NAVIGATING the Future Through the Past The Enduring Historical Legacy of Federal Children's Health Programs in the United States

摘要

The United States excels at treating the most complex medical conditions, but our low-ranking health statistics (relative to other countries) do not match our high-end health care spending. One way to understand this paradox is to examine the history of federal children's health programs. In the 1800s, children's health advocates confronted social determinants of health to reduce infant mortality. Over the past 100 years, however, physicians have increasingly focused on individual doctor–patient encounters; public health professionals, meanwhile, have maintained a population health perspective but struggled with the politics of addressing root causes of disease. Political history and historical demography help explain some salient differences with European nations that date to the founding of federal children's health programs in the early 20th century. More recently, federal programs for children with intellectual disability illustrate technical advances in medicine, shifting children's health epidemiology, and the politics of public health policy. HOW DID CHILDREN'S HEALTH in the United States get to where it is today? In some community hospitals in Miami, Florida, my hometown, every birth is attended by a board-certified obstetrician and a board-certified neonatologist. Prenatal care for expectant mothers is widely available, and children are screened and treated for a host of medical conditions from infancy through their school years. If serious illness occurs, vast resources go to medical specialists and hospitals to address the needs of affected children and their mothers. Yet in some neighborhoods, 48% of children aged 3 years are overweight or obese, and asthma rates are double the national average. 1 My community is not unique: throughout the United States, we excel at treating the most complex medical conditions, yet we rank poorly relative to other nations on population health measures. In a 2006 international comparison, the United States was first in health care spending and 39th in infant mortality rate (IMR). 2 Despite a century of dramatic progress in infant and child mortality, significant disparities that correlate with income, race, and ethnicity persist. 3 Uneven access to health care is one explanation for our relatively poor health outcomes: millions of US children are uninsured or underinsured, with negative consequences for their health. 4 A related factor is that advances in medical care may improve overall health but exacerbate health care disparities, because some populations with better access benefit first from new treatments and health advice. 5 A different set of explanations focuses on the social determinants of health. 6 Because health is determined by a complex array of genetic, behavioral, social, and environmental factors, access to health care is only one contributing influence on population health. Long-standing differences in housing, nutrition, life experiences, and built environment affect health across the life span and contribute to disparities among populations in the United States. 7 The US health care system rarely addresses these underlying causes with the intensity or resources that are devoted to medical care. 8 For example, a 2010 study estimated that local, state, and federal investment in public health programs amounts to less than $100 per person in the United States; overall health care spending, by contrast, is more than $6000 per capita. 9 The neglect of public health in the United States is a vitally important phenomenon that first took shape and then accelerated during the 20th century. In the 19th century, medical practitioners were deeply concerned with each patient's environment, and they were frequently involved in local public health issues. In larger cities, public health professionals viewed social and political reform as critical to improving population health. 10 Over the past century, physicians and public health professionals followed diverging professional trajectories, and tensions arose over the best way to improve the health of US citizens. 11 Physicians have increasingly focused on providing technologically sophisticated care to patients in acute care settings; public health professionals, meanwhile, have become responsible for collecting vital statistics, monitoring epidemics, testing for specific diseases, providing health education, addressing maternal and children's health, and investigating environmental health hazards. 12 Both have increasingly relied on the impartial mantle of science while reducing alliances with overtly political groups that address issues such as income, housing, and civil rights. 13 The 75th anniversary of Title V of the Social Security Act provides an auspicious opportunity to explore how these broader historical trends have affected children's health. Federal health agencies such as the Maternal and Child Health Bureau (MCHB) have their origins in this landmark legislation, 14 and exploring the history o