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PUBLIC HEALTH. The underlying responsibility of the CLEVELAND BOARD OF HEALTH, to promote a healthy environment and improved quality of life through community action, has not changed since the first board was constituted in 1832. Municipal health professionals, with the help of civic and social reformers, and often supported by federal grants, formulated and instituted beneficial municipal health programs in spite of state and local political machinations, public apathy, insufficient funding, and socioeconomic changes. The isolated and sparsely populated Cleveland frontier settlement of 1796 had little need for medical or public-health services. The first physician to practice in Cleveland was Dr. DAVID LONG in 1810. Early settlers contended with arduous living conditions and malarial fever, but suffered few deaths from epidemic or endemic diseases. By 1821 there were more than 600 people in the village, and the trustees adopted simple rules and regulations to control sanitary conditions. Cholera, the first serious epidemic to strike Cleveland, was brought to the city in 1832. Aware of the dangers from this dreaded disease, the trustees, which included Dr. Long, established a board of health. The board erected a quarantine station and hospital and prescribed sanitary measures. Cleveland was chartered in 1836 and granted the right to organize a permanent board of health, but did not do so in spite of periodic epidemics of cholera (see CHOLERA EPIDEMIC OF 1832), yellow fever, influenza, and typhoid. On 7 March 1850, the state legislature authorized the CLEVELAND CITY COUNCIL to form a board of health with powers to abate the nuisances and to enact measures to combat the spread of infectious diseases. Since state laws did not mandate the board, and because the population remained passive to potential dangers, municipal officials did not create a permanent board of health until 10 January 1856. Dr. Fred W. Marseilles was appointed the first health officer. For the next 20 years, the city slowly developed a public-health organization, enacted health ordinances, and provided SANITATION.

As early as 1826, the city poorhouse furnished rudimentary hospital care for the indigent, elderly, and chronically ill. Some improvements in hospital services were made in 1836 and 1855; however, it was not until 1889 that construction of a modern city hospital was begun. It opened several years later. In the interim, health care was provided by private hospitals (see HOSPITALS AND HEALTH PLANNING) operated by medical schools and benevolent and religious organizations. Out-patient medical care for the neighborhood poor began in 1856 with the appointment of Dr. Thomas G. Cleveland as city physician. Following the CIVIL WAR, the increased population and numbers of poor made it necessary to restructure the health-care system and to appoint additional physicians in 1871 and thereafter, as the need arose. In 1986 4 health centers provided care, training, and inspection services to the city, and in some cases to county residents. In the last quarter of the 19th century, sanitary reformers throughout the nation embarked on a crusade in behalf of improved public health and personal hygiene. Dr. Frank Wells, the Cleveland health officer, approved their aims but did not join their ranks. In the annual report of the Board of Health for 1876, Wells attributed the high death rate to poor sanitation, germs, and adverse socioeconomic conditions. He argued that the leading cause of disease was the filth that accumulated in the city. Health ordinances enacted up until 1875 dealt almost exclusively with the problem of unsanitary conditions, the prevention of noxious odors, and the sale of adulterated milk and food. Since it was believed that the main function of the Board of Health was that of sanitary policeman, authority for its activity was vested in the Board of Police Commissioners (see CLEVELAND POLICE DEPARTMENT) on 2 separate occasions--1876-80 and 1892-1902. The results fell far below bureaucratic expectations, and the city was forced to return control to an independent board of health. The preoccupation with filth as the main source of disease disregarded the emerging germ theory. The importance of pathogens in disease causation was acknowledged by city officials in 1901, when William Travis Howard, a professor at Western Reserve Univ. Medical School, was placed in charge of a new municipal bacteriological laboratory to routinely examine potential sources of disease in water and food supplies, and to establish and approve standards for safeguarding the health of the city. Wells also warned of the destructive effect on health of overcrowding, poor ventilation, and improper food and clothing--problems that had been neglected and ignored. Future Cleveland health officers and public-health employees also proposed greater emphasis on socioeconomic issues without negating the dangers of an unsanitary environment. This acceptance released the Cleveland Board of Health from its task as a provider of sanitary services and offered the opportunity to concentrate on new areas in the prevention of illness and disease.

The accelerated growth of INDUSTRY that occurred in the Greater Cleveland metropolitan area in the last 4 decades of the 19th century made the city an attractive place to work and live, in spite of environmental shortcomings that arose when native and foreign workers seeking employment opportunities poured into the city (see IMMIGRATION AND MIGRATION). The changing demographics, lack of planning, economic upheavals, housing shortages, municipal fiscal conservatism, and a pervasive social Darwinism compounded existing public-health problems. Municipal authorities took steps in the last quarter of the 19th century to provide a sanitary infrastructure and reaffirmed their right to enforce sanitary laws. In spite of the progress, however, in 1910 the Board of Health reported that expenditures for the city's health programs had not kept pace with those in other major U.S. cities. Dr. C. E. Ford, secretary of the Board of Health, warned that since public health was a purchasable commodity, Cleveland could "determine its own death rates."

The first serious effort to educate and involve social and civic leaders about public health was made in 1875 when the Board of Health published its first annual report. It detailed the work of the department for the year, aired departmental concerns, and recommended institutional changes. The participation of civic and social reformers in health matters accelerated sharply in the first decade of the 20th century. Their achievements included public-school sanitation and student hygiene; educational programs in SETTLEMENT HOUSES; visiting-nurse services; programs in child and maternal welfare, mental hygiene and nutrition; and the control and prevention of contagious diseases. Almost all of these programs were incorporated into departments of the Board of Health, and by 1921 the voluntary efforts had dramatically altered the composition and the purpose of the municipal health department. Yet some health officials indicated the need for even greater progress. On 1 Oct. 1919, the Cleveland Hospital Council appointed the Committee on Hospital & Health Survey of Cleveland to examine and recommend methods to achieve "better public health and fewer preventable deaths." The study included 4 broad areas--medical education, NURSING education, care of sick individuals, and the advancement of public health and preventive medicine. The Cleveland Hospital & Health Survey was undertaken with the cooperation of national, state, and local health and civic organizations. The report, made public on 22 Sept. 1920, emphasized the city's health and sanitation deficiencies and offered constructive recommendations, not all of which were adopted. Nonetheless, progress was evident, not only in the increased per capita cost for health care between 1920-30 but also in the reduced death rate. However, the improved conditions did not apply to all segments of the population: the death rate for AFRICAN AMERICANS increased for the same period, from 8% to about 15%.

By the turn of the century, SUBURBS became burdened with the same health problems that faced Cleveland. Referring to the adverse conditions that existed throughout the state, the Ohio Public Health Journal stated in Dec. 1918 that local health organizations were notoriously inadequate. State efforts resulted in the appointment of a full-time health commissioner in Cuyahoga County in 1920. The county was granted the authority to provide health care to those communities that previously had supplied only minimal services. The Cuyahoga County District Board of Health (see CUYAHOGA COUNTY GOVERNMENT) grew to 107 full- and part-time employees who served some 736,628 residents in 1984, although Cleveland, EAST CLEVELAND, CLEVELAND HTS., SHAKER HTS., and LAKEWOOD continued to furnish their own health services. To improve the overall health system, various recommendations to combine all municipal department activities of the county into one central agency had been rejected for political and economic reasons (see REGIONAL GOVERNMENT). Many of the recommendations made by the 1920 survey, never fully realized, were finally aborted in the Depression. Fortunately, the federal government, with the cooperation of private welfare agencies, intervened and provided funding for the overhaul and improvement of the sanitary infrastructure and for the continued support of municipal health agencies.

As a result of WORLD WAR II, for a 10-year period, from 1940-50, little attention was paid to the city's health problems. However, it was evident to many health professionals that the course of public health had to be redirected once again: new problems had arisen. A study prepared by the Cleveland Metropolitan Service Commission in 1956 confirmed that preventive medicine and the control of contagious diseases, improved sanitary conditions in home and INDUSTRY, tighter food and drug inspection laws, accurate vital statistics, and a higher standard of living had increased life expectancy, but also raised the incidence of diseases associated with old age. The emphasis shifted to expensive long-term chronic illnesses such as hypertension, diabetes, heart disease, arthritis, mental health, and drug and alcohol abuse.

In the late 1950s the city began a steady and precipitous decline in population; the loss of tax revenues resulted in a sharp reduction in health services. The problem became exaggerated with time. In June 1972 Dr. J. C. Robertson of the Mayor's Health Advisory Committee, in a Proposed Health Program Priority statement, wrote that the city was at the brink of self-destruction. He warned that the Board of Health was "grossly inadequate," underfinanced, understaffed, and deficient in certain key skills--a complaint of health officers for more than 100 years. Robertson proposed drastic measures, which included limiting staff activity to only those tasks that would prevent epidemic catastrophes. Fortunately, with federal programs and funds, the city was able to continue important health services. Since the 1960s the Department of Health & Public Welfare has shared the responsibilities for environmental health with federal, state, and county governments, but it still performed some 48 health and sanitation functions in the 1990s, ranging from animal bites to vending-machine inspections.

The public health problems that confronted municipal health workers in the 19th century were still present in the 1990s, in addition to other problems created by the technological revolution. Cleveland's response would most likely be dictated by changes in medical technology and the availability of federal funding to purchase and implement such medical advances.

Sam Alewitz