The Franklin Roosevelt Administration's first efforts on behalf of child health was the Child Health Recovery Program, which was overseen by the Federal Emergency Relief Administration and the Children's Bureau. It provided emergency food and medical care to needy children, channeling the resources of public and private health care and relief organizations in each state, with physician consultants and part-time public health nurses paid by the Civil Works Administration for performing the work. It was the first and only New Deal program for young children until the SSA of 1935.20
The SSA contained several streams of funding for children. Title IV provided funds to states for the Aid to Dependent Children program. Title V echoed the programs of the Sheppard-Towner Act, giving federal funds to states that passed enabling legislation for maternal and infant health care or services to "crippled" children and to expand existing child health programs. Although the SSA was the seminal first step in a rapid growth of programs for the elderly, culminating in the Medicare legislation of 1965, it did not lead to similar gains for children, although the Social Security Board, the body charged with implementing the SSA, was well aware as early as the 1930s that the number of economically disadvantaged children was as much as sevenfold that of the elderly. Data from the US Public Health Service showed that the number of children receiving relief was 7 times the number of persons aged 65 years.21
Children were, and remain, a social group without political muscle. The Franklin Roosevelt Administration was facing formidable pressure from advocates of flat pensions for all retirees. These advocates helped to ensure the passage of the SSA and sustain its expansion after World War II.22 Thus, Social Security was born, a program that redistributes income from working families with children to the elderly.
In the 1960s, this pattern was repeated with Medicare, a health insurance program for all elderly Americans that remains an extraordinarily popular social insurance program. On the other hand, social assistance programs for children (welfare) and medical insurance for children (Medicaid) are limited to needy children. They are defined by income limits and other qualifications that result in varying levels of eligibility and services from state to state. Because these programs are not guaranteed to all children in the US population, they are politically unpopular and often threatened. Thus, the greatest pieces of social welfare legislation of the 20th century aided millions of elderly Americans but did so by drawing sharp divisions that would ultimately undermine the provision of medical care and social well-being for children.
It is ironic that World War II made clear to American political leaders, as World War I had done a generation earlier, that children's medical needs were not being met. The pregnant wives of servicemen were unable to obtain care from base hospitals that were busy providing services to soldiers, lacked the funds to purchase health care, and failed to qualify for local programs because of residency requirements. These families had an effective group of lobbyists on their side; the American Legion and the Veterans of Foreign Wars convinced members of Congress to pass the Emergency Medical and Infant Care Program in 1943. The Emergency Medical and Infant Care Program provided maternity and pediatric care for the wives and children of servicemen in the 4 lowest pay grades, paying for the births of 1 of every 7 infants born in the United States.23 Despite having aided many women and children, the program was seen not as providing medical services but as a means of boosting the morale of the patriotic men serving their country in a time of war. After hostilities ceased, the program lost support and ended in 1949.
THE POSTWAR YEARS: SCIENTIFIC ADVANCES AND POLICY STALEMATES
Even as the federal government hesitated at establishing laws that directly met the health care needs of its most vulnerable citizens, children, it embraced the promise and possibilities of "scientific" medicine. Funds flowed into laboratory research and hospital construction. A booming economy and active labor movement ensured that sick- and well-child care became available to growing numbers of families as private health insurance, obtained as an employment benefit, helped pay the costs of hospitalization, including maternity care.
Several programs designed to serve the nation's neediest children followed: Medicaid (Title XIX of the SSA), including the comprehensive Medicaid preventive child health program known as Early and Periodic Screening, Diagnosis, and Treatment, which is intended to serve needy children <21 years old; the Special Supplemental Nutrition Program for Women, Infants, and Children; and, most recently, the State Children's Health Insurance Program. The history of each program, their achievements, and the ongoing challenges they face have been well chronicled. What must be noted is that these programs were built on a foundation erected earlier and continue to leave children more vulnerable than other age groups, including the elderly. For example, in 2002, 9.2 million children <19 years old (12% of children) in the United States were uninsured.24 In addition, the United States has one of the highest infant mortality rates in the industrialized world.
CONCLUSIONS
Although much changed over the course of the 20th century with respect to the types of medical problems faced by US children, many child health needs still are systematically neglected. We know from the history of national efforts on behalf of the elderly that it is possible to reduce poverty dramatically and improve access to care substantially for a specific age group. Only with sufficient political resolve from pediatricians and other child advocates will the 21st century see similar achievements on behalf of children.
ACKNOWLEDGMENTS
We thank Bradley Breuer of the University of Pennsylvania, Brian Gratton of the Russell Sage Foundation, Jeffrey Levi of the George Washington University Center for Health Policy, Eric Schneider of the University of Pennsylvania, and Edward Schor, MD, vice president of the Commonwealth Fund, for comments on drafts of this article. We also thank the President's Discretionary Fund of the Commonwealth Fund for generous support of the research for and composition of this article.
FOOTNOTES
Accepted Dec 22, 2004.
No conflict of interest declared.
REFERENCES
Garrison FH. History of pediatrics. In: Abt AF, ed. Abt-Garrison History of Pediatrics. Philadelphia, PA: WB Saunders; 1965:130 :1 –170
Markel H. Academic pediatrics: the view of New York City a century ago. Acad Med. 1996;71 :146 –151
Jacobi A. An address on the claims of paediatric medicine. Trans Am Med Assoc. 1880;31 :709 –714
Meckel RA. Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850–1929. Ann Arbor, MI: University of Michigan Press; 1998
Gifford RR. The founding of the American Pediatric Society. A landmark in pediatrics. Clin Pediatr (Phila). 1969;8 :369 –372
Hamill SM. Responsibility of the pediatrist toward the problems of public health. Trans Am Pediatr Soc. 1914;26 :7 –17
Hollopeter WC. Pediatric outlook. Trans Sect Dis Child Am Med Assoc. 1906;57 :15 –20
MacLeod DI. The Age of the Child: Children in America, 1890–1920. New York, NY: Twayne Publishers; 1998
Meckel RA. Levels and trends of death and disease in childhood, 1620 to the present. In: Golden J, Meckel RA, Prescott HM, eds. Children and Youth in Sickness and Health: A Historical Handbook and Guide. Westport, CT: Greenwood Press; 2004:3 –24
Rothman SM. Women's clinics or doctor's offices: the Sheppard-Towner Act and the promotion of preventive health care. In: Rothman DJ, Wheeler S, eds. Social History and Social Policy. New York, NY: Academic Press; 1981:175 –201
Markel H. "When it rains it pours": endemic goiter, iodized salt, and David Murray Cowie, MD. Am J Public Health. 1987;77 :219 –229
Brosco JP. Weight charts and well-child care: when the pediatrician became the expert in child health. In: Stern AM, Markel H, eds. Formative Years: Children's Health in the United States, 1880–2000. Ann Arbor, MI: University of Michigan Press; 2002:91 –120
Lindenmeyer K. Saving mothers and babies: designing and implementing a national maternity and infancy act, 1918–30. In: "A Right to Childhood": The US Children's Bureau and Child Welfare, 1912–46. Urbana, IL: University of Illinois Press; 1997:76 –107
Cone TE. History of American Pediatrics. Boston, MA: Little Brown & Co; 1979:157
Holt LE. American pediatrics—a retrospect and a forecast. Trans Am Pediatr Soc. 1923;35 :9 –17
Pease MC. American Academy of Pediatrics. June 1930–June 1951. Evanston, IL: American Academy of Pediatrics; 1952
Rothman SM. Woman's Proper Place: A History of Changing Ideals and Practices, 1870 to the Present. New York, NY: Basic Books; 1978
Gordon L. Pitied But Not Entitled: Single Mothers and the History of Welfare. New York, NY: Free Press; 1994
Lindenmeyer K. The federal government and child health. In: Golden J, Meckel RA, Prescott HM, eds. Children and Youth in Sickness and Health: A Historical Handbook and Guide. Westport, CT: Greenwood Press; 2004:107 –125
Gratton B. The politics of dependency estimates: Social Security Board statistics, 1935–1939. J Gerontol B Psychol Sci Soc Sci. 1997;52 :S117 –S124
Brinkley A. Voices of Protest: Huey Long, Father Coughlin and the Great Depression. New York, NY: Vintage Book USA; 1983
Sinai N, Anderson OW. EMIC(Emergency Maternity and Infant Care): A Study of Administrative Experience. Ann Arbor, MI: University of Michigan School of Public Health; 1948
Bhandari S, Gifford E. Children with health insurance: 2001. Available at: www.census.gov/prod/2003pubs/p60-224.pdf. Accessed January 19, 2005(Howard Markel, MD, PhDand)
Department of History, Rutgers University, Camden, New Jersey
ABSTRACT
This article revisits several turning points in the history of child health policy for the purpose of understanding why many current health needs of children have not been addressed. We demonstrate how the rupture of ties between child medical and child welfare leaders, as well as the fault lines between various health care professionals, led to difficulties in establishing programs for children in the early 20th century. We note how wartime mobilizations helped to make the needs of the nation's youth apparent to political leaders and observe that programs begun in response to these discoveries often were ended in peacetime. Finally, we discuss how politics shaped the situation wherein maternal and child health programs, including Medicaid, are need based, severely underfunded, and administered by the states, whereas benefit programs for the elderly, including Medicare and Social Security, are general entitlements administered at the federal level.
Key Words: medical history child health health policy politics child welfare Progressive Era Sheppard-Towner Maternity and Infancy Act New Deal Social Security Act Great Society Medicaid
Abbreviations: AMA, American Medical Association APS, American Pediatric Society SSA, Social Security Act
As we settle into the 21st century, many child health care professionals and scholars take for granted the essential partnerships among local, state, and federal governments and health care professionals, hospitals, clinics, and other institutions or associations. Developed over the past century, such alliances have improved the health of our nation's children despite some unresolved systematic problems. Medicaid, for example, is the major federal health insurance program for children today. Yet, access to that funding often is thwarted by extensive paperwork for billing and documentation, low reimbursement rates, and regulations at odds with the provision of needed services. These hindrances have led many practicing pediatricians to withdraw from the program entirely and declare the current situation unworkable. More troubling from a public health standpoint are potential patients who often are confronted with enrollment barriers. Even families who do succeed in gaining admission to the program must endure ongoing cuts in state funding that limit the kinds of care they can receive.
Policy experts, economists, and political officials have offered important assessments of the shortcomings of Medicaid. Proposed solutions range from higher reimbursement rates to a single-payer national health system. As historians, we take a different approach. We see the problem of provision of child health services rooted in ongoing debates of whether the health needs of poor children constitute a medical or social problem and whether such needs are a matter for states or the federal government. These debates raged several times over the course of the 20th century. The failure to resolve them at critical historical junctures has contributed significantly to our present failures in optimizing the health of every child in the United States.
PEDIATRICS: A SHORT HISTORY
Pediatrics is a relatively new development in the history of medicine, not having taken root until the late 19th century.1 Although the American Medical Association (AMA) established a Section on Diseases of Children in 1880 (which became the Section on Pediatrics in 1933) and the independent American Pediatric Society (APS) was founded by 43 nascent pediatricians in 1888, the profession of pediatrics remained a limited medical enterprise, at best, for much of this time. Beginning in the mid-1800s, a handful of the largest US cities established freestanding hospitals devoted almost exclusively to childhood surgical conditions such as orthopedic anomalies. Although at the close of the 19th century 50 physicians established practices with a focus on children, none practiced pediatrics exclusively.2 Indeed, the leading US pediatrician, Abraham Jacobi, admitted in 1880 that if he restricted his practice solely to the diseases of infancy and childhood, he "would make himself ridiculous."3
During the early decades of the 20th century, the field expanded, as did the places in which pediatricians plied their trade. Children's hospitals, orphan asylums, specialized clinics, and dispensaries sprang up; at special "milk stations," clean milk was provided to poor children in concert with what most pediatricians would recognize today as the well-child examination. However, a critical and more universal theme running through this focused work for child health had to do with social factors. In an era in which child labor was still all too common and many young people grew up in slum housing or impoverished rural communities, activists were inspired to attack the causes and consequences of child poverty and ill health. Among their goals were increasing the income of the workingman or breadwinner so that he could better accommodate the needs of his family; providing widows with aid so that they could rear their children at home rather than placing them in institutions; improving institutional care for orphaned or abandoned children; and cleaning up neighborhoods and improving tenement housing. These income- and environment-focused measures typically overshadowed those aimed specifically at the medical needs of children, but they were seen as ultimately providing for a healthier childhood.
CHILD MEDICAL CARE AND CHILD WELFARE: AN UNEASY PARTNERSHIP
An emerging, albeit tentative partnership among physicians, child activists, female reformers, and journalists was evident at the White House Conference on Dependent Children in 1909. Spearheaded by James H. West, a Washington lawyer, close friend of President Theodore Roosevelt, and later a founder of the Boy Scouts of America, and Theodore Dreiser, the novelist and then-editor of the women's magazine The Delineator, the conference brought together experts from many fields related to children's medical and welfare needs. The meeting proved so successful that White House conferences focused on children's medical and social needs were held every decade thereafter (and continue to be held).
1909 proved to be a pivotal year in child health, marking not only the inauguration of the White House conferences but also the first national AMA conference on infant mortality. This meeting led directly to the founding of the American Association for the Study and Prevention of Infant Mortality. The association encouraged studies of the causes and extent of infant mortality, worked to publicize the findings, encouraged philanthropic and health associations in their efforts to promote pregnant women's health, lobbied for child health bureaus, and held annual meetings at which experts shared the findings of their research and information about programs that succeeded in lowering infant mortality rates.4
The alliance that emerged between pediatricians, public health officials, and infant social-needs advocates in the Progressive Era rested on a shared zeal in reducing unacceptable high infant mortality rates in the United States; for a brief time, the alliance obscured underlying divisions. Pediatricians were just beginning to solidify their position as medical specialists in the diseases of infancy and childhood. On the eve of World War I, only 879 US physicians had the training and qualifications to legitimately call themselves pediatricians.5 Nervous about their professional status, many physicians worried about potential competition from what Samuel McClintock Hamill, MD, the president of the APS in 1914, identified as the "charitably and philanthropically inclined reformer and the sociologist." Dr Hamill, therefore, encouraged his fellow pediatricians to seize control of all programs relating to children. However, there were dissenting voices. Other specialists such as the leading clinician, researcher, and pediatrics textbook author Isaac A. Abt, MD, argued that it was best for pediatricians to focus exclusively on health issues that resided within the domain of medical practice, leaving broader social issues such as child labor and school reform to other child advocates.6,7 This division between reformers and physicians would be mirrored in many local, state, and federal programs, which maintained a division between social and medical programs.
It is difficult for a 21st century reader to imagine the extent of child labor in the early 20th century. In 1910, 12% of children aged 10 to 13 years worked, as did 31% of those aged 14 to 15 years. The majority of these children engaged in long hours of farm labor or worked alongside parents harvesting seasonal crops. Alarmed reformers, however, focused their concern on children working in extractive industries such as mining or industrial jobs such as those working alongside family members in southern textile mills and most especially on children earning income in the streets selling newspapers and delivering goods or messages and in more nefarious activities including prostitution and procuring narcotics. The health effects of the long workdays for the poorest children ranged from psychological difficulties and injuries to death on the job. Eliminating child labor proved to be a particularly vexing issue, because it did not solve underlying problems. Households headed by women were those most likely to include child workers. Paradoxically, state laws passed to protect children tended to force poor mothers into the labor force to make ends meet, often at the expense of their young children and with potential health consequences for themselves. Relatively few states passed laws to keep young children out of the labor force. Among the most famous was New York, at the urging of then-assemblyman and soon-to-be Governor Al Smith, in which a law was passed in 1903 banning child labor in factories, on farms, in sweatshops, and in the street trades. The federal government later passed the Keating-Owen Act of 1916, which banned articles produced by children from being sold in interstate commerce but was overturned by the Supreme Court in 1918. Not until the passage of the Fair Labor Standards Act of 1938 were children <16 years old excluded from full-time labor and those <18 years old kept from hazardous occupations. Many children, of course, continued to labor on family farms; over the course of the 20th century, the health concerns of rural children gained increased attention.8,9
THE SHEPPARD-TOWNER MATERNITY AND INFANCY ACT
The nascent infant and child health movement that united public health officials, philanthropists, health care professionals, and social workers in a crusade to lower the infant mortality rates quickly matured into an effective political organization. A major victory came in 1912 when the US Congress created the Children's Bureau, an agency within the Department of Labor, and gave it a mandate to "investigate and report on all matters pertaining to the welfare of children." The Children's Bureau had long been a dream of groups such as the National Consumers' League, the General Federation of Women's Clubs, and the National Congress of Mothers. Among its early efforts were programs to help communities improve sanitation and milk supplies; the creation of child hygiene divisions in state-run public health agencies; the production and distribution of 2 influential, instructional pamphlets ("Prenatal Care" and "Infant Care"); and campaigns involving free diagnostic evaluations by health care professionals.
These efforts helped to decrease infant mortality in large urban centers in the United States during the opening decades of the 20th century. Nevertheless, infant mortality remained high at 131 deaths per 1000 live births, prompting the Children's Bureau leaders to make combating infant mortality a top priority.10 Early investigative reports documented the effects of poverty on child health and pointed particularly to the problem of maternal employment. The findings led reformers to propose maternity benefits in the form of medical services to pregnant women and compensation for lost wages that would permit them to stay home and breastfeed their infants. Modeled on similar programs in other industrialized nations, the proposals met with vehement opposition from the AMA (which objected to federal intervention in the distribution of medical care) and others who feared that cash payments to low-income households might limit the supply of workers and cause wages to rise. Forced to find another solution, reformers turned to a more constrained program of maternal education and infant child care carefully designed to avoid antagonizing private physicians; the Sheppard-Towner Maternity and Infancy Act, first proposed in 1918, was signed into law in 1921. The act authorized the federal government to grant funds for maternal and infant welfare to each state, provided the individual states passed their own "enabling legislation." The federal government supplied approximately $1.25 million a year to the states, which used the funds for child health and prenatal centers, instructional home visits by nurses, and distribution of educational materials. The funds went only to education and child care; infants and children needing medical care were referred to private physicians or, if unable to afford such services, municipally supported providers.11
Congressional debate over the Sheppard-Towner Act was shaped in part by recent wartime experiences. The poor health of many World War I draftees, with 29.1% judged unfit for service, surprised many who were unfamiliar with the health problems of younger, poorer US citizens. In Michigan alone, >30% of all registrants for the draft in 1918 were rejected because of thyroid enlargements that were the direct result of iodine-poor diets, an indication of the types (and variety) of health challenges facing the nation's youngest citizens. One result was that office-based pediatricians increased their attention to weight, growth, and overall preventive health measures.12,13
Reform organizations used the findings about draftees to press for programs that would facilitate the health of the nation's poor in general and their children in particular. In 1919, the American Association for the Study and Prevention of Infant Mortality became the American Child Hygiene Association, demonstrating its expanded commitment and mission. Under the leadership of Herbert Hoover, the organization merged with the Child Health Organization to become the American Child Health Association. Hoover served as its president for most of the 1920s, while he was Secretary of Commerce in the Harding Administration, until his election to the presidency in 1928. During this period, the Sheppard-Towner Act was passed and implemented.
Efforts to pass federal legislation for maternal and child health, however, divided the medical profession, putting pediatricians at odds with other physicians and the leadership of the AMA. During the 1920s, as pediatrics became one of the fastest growing specialties, anxieties about the relationship between pediatricians and social reformers eased somewhat, but in their place new conflicts emerged. The Sheppard-Towner Act provoked the biggest fight of all. The majority of pediatricians supported the act, as did a number of influential women's groups and social activist societies. Still, although the Sheppard-Towner Act explicitly avoided the free dispensation of clinical care, it sparked the ire of many in the medical establishment. Many opponents invoked the specter of the recent Bolshevik revolution, suggesting it was "inspired by foreign experiments in Communism and backed by the radical forces of this country."14
Most vociferous in its condemnation was the AMA, which claimed that the law would harm the public and mark an unprecedented intrusion onto states' rights.15 While the AMA governing House of Delegates was busy condemning the Sheppard-Towner Act, its Section on Diseases of Children voiced its support. The resulting schism, which culminated with the AMA formally chastising the members of the Section on Diseases of Children, motivated many pediatricians, already estranged from the more elite and research-driven APS, to form a new professional group, the American Academy of Pediatrics, in 1930. Devoted principally to advocacy, education, and primary care, its motto was "For the Welfare of Children."16,17
The Sheppard-Towner Act proved to be short-lived. The political clout and antipathy of the AMA and conservative women's groups such as the Daughters of the American Revolution brought a swift end to the legislation. The law was not renewed by Congress in 1927 and was virtually defunded by 1929. In its absence, a system emerged that decidedly separated the provision of medical care for needy children from children whose parents were working or had financial resources; the former provision was labeled "welfare," and the latter was called "fee-for-service" or private medicine.
The rapid demise of the Sheppard-Towner Act should not be read as a sign of failure. The 7 years that the act was in force saw a significant decline in maternal and infant mortality in regions where it concentrated its efforts.10 The Sheppard-Towner Act also facilitated the routine practice of US mothers bringing their infants to pediatricians for regular checkups.18 Finally, the act established an important precedent: it was the first time that the federal government provided funds earmarked for children's health needs.19
In the wake of growing support for children's health needs and the long shadow cast by the termination of Sheppard-Towner, President Herbert Hoover convened the 1930 White House Conference on Child Health and Protection. From this summit came a seminal document, the Children's Charter, which spelled out the rights of children. Among them were: "For every child full preparation for his birth; his mother receiving prenatal, natal and post natal care" and "For every child health protection from birth through adolescence." Sadly, these noble goals would not be met. Faced with unprecedented fiscal demands during the Great Depression, President Hoover proved unable to marshal the aggressive measures needed to respond to the growing medical and social needs of children or adults. His successor, President Franklin Roosevelt, had far greater success in acting on these pressing needs; it is ironic that his most important effort on behalf of child health, Title V of the Social Security Act (SSA), ultimately would set in stone the divisions between medical care and social welfare and between social insurance entitlements managed by the federal government and public assistance entitlements managed by the states.
SOCIAL SECURITY AND CHILD HEALTH
The Franklin Roosevelt Administration's first efforts on behalf of child health was the Child Health Recovery Program, which was overseen by the Federal Emergency Relief Administration and the Children's Bureau. It provided emergency food and medical care to needy children, channeling the resources of public and private health care and relief organizations in each state, with physician consultants and part-time public health nurses paid by the Civil Works Administration for performing the work. It was the first and only New Deal program for young children until the SSA of 1935.20
The SSA contained several streams of funding for children. Title IV provided funds to states for the Aid to Dependent Children program. Title V echoed the programs of the Sheppard-Towner Act, giving federal funds to states that passed enabling legislation for maternal and infant health care or services to "crippled" children and to expand existing child health programs. Although the SSA was the seminal first step in a rapid growth of programs for the elderly, culminating in the Medicare legislation of 1965, it did not lead to similar gains for children, although the Social Security Board, the body charged with implementing the SSA, was well aware as early as the 1930s that the number of economically disadvantaged children was as much as sevenfold that of the elderly. Data from the US Public Health Service showed that the number of children receiving relief was 7 times the number of persons aged 65 years.21
Children were, and remain, a social group without political muscle. The Franklin Roosevelt Administration was facing formidable pressure from advocates of flat pensions for all retirees. These advocates helped to ensure the passage of the SSA and sustain its expansion after World War II.22 Thus, Social Security was born, a program that redistributes income from working families with children to the elderly.
In the 1960s, this pattern was repeated with Medicare, a health insurance program for all elderly Americans that remains an extraordinarily popular social insurance program. On the other hand, social assistance programs for children (welfare) and medical insurance for children (Medicaid) are limited to needy children. They are defined by income limits and other qualifications that result in varying levels of eligibility and services from state to state. Because these programs are not guaranteed to all children in the US population, they are politically unpopular and often threatened. Thus, the greatest pieces of social welfare legislation of the 20th century aided millions of elderly Americans but did so by drawing sharp divisions that would ultimately undermine the provision of medical care and social well-being for children.
It is ironic that World War II made clear to American political leaders, as World War I had done a generation earlier, that children's medical needs were not being met. The pregnant wives of servicemen were unable to obtain care from base hospitals that were busy providing services to soldiers, lacked the funds to purchase health care, and failed to qualify for local programs because of residency requirements. These families had an effective group of lobbyists on their side; the American Legion and the Veterans of Foreign Wars convinced members of Congress to pass the Emergency Medical and Infant Care Program in 1943. The Emergency Medical and Infant Care Program provided maternity and pediatric care for the wives and children of servicemen in the 4 lowest pay grades, paying for the births of 1 of every 7 infants born in the United States.23 Despite having aided many women and children, the program was seen not as providing medical services but as a means of boosting the morale of the patriotic men serving their country in a time of war. After hostilities ceased, the program lost support and ended in 1949.
THE POSTWAR YEARS: SCIENTIFIC ADVANCES AND POLICY STALEMATES
Even as the federal government hesitated at establishing laws that directly met the health care needs of its most vulnerable citizens, children, it embraced the promise and possibilities of "scientific" medicine. Funds flowed into laboratory research and hospital construction. A booming economy and active labor movement ensured that sick- and well-child care became available to growing numbers of families as private health insurance, obtained as an employment benefit, helped pay the costs of hospitalization, including maternity care.
Several programs designed to serve the nation's neediest children followed: Medicaid (Title XIX of the SSA), including the comprehensive Medicaid preventive child health program known as Early and Periodic Screening, Diagnosis, and Treatment, which is intended to serve needy children <21 years old; the Special Supplemental Nutrition Program for Women, Infants, and Children; and, most recently, the State Children's Health Insurance Program. The history of each program, their achievements, and the ongoing challenges they face have been well chronicled. What must be noted is that these programs were built on a foundation erected earlier and continue to leave children more vulnerable than other age groups, including the elderly. For example, in 2002, 9.2 million children <19 years old (12% of children) in the United States were uninsured.24 In addition, the United States has one of the highest infant mortality rates in the industrialized world.
CONCLUSIONS
Although much changed over the course of the 20th century with respect to the types of medical problems faced by US children, many child health needs still are systematically neglected. We know from the history of national efforts on behalf of the elderly that it is possible to reduce poverty dramatically and improve access to care substantially for a specific age group. Only with sufficient political resolve from pediatricians and other child advocates will the 21st century see similar achievements on behalf of children.
ACKNOWLEDGMENTS
We thank Bradley Breuer of the University of Pennsylvania, Brian Gratton of the Russell Sage Foundation, Jeffrey Levi of the George Washington University Center for Health Policy, Eric Schneider of the University of Pennsylvania, and Edward Schor, MD, vice president of the Commonwealth Fund, for comments on drafts of this article. We also thank the President's Discretionary Fund of the Commonwealth Fund for generous support of the research for and composition of this article.
FOOTNOTES
Accepted Dec 22, 2004.
No conflict of interest declared.
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