Chronic Disease in the Twentieth Century This page intentionally left blank Chronic Disease in the Twentieth Century a history George Weisz Johns Hopkins University Press Baltimore © 2014 George Weisz All rights reserved. Published 2014 Printed in the United States of America on acid-free paper 9 8 7 6 5 4 3 2 1 Johns Hopkins University Press 2715 North Charles Street Baltimore, Maryland 21218-4363 www.press.jhu.edu Library of Congress Cataloging-in-Publication Data Weisz, George, author. Chronic disease in the twentieth century / George Weisz. p. ; cm. Includes bibliographical references and index. ISBN 978-1-4214-1302-0 (hardcover : alk. paper) — ISBN 1-4214-1302-7 (hardcover : alk. paper) — ISBN 978-1-4214-1303-7 (pbk. : alk. paper) — ISBN 1-4214-1303-5 (pbk. : alk. paper) — ISBN 978-1-4214-1304-4 (electronic) — ISBN 1-4214-1304-3 (electronic) I. Title. [DNLM: 1. Chronic Disease. 2. Health Policy—history. 3. History, 20th Century. 4. Public Health Practice—history. 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Contents Preface vii List of Abbreviations xv Introduction 1 part i: Chronic Disease in the United States 1 “National Vitality” and Physical Examination 17 2 Expanding Public Health 37 3 Almshouses, Hospitals, and the Sick Poor 56 4 New Deal Politics and the National Health Survey 77 5 Mobilizing against Chronic Illness at Midcentury 101 6 Long-Term Care 128 7 Public Health and Prevention 148 part ii: Chronic Disease in the United Kingdom and France 8 Health, Wealth, and the State 171 9 Alternative Paths in the United Kingdom 176 10 Maladies chroniques in France 204 Epilogue 233 Notes 247 Index 295 This page intentionally left blank Preface he structure of this book reflects my conviction that chronic disease—though Ta traditional medical term—was primarily an American policy construct during the first half of the twentieth century. In part I, I devote seven chapters to the United States and offer what I hope is a somewhat different perspective on the history of American healthcare from that offered by work focused on political battles over health insurance. I argue that the concept of “chronic disease” was developed in three domains during the interwar period. By the mid-1950s, two transformative developments had made the concept central to the rhetoric and organization of public health, healthcare, and research, and allowed individuals in different domains, for by now there were more than three, to come together and negotiate the meanings of and actions around chronic disease. In part II, three chapters discuss the very different British and French approaches to chronic disease. Chapter 1 deals with the first of these domains, which appeared around the time of World War I. Its earliest manifestation was concern about chronic illness that emerged within New York City’s Health Department. This concern was justi- fied by apparently rising mortality rates for illnesses like cancer, an increase that was in fact hotly contested by many statisticians, who viewed it as an artifact of changing disease categories and diagnostic procedures. (This debate, which con- tinued to be a divisive issue, recurs throughout this book.) But the wider spread of a chronic disease problem owed much to the movement for periodic physical examinations that emerged from the insurance industry and eugenic movement. In 1908 the economist Irving Fisher wrote a report on “National Vitality” for President Theodore Roosevelt’s Conservation Commission, in which he argued that there was huge waste of American life and health as a result of failure to make use of existing knowledge about diseases. Several years later Fisher was viii Preface involved in the creation of the Life Extension Institute (LEI), a business enter- prise that performed medical examinations for many clients, but notably life in- surance companies with an interest in keeping their clients alive as long as pos- sible. The American Medical Association (AMA) and the public health movement quickly adopted the principle of the periodic physical examination, even if the practice failed to achieve mass popularity. Although all incipient diseases and “defects” might be detected and remedied, degenerative chronic diseases were especially appropriate targets for examination because they were frequently “si- lent” and without symptoms until they became too advanced to treat. Chapter 2 discusses a second domain in which the public health movement sought to expand its reach beyond sanitation and the prevention of infectious diseases to the prevention and care of all illnesses. Small, disorganized, and fo- cused on a narrow range of problems, the public health movement began to evolve in the 1920s. By the middle of that decade, influential voices, notably that of Charles Winslow of Yale, began calling for expansion beyond traditional public health activities to include care of degenerative diseases like cancer, diabetes, and heart disease. New measures, he argued, were needed to face new conditions. This was a controversial position because it entailed a major expansion of the scope of public health. It also involved breaking down the distinction between prevention and cure; this was already occurring in public programs dealing with venereal disease and tuberculosis, which sought to find and cure individuals with these diseases but which could be justified as public health measures to prevent the spread of communicable diseases. Creating similar programs solely to pre- vent disease from reaching the stage of incurability was a new and contentious idea. By the mid-1930s, however, prestigious voices within public health institu- tions were making such arguments and referring to the new category “chronic disease,” which was to be at the center of the expanded public health movement. Thus, early concern about chronic disease associated with periodic medical examinations combined with a push by public health professionals to extend their reach. In chapter 3, I discuss a third domain and the one most directly de- voted to chronic care, which emerged during the 1920s in the world of social welfare institutions, including hospitals, dealing with the destitute poor. Doctors working with this population like Ernst Boas, then medical director of the Mon- tefiore Hospital for Chronic Diseases in the Bronx, hospital administrators in public hospitals seeking to free beds for acutely ill patients, and social welfare workers trying to place sick and infirm people in appropriate institutions domi- nated this movement in its early years. A series of local health surveys of welfare Preface ix cases in various cities and states showed that a very large proportion of those dependent on welfare institutions suffered from chronic diseases or disabilities and that almshouses where they traditionally resided were inadequate and fre- quently inhumane. The goal of this reform movement was to create an appropri- ate and rational system of care for “indigent chronics” that included visiting nurs- ing care in the home, purely custodial care, skilled nursing care, and sophisticated medical care when necessary. The most striking example of this welfare form of chronic care occurred in New York City, where an extraordinary array of reports, services, and institutions was organized, culminating in the opening in 1940 of the huge Goldwater Chronic Disease Hospital on Welfare (now Roosevelt) Island. Chronic illness expanded into the national arena during the mid-1930s. In chap- ter 4 I analyze one transformational moment in this shift. New Deal reformers— including many New Yorkers who brought their city’s welfare concerns to Wash- ington—needed to demonstrate that the Depression had created terrible health conditions in order to advocate effectively for a broad transformation of Ameri- can healthcare. They could not utilize mortality statistics, however, which were improving. A group led by pioneering epidemiologist Edgar Sydenstricker stum- bled on the concept of “days of disability” developed in unemployment surveys and utilized it as a measure of illness status. No one had more days of disability than people who were chronically ill and disabled, and the result was the massive National Health Survey of Chronic Illness and Disability (NHS) undertaken in 1935–36. This survey purported to show that more than one in six Americans suffered from a chronic disease or disability. These figures were highly dubious and, although they were eventually revised, the original dramatic figures some- how stuck. The immediate effect of the survey was to transform chronic disease into a national social problem. During the two decades following World War II, chronic illness emerged as a center of American health policy. In chapter 5, I examine a second transformative development, an unprecedented alliance of public and private institutions that focused on chronic illness, largely as a way of creating consensus around health- care reform that avoided the virulent disagreements surrounding national health insurance. This alliance was embodied by the Commission on Chronic Illness (CCI, 1947–56), which brought together some of the major institutions