Public Health

Milwaukee has proven exceptional in its reform-minded approach to public health since it established a Board of Health in 1867. Later efforts to improve public health began after the city’s rapid population growth in the late nineteenth century (by 1910 Milwaukee was the twelfth largest city in the United States, with a population of 373,857). The unintended consequences of rapid urbanization included the spread of infectious diseases, crowded and dangerous housing, open sewers, and infected water supplies. Industrialization also led to social ills, including air and water pollution.[1] Toward the end of the nineteenth century, tuberculosis caused 10 to 14 percent of deaths in Milwaukee every year.[2] There were also occasional smallpox and typhoid outbreaks, among other diarrheal and respiratory illnesses that consistently affected the city’s growing population, especially in the congested neighborhoods on the south side of the city.[3] Other issues associated with urbanization included food safety and pollution. These problems alarmed local politicians, health experts, and the city’s residents, ultimately leading to programs aimed at improving public health. Throughout the late nineteenth and early twentieth centuries, Milwaukee’s city government took more responsibility for the public’s health; eventually Milwaukee took the lead nationally in promoting government responsibility in urban public health efforts.

Reformers Address Public Health Problems

In the mid-nineteenth century there were a few provisions for the sick in Milwaukee, including private charitable endeavors and the Milwaukee City Medical Association, which was formed in 1845.[4] In 1848, the Daughters of Charity established St. John’s Infirmary, which was later renamed St. Mary’s Hospital.[5] Beyond the private initiatives, and inspired by the Metropolitan Board of Health in New York City, in 1867 the city created a five-member Board of Health appointed by the mayor to oversee public health improvements.[6] Dr. James Johnson became Milwaukee’s first health officer. Johnson’s primary efforts centered around food safety and the alleviation of infectious disease epidemics.

Food safety fell within the purview of the Health Department beginning in the late nineteenth century. Public-health reformers focused their attention on milk production in particular. Milwaukee’s residents received their milk from urban and rural cows, but in the late nineteenth century milk was identified as a transmitter of tuberculosis. Investigations in 1878 and 1879 led to the city government proposing numerous ordinances to regulate milk sales. Laws were passed in the late 1880s, but more than two decades later opponents challenged the milk programs in court. Adams v. Milwaukee reached the United States Supreme Court in 1913. The court’s settlement provided the city the right to test cattle for tuberculosis regardless of the cow’s location, which in practice extended the power of the Health Department outside of the city itself.[7] Pasteurization also increased the safety of milk consumption. The regulation of milk production probably decreased mortality rates in children under age five and certainly reduced the spread of tuberculosis.[8]

Besides food safety, late nineteenth-century public health officials attempted to counter health crises stemming from epidemics. There were numerous smallpox outbreaks in Milwaukee during the nineteenth century, including a major epidemic in 1876-1877.[9] During a smallpox epidemic in 1894-1895, public health reform efforts were dealt a considerable setback when controversy arose over health officials’ strategy of fighting the epidemic with vaccinations and quarantines. Responding to the public outcry, the Common Council temporarily repealed measures that gave public health officials the ability to combat infectious diseases. However, worsening economic conditions due to a depression in the 1890s resulted in enough desperation among the city’s population that they increasingly accepted an expanded role for government in daily lives of citizens, not only to alleviate economic conditions, but also to improve public health. Public health officials also became more effective at working with the city’s diverse population, and to promote reforms at the local level the Health Department became more closely aligned with private organizations, such as the Milwaukee’s Children’s Hospital and the Milwaukee Medical Society. These combined changes greatly increased the efficacy of public health efforts and ensured that the city’s residents supported government-run health programs.[10]

Socialist Reform Efforts

By the turn of the century, there were noticeable improvements in public health due to the city’s efforts to improve food safety and to combat infectious disease epidemics, and to the work of private charitable organizations among the city’s poorest residents. In 1910 Emil Seidel became the first Socialist to govern a major American city. He and his supporters hoped to make Milwaukee a model city for working-class families through civic improvement efforts and quality governance.[11] By the early twentieth century, the Socialists’ platform included public health and offered promises of building new health facilities to fight disease. Beyond combatting infectious diseases, the Socialists were also dedicated to cleansing the city of garbage, sewage, and industrial pollution, in addition to providing a cleaner water supply.

These efforts had begun in the late 1870s, when the first city-wide garbage collection contract was issued.[12] However, garbage continued to pollute Milwaukee’s water supply, as did animal manure that littered the city’s streets. Public health officials presumed that solving the city’s garbage problem would also increase the health of the city’s inhabitants. Even though the first city-wide garbage contract was issued in 1878, garbage collection and disposal were still a problem in the 1890s. There were effectively three disposal solutions: create landfills, cremation, or dump garbage in Lake Michigan. By 1911 responsibility for garbage collection transferred from the health department to the Department of Public Works. A new municipal incinerator was built in 1910; it helped to dispose of Milwaukee’s garbage until 1955.[13]

Beyond garbage collection, water safety also remained an important issue through the 1920s. In 1910 city officials began to chlorinate the water lines, but after a major outbreak of water-borne illnesses struck in 1916, the decision was made to overhaul the city’s waste disposal systems. In 1925 the sewage treatment plant still presently in use went into operation on the north end of Jones Island.[14] While the Jones Island sewage treatment plant helped resolve waste disposal, it was during the Great Depression that Milwaukee saw major improvement in its drinking water supplies. The Linnwood Avenue Water Treatment Plant was funded through a grant and loans from the federal Public Works Administration, one of the New Deal economic relief programs. The project required work from 1,700 people over the course of its year-long construction; it was finished in 1938 and cost $5 million. The Linnwood Avenue water purification plant is also still currently in use.[15]

The 1918 influenza epidemic in the United States tested the public health efforts established over the previous three decades. Department of Health officials isolated the sick, temporarily closed schools, regulated how many people could use streetcars, and relied on teachers to investigate unreported cases. Residents were more accepting of city efforts to curtail the effects of the influenza epidemic. The result was that Milwaukee had one of the best outcomes in the country. Wisconsin had 2.91 deaths per thousand, while the national state average was 4.39 per thousand, and Milwaukee, where 1,292 people died of the flu, experienced one of the lowest death rates in the country for a city of its size.[16]

In 1930 the United States Chamber of Commerce named Milwaukee the number one city in the country in public health. The award was the culmination of city-led public health reform efforts in the late nineteenth and early twentieth centuries.[17] Most importantly, city leaders provided greater resources to health officials, and the Department of Health became more effective in its targeted reform efforts. Health officials worked alongside volunteers and charitable organizations; they relied on technical expertise when necessary, paid greater attention to the interaction between health reform and cultural diversity, and shifted from managing epidemics to prevention of illness. These efforts helped establish Milwaukee as one of America’s healthiest cities throughout the first half of the twentieth century.

Expansion and New Urban Public Health Challenges

However, like other major urban centers in the United States, Milwaukee continued to have considerable public health challenges throughout the twentieth century. A primary concern of health officials beginning in the 1970s was childhood lead poisoning, the main source of which is deteriorating lead-based paint. Although lead-based paint was banned for use in housing nationwide in 1978, the vast majority of homes in Milwaukee were built before then, and therefore are at risk for lead exposure from deteriorating paint. If children are exposed to lead, they have an increased chance of developing lifelong learning and behavioral impairments. Efforts to eliminate lead paint hazards continued through the 1990s, when over 50 percent of Milwaukee’s children had still been exposed to some level of lead. Beyond lead paint, public health officials have also drawn attention to other sources of lead, including in soil and in drinking water. While Milwaukee’s childhood lead poisoning rates have dropped substantially, Milwaukee’s efforts to eliminate all sources lead from homes is a public health challenge that the city is still attempting to resolve.[18] Although lead flakes and lead dust (due to deteriorating lead paint) in homes and in the soil remain by far the greatest health threat, controversy arose in early 2018 over water line replacements that temporarily increased lead levels in drinking water. As a result, city officials attempted to raise awareness over lead in drinking water by directly mailing 70,000 at-risk homes. The city also called on homeowners to use water filters, and in some cases, provided free filters to poor residents.[19]

The city of Milwaukee faced new health challenges at the end of the twentieth and early twenty-first centuries. The Cryptosporidium outbreak of 1993 infected more than 400,000 people, making it the worst single-source waterborne disease outbreak in U.S. history.[20] Milwaukee was forced to reassess its freshwater infrastructure as a result of the outbreak, in addition to making other public health changes. For example, the city’s Health Department instituted real-time syndromic surveillance programs in conjunction with pharmacies and area emergency rooms, a closer working relationship between the city’s Water Works and Health Department, a new inlet water pipe reaching further into Lake Michigan, and new investments in water purification technology. In 2003 Milwaukee had the first instance of monkeypox (similar to smallpox) in the Western Hemisphere.[21] There were also at least two E. coli O157:H7 outbreaks in the early twenty-first century. The first, in 2000, originated in a restaurant and resulted in sixty-five illnesses and one fatality.[22] The second, in 2006, was caused by infected spinach and infected at least twenty-nine people and caused one death.[23]

Perhaps the most dramatic outbreak since Cryptosporidium in 1993 was the 2009 H1N1 influenza (“swine flu”) pandemic. Cases were first reported in California in late March 2009, and high death rates were reported early on as well. By late May 2009, Wisconsin had the most reported cases of any US state, and that number continued to rise, reaching 3008 by June 12—of which nearly 2,000 were in Milwaukee.[24] Milwaukee was harder hit than many other cities, but it also identified more cases because it implemented an aggressive surveillance strategy: beginning April 27, the Milwaukee Health Department (MHD) began recommending use of H1N1-specific reverse transcriptase polymerase chain reaction (RT-PCR) testing for anyone with influenza symptoms and travel history to areas reporting H1N1 cases.[25] The MHD lab was one of the first with this capability, as was the virology lab at Children’s Hospital of Wisconsin (also based in the Milwaukee area).

Due to the high numbers of schoolchildren affected by this pandemic, the Milwaukee Health Department began closing schools to prevent disease spread: by the beginning of May, 2009, 22 public and private schools had been ordered closed by MHD, and MHD was considering closure of the entire Milwaukee Public School system, which would have affected nearly 90,000 students and their families. Ongoing efforts by the US Centers for Disease Control (CDC) at analyzing the severity and mortality rates of the pandemic H1N1, combined with the Milwaukee Mayor’s insistence on a direct weekend phone conversation with CDC officials, resulted in applying a revised CDC recommendation to no longer close schools as a method to prevent disease spread. Nonetheless, by July 16, 2009, Milwaukee had 3,278 confirmed cases and four deaths due to H1N1.[26] The pandemic continued through the fall of 2009, when vaccine finally became available. MHD held large, community-based vaccination clinics. Close communication with the Milwaukee community, with national experts, and with local healthcare providers were key to the management of this global pandemic’s effects in Milwaukee, as was Milwaukee’s highly-rated surveillance system (first implemented in response to the Cryptosporidium outbreak).

In the early twenty-first century, infant mortality—and racial disparities in infant mortality—was a prominent public health concern for Milwaukee’s Health Department. Milwaukee has one of the highest infant mortality rates in the country, which impacts African-American residents at a rate three times higher than other Milwaukeeans. On average, about 60 percent of infant deaths in Milwaukee are due to complications of prematurity, 20 percent due to birth defects, and 15 percent due to unsafe sleeping conditions. In 2009, Milwaukee began an aggressive public campaign to reduce infant deaths resulting from unsafe sleeping conditions. Further, Milwaukee public health officials have attempted to reduce the rate of premature births, which has included home visit programs for at-risk mothers.[27] Milwaukee has made little progress in reducing its sexually transmitted disease (STD) rates. Since the mid-1990s, and perhaps earlier, Milwaukee has often ranked in the top ten cities in the county for gonorrhea rates, and in the top five for chlamydia rates.[28]

Many of the public health issues facing Milwaukee—or any major urban area—correlate with poverty and unemployment rates; Milwaukee, since the 1980s, has seen a significant decline in manufacturing jobs, and a significant increase in poverty and unemployment, particularly in the African-American community. While the general public tends to believe that health outcomes are driven primarily by individual health behaviors (exercise, nutrition, not smoking, etc.) and access to quality medical care, in fact more than half of health is driven by social and economic factors.[29] Much recent data suggests that chronic stress caused by adverse social determinants of health “gets under the skin,” and, through hormonal and epigenetic mechanisms, drives poor health outcomes ranging from preterm birth to cancer and heart disease—even in the face of healthy behaviors and healthcare access. Public health officials in Milwaukee were early adopters of the idea that governmental public health needed to expand beyond direct service provision and begin to address the social determinants of health. Social determinants of health include living and working conditions, income and poverty, educational attainment, availability and affordability of goods and services such as safe and stable housing, healthy food, quality childcare, public transit, etc., and the public policies that drive those conditions.

Funding for public health has become a major challenge since the 1990s. The Milwaukee Health Department has been remarkably successful in garnering grant funds to help support its efforts; in most years, grant funds account for between 40 percent and 60 percent of the department’s overall budget. The department is significantly smaller than in the past. In the 1970s and 1980s there were 400 to 500 staff at the department and enough public health nurses to make a home visit for every newborn in the city. However, budget cuts beginning in 1989 and continuing more or less steadily ever since resulted in a staffing level in 2017 of about 230 (including clinical personnel and inspectors as well as clerical and custodial staff). These budget challenges are intensified by the fact that per-capita spending on public health by the state of Wisconsin has historically been among the lowest five to ten states in the nation.[30]

While significant public health challenges continue to challenge Milwaukee’s Health Department, the city has shown a unique capability to confront and alleviate health problems throughout the previous century. These efforts have improved the health of Milwaukee’s residents and have contributed to Milwaukee being a cleaner and safer city to live.