Epidemic Preparedness in the Age of Chronic Illness: Public Health and Welfare in the United States, 1965-2000

George Aumoithe is a Ph.D. Candidate Department of History Columbia University. He is a 2016-2017 Consortium Research Fellow. 

 

My dissertation “Epidemic Preparedness in the Age of Chronic Illness: Public Health and Welfare in the United States, 1965-2000" is a history of how fear of inflation in the 1970s shaped Medicaid and hospitals in ways that hobbled public health's response to the AIDS epidemic in the 1980s. The dissertation considers the political-economic implications of hyperinflation in the hospital sector, the decline of health insurance coverage, the stagnation of wages, productivity, and unions, and how cost containment policies from the Nixon to Carter administrations shaped a fiscal regime that created a bipartisan policy to restrict healthcare expenditures. In light of these changes and through the lens of the AIDS epidemic that followed, the dissertation re-interprets the late-twentieth-century history of healthcare in the United States. The dissertation undermines the story that AIDS was a shocking surprise that emerged out of nowhere, which inevitably produced a weak public health response.

 

The AIDS crisis revealed the public health system's inadequate response to pre-existing social and economic inequalities during a period where antagonism against the welfare state hemmed the possibilities of healthcare for all. The dissertation centers on the New York City Health and Hospitals Corporation, founded in 1970. The corporation was the largest municipal hospital system in the country. Its operation illustrated how federal health planning and hospital cost containment policies ramified in local context. Hospital closures and cutbacks to services in New York City, especially following the fiscal crisis of 1976, left health providers and community groups scrambling to contain the AIDS epidemic that began in 1981.

 

The challenge, therefore, involved finding sources that could inform how pivotal the 1970s were for healthcare in the U.S. The Consortium for History of Science, Technology, and Medicine facilitated research at the following institutions: the New York Academy of Medicine, the College of Physicians of Philadelphia, the Kislak Center for Special Collections, Rare Books and Manuscripts at the University of Pennsylvania, and the Rockefeller Archives Center. These collections deepened my understanding of the health planning process at the state and regional level. They demonstrated the activism and contributions of progressive physician groups as well as conservative resistance to reform. The archives also highlighted the role of foundations and civil society in grant making and studying the healthcare system’s problems.

 

In November 2016, I visited the New York Academy of Medicine (NYAM). Until this point, I conducted most of my research at presidential libraries, archives, and federal records. Research in NYAM's collections bridged the gap in sources between state and local health planning efforts. Archivist Arlene Shaner informed me of an underused collection of records from the Health and Hospital Planning Council of Southern New York. The Planning Council operated from 1938 to 1976 and was the only voluntary agency authorized to administer federal hospital funding. The collection reveals how jurisdictions of health planning in New York State overlapped, especially after the founding of the Health and Hospitals Corporation in 1970, which often confused health administrators. Despite duplicative efforts, the Planning Council accomplished much of its original purpose by compiling a directory of hospitals as well as data on bed capacity and utilization—information that did not previously exist in any organized fashion.

 

In April 2017, I visited the College of Physicians of Philadelphia and the Kislak Center at the University of Pennsylvania. The College of Physicians of Philadelphia contained material related to professional conferences about the AIDS epidemic as well as position papers on Pennsylvania’s Medicaid system during the crucial fiscal year 1979-1980, when many stringent cost containment policies became law. The Kislak Center contains two collections that enrich the early story of Medicare and Medicaid and the physician activism that was necessary to implement the law throughout the country. Archivists John Pollack and Tom Hensle pointed me to the Physicians Forum collection, which shows how progressive physicians organized during the 1960s to affirm the need for a hospital insurance act and to desegregate the nation’s hospitals. The Medical Committee for Human Rights (MCHR) collection highlights another facet of progressive organizing by medical students who supported the Civil Rights Movement and groups like the Student Non-violent Coordinating Committee. These files provided an unexpected look at healthcare social movements that helped implement Medicare and Medicaid in areas with a legacy of de jure and de facto segregation. Founded in 1963 MCHR remained active during the 1970s and closely followed the later debate about hospital cost containment. They were particularly concerned about how changes to Medicaid and cost cutting would affect the nation’s poor, rural, and communities of color.

 

Finally, in June 2016, I visited the Rockefeller Archive Center for the “New HIV/AIDS Histories” archival conference convened by Senior Fellow Pat Rosenfield and historian Dan Royles. Archivist Tom Rosenbaum helped me locate an insightful slice of the archive's extensive holdings and I looked at the Commonwealth Fund’s records and the gubernatorial records of Nelson A. Rockefeller. These sources add another layer to the story about healthcare and hospitals in the U.S. from the 1970s into the new millennium. The conference focused on the intersections of HIV/AIDS, philanthropy, and archival interpretation. As such, the discussion and collaborative nature of the archival work during this leg was distinct from solitary efforts in other archives. Reading documents alongside activists who received foundation money to carry out their AIDS work, as well as with the program officers who reviewed their applications, was a unique learning opportunity.

 

The Commonwealth Fund records demonstrate how philanthropies in the 1980s filled gaps in the social safety net exacerbated by the prior decade's welfare policy. On one hand, the foundations supplemented the essential on-the-ground efforts of AIDS activist groups with crucial infusions of money. On the other hand, by funding these organizations and seeking community-based solutions to the epidemic, they inadvertently sidestepped long-standing questions about the government’s role in ensuring healthcare. Foundations and service delivery groups' work both supplemented deficiencies in public health and legitimized a shrunken welfare state.

 

CHSTM’s support has enriched my initial project. The dissertation has benefitted from engagement with state, local, activist, and philanthropic sources. These archives tell us that when it comes to epidemic preparedness, a view of the whole community and long-term risks far outweighs ad hoc, temporary, and short-term approaches. These lessons are especially true for populations today who are most highly exposed to HIV/AIDS: men who have sex with men, people in the South (whose governors have refused to expand Medicaid), and those who are black, brown, poor, gender non-conforming, and queer. Instead of a surprising epidemic that inevitably impacted these populations, the archive demonstrates the need for robust health planning that organizes around the principle of equity at all levels of government and in all communities. Lessons from our recent past can shed much needed light on today's healthcare problems.