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Milbank Quarterly Classics Public Health
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Edgar Sydenstricker deserves a spot on any list of the “giants” of public health. After joining the Public Health Service, he worked on classic studies about the link between economic conditions and health among textile workers in New York City.1 Perhaps, most famously, he worked with Joseph Goldberger on pellagra in the American South, a case study still taught frequently in introductory public health courses for its incisive acumen about disease causation. And, as if that were not sufficient, as the head of the Office of Statistical Investigations, he started the Hagerstown (Maryland) Morbidity Survey that eventually became the US National Health Survey. He had a front row seat to, and was a participant in, the rapidly growing field of public health in the first quarter of the twentieth century. His classic article, “The Changing Concept of Public Health,” published in The Milbank Memorial Fund Quarterly in 1935, just a year before his untimely death at age 54, represents a culmination of a professional lifetime of engagement with public health.2 It served as a statement both of the challenges the United States faced in health as he saw them, and the opportunities he thought were possible if we adopted a broader view of health than was then, and still is now, the case.
When Sydenstricker wrote his paper, US life expectancy was 60.9; it stands at 78.9 in 2019. He wrote of health conditions in which he saw progress could be made. He suggested that the infant death rate—which had been cut in half in the preceding 25 years—could be cut in half again. He was indeed correct on this; infant mortality did drop roughly in half in the subsequent 25 years; and almost tenfold at the present.3,4 He suggested that two-thirds of annual maternal deaths were unnecessary; maternal mortality fell to less than 10% of its 1935 level within 25 years, and today stands at less than 2% of what it was in 1935. He also noted that half of the cases of syphilis did not receive treatment, and accidents and homicides were responsible for 1 death per 1,000, suggesting that both should and could be resolved. He was partly correct: Syphilis patients now receive treatment nearly universally and death from accidents has dropped by more than ten-fold since 1935, but the homicide rate has changed relatively little since the 1940s. Rereading “The Changing Concept of Public Health” serves as a helpful time capsule, reminding us of the very real achievements of public health, and how in many respects we have realized the potential that one of the leading thinkers in the field at the time could see us achieving.
And yet, what makes this paper a classic is not the articulation of bills of morbidity and mortality or the predictions about the targets to which we should aspire on disease reduction. Sydenstricker’s core thesis was less that we had disease reduction to achieve, and more that in order to achieve true progress in public health we needed to understand, once and for all, that we could achieve better health in populations if we could “control, so far as means are known to science, all of the environmental factors that affect physical and mental well-being.”
Sydenstricker articulates areas where we feel we have a “basic responsibility.” These areas ring as true today as they must have to the readership of The Milbank Quarterly in 1935. He discusses economic security and healthy housing, availability of nutrient-dense food and opportunities for exercise, and efforts to provide social security for all as essential to the public’s health. Perhaps presciently, he agitates for the importance of universal access to health care, recognizing that “thousands upon thousands of families are unable to purchase medical care when sickness occurs.” Sydenstricker is careful to hew to the science in making these prescriptions. He notes that “the precise relationship of housing to health is not fully known” and that we would do well to focus on areas where we would have, in more latter-day language, a higher return on investment. In all, Sydenstricker is clear that absent a full reckoning with the forces that generate health, we will not achieve health improvement that we are capable of, continuing to fall shorter on health than we should.
Remarkably perhaps, Sydenstricker’s paper presages the movements that have risen to prominence in population health science over the past 25 years by a full three-quarters of a century. His prescriptions resonate with an engaged social determinants of health agenda, or a “health in all policies” approach, both of which have become rallying cries for public health professionals in the US at the start of the twenty-first century.5 The importance of housing, opportunities for exercise, economic security, and nutritious food as central to the health of the public is now recognized by scholars and practitioners alike, serving as the foundation of action articulated by the Centers for Disease Control and Prevention (CDC) Health Impact Pyramid.6 And yet, as US health continues to lag behind that of its peers, and with a decline in life expectancy in recent years not seen since Sydenstricker’s era, one can reasonably wonder: What took us so long to embrace the role of social and economic forces in shaping the health of populations?
The explanations for our relative neglect of these forces until recently are many. The country was slow to reckon with the long shadow of slavery and Jim Crow, with its attendant deep echoes in racial and ethnic divides in health. We have allowed economic individualism to dominate our public conversation, chipping away both at notions of collective responsibility for the public’s health and an understanding of our collective health as being inextricable from a compassionate world in which all have opportunity to live in an environment that generates, rather than harms, health. And, time and again, we have evinced a fascination with the potential of medicine to cure all ills, being willing to accept higher rates of disease as long as we have medicines to cure us, at the expense of investing in measures that can prevent us from getting sick in the first place. At core, though, we, as a country, have not understood that our health is ineluctably linked to the world around us, and that unless we invest in the forces that generate health, “the plain fact must be faced notwithstanding great advances in medicine and public health protection, the American people are not so healthy as they have a right to be.”
The ultimate prescription, a way forward, is also captured well by Sydenstricker. In perhaps the paper’s most soaring aspiration, he hopes that “someday the basic criterion of any condition or any practice or any proposal will be the effect it may have upon the public health.” That day has not yet come. Revisiting Sydenstricker’s paper, close to a century after he wrote it, reminds us that elevating health to the heart of all we do was then—and remains now—essential if we are to improve the health of populations.
Published in 2019 DOI: 10.1111/1468-0009.12435
Sandro Galea, a physician, epidemiologist, and author, is dean and Robert A. Knox Professor at Boston University School of Public Health. He previously held academic and leadership positions at Columbia University, the University of Michigan, and the New York Academy of Medicine. He has published extensively in the peer-reviewed literature, and is a regular contributor to a range of public media, about the social causes of health, mental health, and the consequences of trauma. He has been listed as one of the most widely cited scholars in the social sciences. He is chair of the board of the Association of Schools and Programs of Public Health and past president of the Society for Epidemiologic Research and of the Interdisciplinary Association for Population Health Science. He is an elected member of the National Academy of Medicine. Galea has received several lifetime achievement awards. Galea holds a medical degree from the University of Toronto, graduate degrees from Harvard University and Columbia University, and an honorary doctorate from the University of Glasgow.
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