How American Tragedies Shaped Healthcare

Over the course of our nation’s history we’ve faced enormous national challenges. As Americans, we take pride in our ability to overcome these tragedies and remain resilient. The current COVID-19 crisis feels genuinely different altogether.

Below are a few examples from the last 100+ years that illustrate how tragedies, heart wrenching, unjustifiable and in some cases preventable as they were, have pushed our nation to make significant changes to the way we care for our people.

The 1918 Flu

Many people are talking about the similarities between the current COVID-19 crisis and the 1918 flu that ravaged not only our country, but the world. 

The flu coincided with the Progressive Era in America history and it revealed the essentially non-existent healthcare system at the time. Before the outbreak, most doctors worked for themselves or were funded by charities or religious institutions. They had no way to reliably test for diseases, no vaccines to speak of or even antibiotics to combat the pneumonia-like systems which ultimately ended up killing many of the flu victims. ⁱ

The flu spurred a global movement to embrace the concept of socialized medicine. It helped shed the idea of eugenics and developed the concept of health insurance (then known as sickness insurance). On economic and social grounds, the United States and countries around the world began to believe that individuals should require sickness insurance to provide recompense for lost wages during sickness. Though it would take a while for this concept to gain ground in America, its roots were found in a public health crisis. ^{ii iii}

This was also the start of the time when the world was beginning to see the need for global coordination and cooperation (think League of Nations). We started to recognize that public health was a part of that need as well. In 1919, an international bureau for fighting epidemics opened as well as the health branch of the League of Nations. Those were forerunners to the World Health Organization (WHO). ^iv

The Great Depression

After the stock market crash of 1929, Americans faced a decade of economic downturn, the consequences of which still echo in today’s survivors who keep every Cool Whip® container for food storage or use old peanut butter cans for nails and screws. It was a nationwide tragedy that got into the lifelong psyche of our citizens.

The Great Depression also advanced the idea of government intervention to assist its citizens in a way never before seen in the United States. The Federal Emergency Relief Act (FERA) was passed in 1933 which contained funds specifically for medical care. It largely put those funds into the hands of the state or local agencies to provide care for those suffering from acute conditions and emergency illnesses only.

In the following year, one million dollars of the FERA budget went to providing medical care for people in rural areas. FERA also established nursing programs that sent nurses to make home visits to sick people or those unaware of the availability of care.

Now remember that was President Herbert Hoover’s time who, even with a long history of child health advocacy, largely believed people should handle their own business. But when President Franklin Roosevelt came on the scene, he signed the Social Security Act of 1935 which, among other things, ushered in sweeping funds for public health.

“This ‘… is a new condition,’ he wrote, ‘… different from what prevailed in other times and in other countries when they faced the problem for planning for economic security against sickness.’” ^v

Ultimately the public health initiatives passed in the Social Security Act were focused on putting people to work through the Public Works Administration (PWA). They were responsible for building hospitals and similar facilities as well as improving water and sewer systems. These projects significantly improved public health during this era. The Social Security Act also provided grants to states for health insurance programs.^vi

And finally, medical research was funded, which led to advancements in medicine including understanding how diet affects health. This then led to more regulations on how foods and drugs were made.

The U.S. Public Health Service, now known as the Department of Health and Human Services, began programs during this time that are still in progress today such as vaccination programs, sanitation efforts, prenatal care and cancer screenings.^vi

The New Deal, spurred on by economic tragedy, made such enduring changes to our public health system that we can never know how it would have progressed otherwise.

A Word About Wars

The consequences of war are far reaching and include changes to healthcare as one of those consequences. Here are some of the major advancements brought on by wars during this time period.

World War II saw the development of chemotherapy treatment. They discovered that people exposed to mustard gas had toxic changes in the bone marrow cells that develop into blood cells. ^vii World War II also saw the mass production and therefore expanded use of sulfa drugs and penicillin.

MASH (Mobile Army Surgical Hospital) actually began at the very end of World War II but is more closely associated with the Korean War. MASH demonstrated our learning that any delays to medical care for trauma reduces positive outcomes.

Military doctors also made significant advancements in vascular reconstruction surgery during the Korean War which significantly reduced amputation rates.

It was actually also World War II that we first saw the use of helicopter transport (1944^viii), but it was the Vietnam war that made air ambulances and helicopter evacuation widespread and standard practice. Vietnam also brought us the use of paramedics to care for the wounded before they could be transported. This job transferred to the civilian world and are known to us as EMS (Emergency Medical System). And significantly the identification and subsequent research of PTSD came from the Vietnam War.

Damage control surgery was introduced in the 90s and became standard procedures in the Iraq and Afghanistan war. And medical innovations like Quik-Clot (chitosan) was a benefit from this time period as well.

Many of the improvements in emergency response and trauma care came from techniques developed during these times of war.^ix

The Death of JFK

To understand how the death of President John F. Kennedy shaped healthcare you have to look back to what was brewing before he took office. In 1957, we see the first proposal actually considered by Congress for federally financed health insurance for the elderly population. For all the economic boom going on, there was also persistent poverty and unemployment which exacerbated economic and social divisions in our country. ^x

President Kennedy campaigned on a “war against poverty and degradation” which became his platform as he began his presidency. ^xi

With JFK’s untimely death the nation went into mourning and Vice President Johnson assumed the role of President. Kennedy's death made Johnson president, but some argue it also propelled the nation to a democratic majority in the following year when Johnson was elected. Johnson’s democratic majority was then able to pass some of the most significant healthcare legislation in American history.

In 1965, Congress passed the Social Security Amendments Act. Medicare and Medicaid were established as a part of this legislation. This marked the first time there was a federally funded health insurance program. The consequences are far reaching and have embedded themselves into the fabric of the America we know now.

Beyond the health insurance aspect of the 1965 bill, significant money was pumped into disease research and facility enhancements to counter some of the common killers such as heart disease, cancer and stroke. ⁱⁱⁱ

The Social Movements of the 60s, 70s and 80s

During the time of social unrest in our country there were significant improvements made to our healthcare system as groups of disenfranchised people made their voices heard about the inequalities found in our society.

Notably, the civil rights movement drew attention to the large disparities in medical care for African Americans, some disparities that we still see today. Civil rights activists were able to get hospitals integrated, yes, but they were also instrumental in ensuring adequate hospitals and physicians remained in predominately African American communities. Among their other well-known activities for equality, activists initiated class-action lawsuits demanding hospitals remain in inner cities and take more Medicaid patients. They also were instrumental in setting up local neighborhood health clinics. ^xii

The women’s social movement was another initiative that drove tangible healthcare results. Generally, people think of reproductive health care and family planning as the health programs championed by women, which is true, but health care coverage was also an important part of their platform. At the time much of health care was employment-based and discriminated against women who often were found in part-time, temporary, service, small business or homemaking fields – therefore leaving them under or uninsured. They were also instrumental in championing primary and preventative care along with mental health care, counseling and domestic violence screening. ^xii

The AIDS crisis of the 1980s brought about significant changes to our healthcare system including speeding up drug trials, pharmaceutical price reductions and significant AIDS research. AIDS activists protested the exclusions that many health and disability insurance companies had for people with HIV and then later for the exorbitant costs levied on those with the disease. ^xii

Each of these leaps and bounds to healthcare improvement came at the cost of enormous tragedy. 

The 9/11 Attacks

The tragedy that unfolded on the morning of September 11, 2001 revealed the need for public health disaster planning and training as well as improved coordination between agencies.

As a result of the problems these terrorist attacks exposed, we experienced a cultural shift in the way hospitals, states, health departments and federal agencies interact during a time of crisis or disaster.

The Pandemic and All-Hazards Preparedness Act of 2006 was passed to improve health security, provide resources for research and mitigation of infectious diseases and align agencies in a time of crisis. The National Response Framework was created as a guide to how the nation responds to disasters. The CDC also increased their national stockpile of lifesaving drugs and antidotes to counteract bioterrorism. ^xiii

The 2008 Financial Crisis

The 2008 financial crisis led to some of the most significant changes to the healthcare system since 1965.

The American Recovery and Reinvestment Act (ARRA) of 2009 was an economic stimulus package passed to help bring America out of the Great Recession. Much like the stimulus packages signed in the 30s, the goal of this act was to save and create jobs. And also like the previous bills, it included funds to improve public health. Funds went to Medicaid enhancement, health research, facility improvement and construction, prevention and wellness services, healthcare worker training and technology investments. ^xiv

To that last point, the ARRA enacted the Health Information Technology for Economic and Clinical Health Act (HITECH Act), which provided money to invest in health information technology in the form of the Meaningful Use (now Promoting Interoperability) program. This program, in the short of course of 10 years, brought almost all hospitals and practices into the digital era with the mandatory use of EHRs.

In the following year the Affordable Care Act (ACA) passed the first version of a type of universal federally funded healthcare. The ACA also expanded the Medicaid program and promoted activities to help improve quality of care and lower healthcare costs. ^xv

What Advancements Will COVID-19 Bring?

Of course, this question can’t be answered right now. Although even at this early stage it seems clear that the rapid and pervasive use of telehealth will change the system dramatically.

None of this is to say that medical advancements justify the tragedies listed here. Significant pain and suffering afflicted so many along the way. We remember the sacrifices they made, through war, through activism, through disease, through financial instability. And we honor them by saying what we did before is not enough. We will do more. We will be better. And that is absolutely something we intend to do as nation in the aftermath of COVID-19.

Sources
i. https://www.encyclopedia.com/education/news-and-education-magazines/public-health-1929-1941
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vii. https://www.cancer.org/cancer/cancer-basics/history-of-cancer/cancer-treatment-chemo.html
viii. https://aams.org/member-services/fact-sheet-faqs/
ix. https://mpt.pbslearningmedia.org/resource/vietnam-medical-advances/vietnam-medical-advances/support-materials/
x. https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-people.html
xi. https://www.encyclopedia.com/history/united-states-and-canada/us-history/war-poverty
xii. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447696/
xiii. https://www.cdc.gov/cpr/documents/lancet_article_sept2011.pdf
xiv. https://www.washingtonpost.com/wp-dyn/content/article/2009/05/15/AR2009051503667.html
xv. https://aspe.hhs.gov/report/provider-retention-high-need-areas/american-recovery-and-reinvestment-act-arra-and-patient-protection-and-affordable-care-act-aca-funding-expansion
xvi. https://www.cdc.gov/ehrmeaningfuluse/introduction.html
xvii. https://www.phe.gov/Preparedness/legal/pahpa/Pages/default.aspx
xviii. https://www.ssa.gov/history/ssa/lbjmedicare1.html