Healthcare Reform in Early Twentieth-Century Milwaukee
October 23rd, 2007
Judith Walzer Leavitt's The Healthiest City: Milwaukee and the Politics of Health Reform "seeks to determine how and why municipal governments increased their responsibility for the people's health" by using Milwaukee as a case study (p. 9). She claims that her study of Milwaukee has many similarities to public health reform in other cities and that her conclusions can thus be generalized to beyond Milwaukee's borders (p. 6). Leavitt argues that the factors affecting health reform included "the medical or technical knowledge available, economic interests, interurban competition, political ideologies, ethnic diversity, corruption, inefficiency, and simple frustration." (p. 5) She contends that improvements in Milwaukee’s public health during this time period were primarily the result of healthcare reforms, not to improvements in medicine or technology.
The rapid growth of the city through the late-nineteenth and early-twentieth centuries created many health problems and, over time, most Milwaukee residents came to accept a greater level of government involvement in public health. A coalition of physicians, middle-class reformers, business interests, and trade union Socialists gradually emerged to push forward public health reform, culminating in the electoral victory of the Socialist party in the 1910 election. By 1930 Milwaukee was named the healthiest city in America.
Leavitt's first chapter discusses Milwaukee's public health problems. Over the course of the late-nineteenth and early-twentieth centuries the city experienced rapid growing, going from 20,061 people in 1850 to 373,857 people in 1910. With the growth of the city came overcrowding and growing health problems. Mortality rates began to rise as diseases such as tuberculosis, diphtheria, and pneumonia spread through the city. The city was hit with multiple epidemics of smallpox and other diseases.
These health problems led to the creation of the City Health Department, the subject of chapter 2. Physicians and businesspeople realized Milwaukee's health problems would hamper its growth and so began lobbying for a public health board, eventually succeeding in persuading the state legislature to require the Milwaukee mayor to appoint one. Leavitt discusses the careers of various public health officers and analyzes the policies implemented by succeeding administrations.
Over time the Health Department increased its powers over the citizenry, which Leavitt attributes to its attempts to improve their health. She largely neglects a possible alternative interpretation - that the Health Department was, rather than merely benignly looking out for the populace's health, following an institutional imperative common to many government agencies - to increase its power, budget, and “bureaucratic turf.” Much of The Healthiest City cries out for a power-centric analysis yet Leavitt neither makes this analysis nor explains why such an analysis would be inappropriate.
Similar flaws appear in chapter three, which discusses reforms she claims were intended to prevent and/or limit smallpox epidemics. The Health Department attempted to forcibly transfer sick children and other individuals to quarantine in a hospital and heavily pressured citizens to be vaccinated against smallpox. This coercive approach resulted in considerable resistance, especially by German and Polish immigrants. Anti-vaccination campaigns emerged and an insurrection against the Health department even occurred during a smallpox crisis, resulting in the impeachment of Health Commissioner Walter Kempster. Later Commissioners relied more on education and persuasion and less on coercion, which proved more effective and resulted in less resistance. As with other parts of the book Leavitt assumes the Health Department was primarily motivated by concern for the health of the general populace and largely ignores the possibility that its activities with regard to smallpox were motivated more by power or social control. Even its educational activities could be viewed as a way of getting citizens to internalize this control, rather than as solely directed as improving health.
Chapter four is a history of garbage reform. In the nineteenth century the prevailing miasmatic theory placed a great deal of emphasis on removing filth and the noxious odors it produced, making garbage removal an important priority for public health reformers. The city experimented with various forms of garbage removal and disposal, attempting to find an optimal solution to the problem. As the germ theory displaced miasmatic theory garbage disposal moved away from the realm of public health and became an engineering problem instead.
Chapter five discusses public health reform in the area of milk. The Health Department attempted to impose regulations to keep contaminants and diseases out of milk, but faced resistance from milk producers. They resented interference in their affairs, opposed added costs associated with the regulations, and, in the case of small milk producers, feared being forced to shut down due to the regulations. The most dramatic instance of resistance was the “Milk War” of 1914 in which many milk producers boycotted Milwaukee over its health regulations. The Health Department ultimately won out and milk producers eventually came to accept its regulation of milk production and distribution.
Chapter six analyzes how non-governmental organizations, including middle class reform organizations, settlement houses, charities, and religious organizations, affected health reform. Here Leavitt's failure to address a potential social control interpretation of these events is most blatant. There is a rich literature arguing that settlement houses and other progressive reformers were forms of social control by the middle and upper class over immigrants and the working class: an attempt to inculcate them with middle-class values. Leavitt fails to either take this into account or argue against this interpretation.
Leavitt's seventh chapter argues twentieth century public health reforms faced less resistance due to greater public acceptance of the programs. She uses two examples - the Child Welfare Commission and the response to the 1918 influenza epidemic - as examples to support her argument. The Socialist party won elections to both the city council and mayor's office in the 1910 elections, in part due to promises of sweeping public health reform. In 1911 it created the Child Welfare Commission to reduce child mortality, initially focusing on Polish immigrants. Even though the socialists were defeated in the 1912 elections, the Health Department continued similar child welfare work. The reforms passed by the Socialists were mostly in line with reforms advocated by non-Socialist middle and upper class progressive reformers at the time, allowing them expand their share of the electorate and, at times, even gain support from the progressive wing of the business community, who appreciated the Socialists’ anti-corruption and honest government advocacy.
Although the Health Department's attempts to deal with the 1918 influenza epidemic created a small amount of discontent, it had a much higher degree of public support than the Department's efforts to combat epidemics and promote public health in the nineteenth century. Thus, a fundamental shift in public attitudes towards public health had taken place. The majority of Milwaukeeans, according to Leavitt, rejected free enterprise principles when it came to public health and for the next several decades accepted a higher degree of state intervention to promote public health.
Though titled “The Process of Change" Leavitt's eighth and final chapter is essentially a conclusion. The majority of it consists of summarizing the conclusions she came to in previous chapters. Here she partially acknowledges the possibility of an alternative social control model, noting that "cultural divisions also reveal an element of social control that may have motivated some of the people advocating health policy change." (p. 263) Yet this one paragraph barely acknowledges this possible interpretation and fails to even attempt to refute it.
Although naive about the motives of the state, the book is still worth reading for those interested in the history of healthcare reform or early twentieth-century US. Leavitt’s core argument - that Milwaukee’s public health improved mainly due to reform not to technological changes - is well-supported and clearly true, and she provided a good window into early-twentieth century reform politics.