What historically has constituted occupational safety and health? From as early as the nineteenth century, from the very origins of the American industrial revolution this question was as much a political and social issue as it was a medical one. Were they only problems of accidents or acute poisonings caused by exposures to lead, arsenic, mercury and other heavy metals or did they include chronic diseases such as silicosis and asbestosis, harbinger of the problems we now confront in the wake of the new industrial world that emerged in the middle of the twentieth century?

To doctors and public health practitioners throughout the past two centuries, occupational safety and health has changed as the new industrial age has exposed millions of people to dusts and chemicals that have become the basis of much of modern society. Today, as we have become dependent on coal, petrochemicals and new sources of energy, the presence of dust and various toxins in the working and living environments is no longer exceptional. It is not only doctors and public health officials who have been engaged with these issues, but industry and labor have helped to define the boundaries between normal and abnormal, healthy and diseased. Industry often argued that workers and their families had to accommodate to the new industrial realities. To inhale dust was a normal everyday occurrence for people living in industrial communities and cities. Under these modern conditions, health and disease were part of one continuum, not two dichotomous categories. The presence of dust in workers’ lungs was not pathological; only ‘excessive’ amounts that limited their activity could be considered pathological. However, as we trace in this chapter through to the contemporary period, for workers and their families the normalizing of insults to their bodies had personal meaning that was part of a larger struggle over who would control their bodies and their lives.

INTRODUCTION

Biological explanations do political work, writes anthropologist Margaret Lock, “creating the rules for belonging and exclusion” (Lock 1999, 83–113). Scientific criteria have long served as a means to create and justify social categories on the basis of “natural” distinctions. The biological sciences have been used to differentiate “good citizens” (those who, in a prevailing social context, will contribute to work, economic growth, and prosperity) from “bad citizens” (those who are criminally inclined, dependent, unhealthy, or likely to be costly risks). They have been used to identify membership in particular racial and ethnic groups for purposes of entitlements, and they have been used to explain inequalities by casting the differential treatment and status of particular groups as a natural consequence of essential, immutable traits.

The power of science as a means of categorizing people expanded in the late nineteenth century when clinicians and public health officials began to explore the etiology of disease in the distinctive features and susceptibilities of individual patients and their social milieu. Historian Matthew Jacobson describes how the increased focus on the individual had significant implications for many areas of social policy (Jacobson 1998, 113). Scientific fields such as craniometry and phrenology were developed to evaluate and categorize people according to their behavioral characteristics, susceptibility to disease, and ability to do particular types of work. They became tools in criminal investigations and provided guidelines for employment practices.

In recent years, occupational diseases have become an area of intense interest to medicine, public health, industry, and labor. Whole new areas of medical and public health specialization have developed since the end of World War II, partly in response to the detection of carcinogens in the workplace, dust in the air that workers breathe, and human-made chemicals that workers touch, taste, or inhale. Black lung (coal workers’ pneumoconiosis), brown lung (byssinosis), and white lung (asbestosis) are three industry-specific diseases that have gained international attention and highlighted the role of occupation in the creation of illness. Laborers as well as physicians have become acutely aware of the dangers posed by substances and materials at work in a host of industries from steel to petrochemicals.

The growing attention to the hazards of the industrial workplace has alerted workers even in “clean” worksites to occupational disease. Physical dangers are posed to office workers by video display terminals, poorly designed furniture, noise, and vibrations. Stress at the workplace is now seen as important in the creation of the modern epidemics of high blood pressure, heart disease, and stroke. The very definition of disease has been altered by a rising popular and professional consciousness of the importance of occupation as a source of illness.

The 1890s were hardly gay for the majority of Americans. Before the decade was halfway completed an economic depression of unheard-of magnitude had swept the country and threatened the very existence of millions of blue-collar workers, small businessmen, and even bankers. Following the panic of 1893, over 600 banks closed, 16,000 business firms went bankrupt, and 2.5 million laborers were suddenly jobless. The 1,300 strikes by workers in most heavy industries, coupled with the obvious plight of thousands of workers who marched on Washington in “General” Coxey's army, led one senator to fear that the country was “on the verge of revolution.”

In New York, the effect of the Depression was extremely severe. “Times were hard,” recalled Lillian Wald, the famous founder of the Henry Street Settlement. “In the summer the miseries due to unemployment and rising rents and prices began to be apparent, but the pinch came with the cold weather.” The winter of 1893–1894, the first of a depression that was to last through 1897, was most memorable to Wald. She observed firsthand “the extraordinary sufferings and the variety of pain and poverty” of those living in the tenements of New York's lower East Side.

The city's merchants were also severely affected by the Depression, as were the small charity institutions that depended upon their contributions. Coming on the heels of a steady rise in the costs of supplies, fuel, and food, the shock of reduced support was disruptive and, for some facilities, fatal.

Because hospital trustees could no longer depend primarily on private benefactors to support their institutions and were instead forced to begin charging patients significant sums, it became necessary to organize and present the hospital to the public in a new way. If patients were to be encouraged to pay for services, the hospitals would have to offer them something different from the services provided at minimal or no charge to the indigent. Some trustees and hospital spokesmen began to organize distinct services for different classes of the population – sometimes separate services within a single institution, and sometimes entirely separate institutions for those who could pay and those in need of charity care.

Once separate private services were introduced, it became necessary to convince the merchants, white-collar workers, and skilled craftsmen who might be expected to use them that hospital care was superior to the treatment they had traditionally received at home, sometimes with the aid of private physicians and private-duty nurses. Accordingly, hospitals began to offer amenities like private and semiprivate rooms, private nurses, better food, and pleasant accommodations for those patients willing to pay the price. But more was necessary to attract to the hospital people who had long received private medical care in their homes. Hospital representatives began to advertise their improved services and also to encourage public newspaper reports from patients convinced of the superiority of hospital care. Often these reports portrayed the hospital as nothing more than a “hotel for rich invalids”.

As we have seen, the Progressive era brought major changes in the city's political and social arrangements. The demographic shifts, economic upheavals, and political reforms that undermined the cohesiveness of neighborhoods and their small hospitals also hurt the free-standing dispensaries and small walk-in clinics located throughout working-class neighborhoods. Like the small hospitals, dispensaries were nearly totally dependent upon the influence of local merchants and leaders to obtain city money for their survival. When power shifted from locally elected politicians to city officials and bureaucrats, and when the state comptroller's officials changed reimbursement regulations to favor large institutions, the freestanding dispensaries felt the pinch most severely.

The Progressive era's shift in the locus of decision making was accompanied by similar changes throughout the society. In commercial activities, large corporations replaced local businessmen. Everywhere, people tended to place greater and greater faith in large, impersonal, bureaucratic institutions, and to question the ability of smaller organizations to provide services. The locus of health-care services also shifted away from small-scale undertakings toward larger corporate institutions. Doctors' offices and the small dispensary were replaced by large hospitals with a wider base of financial support, more influential trustees, and a more extensive and sophisticated physical plant. Individual doctors moved to these larger institutions; dispensaries came to be regulated by the state; local merchant-trustees lost power to organized charity. The decline of the dispensary as a viable form of basic health-care delivery in the twentieth century reflects the move to corporate forms of health-care organization.

The neighborhood focus of nineteenth-century medical practice

Nineteenth-century American life revolved around small communities and narrow personal contacts. Most Americans lived in rural villages and towns that were essentially isolated from each other, and even those who lived in the city lived in highly structured communities separated from each other by culture, ethnicity, and sometimes language. Because there were no adequate transportation and communication systems early in the century, there was little chance for relationships beyond one's immediate neighborhood. In these so-called walking cities, life revolved around the local church, school, and other small institutions. Government was a neighborhood responsibility watched over by the local ward boss, who, as part of the political machine, was able to attend to the needs of the community.

A strong neighborhood focus of necessity characterized nineteenth-century medical practice as well. For much of the century, New York City was a highly congested series of neighborhoods spread between the southern tip of Manhattan and Fifty-ninth Street. Before the introduction of electric trolleys and elevated railroad lines, the horse was the major means of transportation. Although the city's gentry owned private carts and wagons for transportation, most of the working people depended upon slow and undependable horse-drawn trolleys, which had to negotiate streets that were continually “torn up, blown up or dug up” for construction.

This book began with a relatively simple premise: that the organization of health and hospital services was, in a variety of ways, a reflection of historically determined societal values and interests. It was my purpose to investigate these relationships and to understand how certain practices arose and how they changed over time. Of particular interest to me was the history of the relationship between patients, professionals, trustees, workers, and politicians, all of whom had different ideas and distinctly different goals at crucial moments when the modern health system was formed. To address the history of health care in any meaningful way it was necessary to understand the perspectives and interests of the different actors.

My own perspective was shaped by my experience as an administrator in New York's health system as well as by my training in the history of science and American social history at Harvard. It was this background that prompted me to use the tools of urban and social historians to analyze health policy issues of concern to health professionals. This book centers on the historical roots of distinctions in services based upon geography, income, race, and employment status – referred to as “access” and “availability” issues by planners and policy makers; the changing nature of trustee and staff relationships; and the development of new models of hospital and health care – which are often borrowed from business enterprises rather than from other social services.