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Gunn and the American NGOs

The formation of voluntary organizations favoring a variety of good causes was a typically American custom, one that Tocqueville commented on already in the 1830s. In some way this development filled the space which in Europe had been filled by programs sponsored by national and local government. This “American way” met with great approval to the point where Winslow claimed it to be “almost” equivalent to “the discovery of the germ theory of disease itself.”

Gunn’s first contact with an American voluntary organization probably took place in Orange, NJ where as a health officer he developed a cooperative campaign with the local branch of the National Tuberculosis Association (NTA), voluntary social work agencies, and the board of health to help detect unidentified tuberculosis cases. The project encouraged patients to seek care much earlier than normally would have been the case. Many physicians were reluctant to report the disease, in many instances simply waiting until after their patients had died.

Gunn seriously entered the world of voluntary health organizations when in 1913 he took over from Livingston Farrand as Secretary to the committee established to study such organizations. It is noteworthy that this study was called for by the AMA which at the time was as deeply concerned with the development of public health in America, as was the American Public Health Association, as hard as that may be to believe today. In fact, the study of voluntary organizations was one part of a much wider effort that included a “thorough investigation of present public health conditions in the United States,” “education of the public by every possible means in order that the people may understand the enormous advances in scientific medical knowledge during the last generation,” and “the crystallizing of such educated public sentiment in necessary public health laws, regulations and ordinances which will render possible a conservation of human life.” Although funding became tight, the program did lead to the conduct of Chapin’s study of all State Boards of Health, mentioned earlier; it also funded Gunn’s study of the 39 voluntary organizations that agreed to participate.

Gunn compiled the responses to a questionnaire which aimed to learn if these voluntary organizations would be willing to cooperate in the establishment of a central bureau to coordinate their activities. There were 18 who answered definitely yes; 1 answered no; 9 probable, and 9 deferred. When asked to suggest what work such a bureau should concentrate its attention on, a wide-ranging response was obtained. The American Association for Labor Legislation regarded health insurance as the most essential activity that should be taken up for the advancement of public health. The American Genetic Association proposed the dissemination of knowledge of the laws of heredity. The AMA – the coordination of existing organizations, the division of field and conservation of resources. The Bureau of Municipal Research – a program for the reduction of mortality from diseases of the heart, arteries and kidneys. The Conference of Secretaries of the State and Provincial Boards of Health of North America – an amplification of the public health activities of the national government. The National Association for the Study and Prevention of Tuberculosis – the improvement of housing conditions through legislation and otherwise, and the betterment of working conditions by increased wages, better factory hygiene, etc. The National Consumers League – reduction of working hours to eight and the establishment of minimum wage boards. The Postal Life Insurance Company – a campaign for pure water, pure air and plenty of it, pure food, regular exercise in the open air, careful mastication of food. And finally the APHA – the coordination and cooperation of existing volunteer health organizations, so as to make education of public in health matters more effective.

While the report was under preparation, the APHA leadership proposed that its’ organization might be the most logical organization to act as a national bureau if it were ever created. William C. Woodward, President of the APHA in 1914, observed in his Presidential address that it was probably because the APHA had not been “an active factor in molding public opinion” that the National Association for the Study and Prevention of Tuberculosis had been formed in 1904. Logically, the APHA being the oldest of the voluntary organizations, such a program should have been organized through the APHA. But money was scarce, it membership was small and it was “lacking in vitality when the need for action arose.

Historically, matters were a bit more complicated as it was the APHA in 1893 that had endorsed the idea that other voluntary organizations should be established to share the public health workload. Be that as it may, Gunn used his annual report as Secretary to the APHA and Editor of the AJPH in 1914 to challenge the members to make the Association something more, or as he put it: to “build up an organization that will be able to make itself felt every day in the year if need be.” His proposal came in the form of one long question:

Do the members want the Association to become a great active health organization, assisting in the formation of affiliated state health associations, helping to bring about desirable legislation in federal, state and municipal governments, advising and assisting communities and individuals engaged in public health work, aiding in correlating and coordinating much of the public health effort which is being attempted?

The debate that was launched in 1914 was effectively interrupted by the onset of World War I, so much so that, when the Metropolitan Life Insurance Company provided the APHA with a grant of $25,000 in 1917 to improve the quality of health service throughout the country, the Executive Committee thought it unwise to initiate such a program “until the country is functioning along more normal lines.”

Mobilization for the war took many forms. The New York State Department of Health, for example, placed its organization and resources at the disposal of the State Council of Defense and the Adjutant General’s office. The council had responsibility for the general mobilization of the State’s resources. The Adjutant General’s office had charge of the National Guard and detailed planning for the mobilization.

Another factor contributing at the time to a falloff in the push for coordinating the work of voluntary organizations in America was the fact that many leading American public health figures had become involved in the war. As already discussed, the exploding incidence of tuberculosis in France led Biggs to spend time in France followed by Farrand, Gunn and others moving to France. But it was not only the International Health Board that had shifted its attention from America elsewhere. Individual public health specialists for a variety of reasons spent time abroad, mostly as a direct consequence of the war and in its aftermath.

Almost immediately with the onset of the war, the American Red Cross found itself operating around the world: China, Japan, Mexico, the Balkan States, and Turkey. Although these were essentially aimed at providing relief in one form or another, as the end of the war approached, attention turned towards preventive activities. Led by Henry P. Davison, who President Wilson had chosen to be Chairman of the War Council of the American Red Cross, the aim was to transform Red Cross Societies throughout the world into organizations that during peace-time would work to protect human health by a wide-ranging program that featured all of the progressive elements present at the time.

The War Council had been established by President Wilson in May 1917 with the purpose of ensuring that all war relief would be coordinated by one organization. Upon its creation Davison announced that some $50,000,000 would be needed for such an effort. Although many at the time thought this figure far too great to be realized (or in fact needed), a campaign was launched to raise $100,000,000. In the end some $400,000,000 was collected during the war and the post-war period!

Davison argued that “it was the duty of those who had led in the development of the Red Cross during the war to capitalize the humanitarian spirit which the war had aroused for the sufferings of their fellow beings throughout the world.” In this case “duty” was supported by some $50,000,000 that remained after the war ended plus $25,000,000 worth of relief supplies. This offered an extraordinary opportunity for making the American Red Cross the center of an international public health effort. If this opportunity was not seized upon immediately it would disappear as quickly as it had arisen.

Davison obtained the backing of President Wilson. At the same time Farrand accepted the job as the new chairman of the ARC. Davison believed that someone of his quality was needed to ensure that an international spirit would reign at home while others were pursuing the cause elsewhere. Earlier (December 1918) George Vincent had been approached for the job, but he declined the offer while agreeing “that Farrand is the man.”

Davison was able to convene the meeting in Cannes that led to the creation of the LRCS an organization which as we have seen fell far short from fulfilling Davison’s vision.

Following the end of the, Vincent attempted to resurrect the idea of creating a national mechanism for coordinating the work of the voluntary organizations. In a speech to the APHA in December 1918 entitled Teamplay in Public Health, he argued that just as the US  Government had brought together its health programs under one roof during the war, the voluntary health agencies should do the same thing or, as he put it, no longer should they “withstand the demand for teamplay.”

Critics laid stress upon “the wasteful of time, energy and money, the confusion of the public mind, the overlapping of effort, and the discrediting of public health undertakings.” But more “subtly menacing” in Vincent’s mind, was the “assumption that there is a definite and verified body of scientific and administrative knowledge which is guiding the activities of all public health agencies, government and voluntary.” It was precisely such a body of knowledge that was needed, but it was impossible to create it where “each group tends to over-emphasize the significance of the disease with which it deals.” A further danger lay in “prematurely forcing upon municipal and state administrations half-baked public health policies which may endanger the common welfare, waste the public funds, discredit the cause of public health in a community, and produce popular reaction.”

To counter this trend, Vincent proposed three things: (1) A definite body of scientific knowledge, medical, statistical, and sociological; (2) the effective demonstration of the application of such knowledge in communities, states and the nation: (3) a systematic, unified, consistent education of the public in the scientific basis and the principles of procedures of public health.”

Research was needed that was unbiased; results should be checked by impartial observers “who have no special cause to serve, no preconceived theory to support.” “Administrative teamplay is essential,” especially as it pertained to public health education.  Teamplay in research, in administration and in education, could be approached from the center to the periphery or from local communities to the nation. Perhaps both kinds of effort might be made at the same time.

Vincent saw no problem in sketching out on paper what form a national organization might take. It would “naturally include…an American Public Health Association which should aim at organizing on a national scale a maximum constituency of individuals interested in the promotion of public health.” Local chapters and state societies would form part of the whole. Special groups would form sections to deal with special issues: tuberculosis, child welfare, venereal diseases, public health administration, etc. In this connection, “the peace plans of the American Red Cross ought to be considered.” The Red Cross had grown from some 17,000 members in 1914 to over 20 million by the end of the war. Vincent thought it conceivable that the Red Cross might be “willing to make an annual appropriation toward the budget of a national public health association” or it might itself “directly undertake to affiliate and coordinate the various public health agencies.”

Vincent added one further argument in favor of the voluntary agencies moving in the direction he had outlined. If they did not, “they will be in no position to bring to bear upon the Federal government pressure for the creation of a federal department of health with a secretary of health in the cabinet of the President.”

Farrand, as the newly established head of the ARC, used his speech to the Conference of State and Provincial Boards of Health in June 1919 to clarify the position of the ARC in such an undertaking. He made it clear that the Red Cross was not intending to try to take over the responsibility of public health and disease prevention in America. That job “in the last analysis (is) a public and an official responsibility.” As regards the voluntary movement, “it would be folly for the Red Cross… to attempt in any way to absorb these independent movements that have grown up in past years.” He was willing to talk about coordination and education, because “as everyone knows, the public health campaign rests in the last instance upon the education of the people.” He also indicated the Red Cross’ willingness to finance the training of more public health nurses and visiting nurses, citing this “as one of the greatest deficiencies at the moment,” but with the expectation that in time this “and other phases of public health activity will be assumed by the public health authorities.”

With the ARC making its position clear and other voluntary organizations expressing a reluctance to give up their independence, the voluntary movement entered a phase where the main point of agreement was a willingness to coordinate their respective activities. Following the lead of the ARC, the APHA and NTA, along with 7 other voluntary organizations, the National Health Council was created; it opened its office in New York City on 1 January 1921 with Farrand as president. Farrand stayed for only a short period of time in this post, resigning in October to become president of Cornell University. However, even after having left the Council, he still attempted to obtain financial aid for the Council. In November 1921, for example, he paid a call on Vincent where he indicated that only $16,000 out of $39,000 for the budget for 1922 was “in sight.” The Red Cross promised an annual contribution but the help of the foundations was needed to get the Council through a “transition period.” The foundation ended up contributing $25,000 towards general expenses for the period 1922 to 1924.

It is at this point that Gunn began to explore with Rose the possibility of moving back to America because of the fragile health of both his wife and daughter. We first learn about these in a letter in August 1921 in which Gunn informed Rose that he had been offered the “directorship” of the American Red Cross health services at a salary of 7,500$. In a letter to Winslow a short time afterwards, he wrote that the offer placed him “in a difficult mental situation.” He wanted to accept but did not see how he could leave his current situation until 1922. He was worried that this would leave him with too short a time in Prague and concluded in a somewhat resigned manner: “I imagine that it means that I shall stay on here.” He did not add that his wife had cabled him to advise consideration of the ARC offer.

At the same time, however, Gunn expressed the opinion that he did not feel that he wanted “to make my entire career in Europe,” adding “far from it. I have written Rose to this effect and I hope that in a year from now something else may turn up at home which will suit me.” For the moment, he felt “a moral obligation … to see this job well started.” Six weeks later he indicated that it “was with regret” that he had refused the offer from the ARC, adding, “this does not mean that I wish to become once again a European.”

Winslow kept Gunn informed of the situation regarding the American Red Cross. Late in 1921 he noted that “the public health idea has taken hold much less deeply then I had supposed was the case and I am inclined to believe that Mr. Wells and I representing the League (LRCS) may really be able to influence the situation in an important degree.” But this would require that “the right man was in charge,” leading Winslow to conclude: “I wish you were on the job, but of course I appreciate most fully the motives which led you to want to finish up the work in Prague.”

By May 1922 Winslow was reporting “the Red Cross in Washington had been absolutely dead so far as health work is concerned.” Its head, Judge Payne, (Farrand’s successor) had set up an advisory committee on health on which Winslow sat but no meetings had been called as yet. In the same letter to Gunn, Winslow also reported that the attempt to develop the APHA as a “big propaganda organization has definitely failed.” It would now return to being “a professional organization of sanitary experts, leaving the field open for the National Health Council to mobilize “public sentiment.”

Even after he had indicated that he was not available, Gunn continued to be pressed to take the job with the ARC. They were willing to wait until July, even October, 1922. Those urging him to take the job indicated that it would provide him with an “opportunity for your leading important health program throughout country” as well as automatically making him a member of “important boards.” But by then Gunn had made up his mind. Even Rose informing him that he had told the ARC that he regarded Gunn as “the best man they could get to undertake” the job, did not alter Gunn’s mind. Rose went on to add, “as far as we can see we should like to continue you in Europe for some time to come.”

Perhaps Gunn knew more about the situation of the ARC than Winslow and Rose. From his many contacts with the ARC in Europe, he may have learned how committed they were to cutting down their programs. Bicknell was in Paris when Farrand’s resignation was announced (an event he considered at the time to be “extremely inopportune”). Later he described the arrival of Farrand’s replacement, Payne, as follows:

The appointment of Payne was a surprise to everyone in the Red Cross organization as he had never in any way been associated in Red Cross work and at the time he was appointed had little knowledge of the organization… He found himself confronted with a tremendous, and what would have been to another, a disagreeable task … Retrenchment and economy were two of his fixed principles and now he had the opportunity to enforce them … Judge Payne came in, just in time to deflate the Red Cross. (Bicknell, p449)

In May 1922 Gunn wrote Winslow that he was “not permanently wedded to work in Europe.” He envisaged eventually returning to the States, “preferably to a teaching position.” Thus encouraged, Winslow informed him that the Milbank Foundation was starting a “gigantic Framingham demonstration in New York” suggesting that he might be “interested if he returned in the fall.”

The Framingham project was a major effort in Massachusetts that had been initiated in 1916 to demonstrate the impact of anti-tuberculosis measures on mortality and morbidity. Already by 1919 (September 12) the New York Times had headlined this project with the title “Death Rare Cut in HealthTown.” By April 9, 1922 results were so favorable that Farrand was quoted as saying: “An analysis of the results of the Framingham health and tuberculosis demonstration makes it one of the most impressive facts of recent years. If a demonstration covering a number of typical units of population aggregating several hundred thousand could be carried on for a few years, and should, as I believe it would, secure results comparable with those of Framingham, the effect would be so striking as to force every municipality in the United States to appropriate sufficient money to secure the absolute and speedy control of tuberculosis.” Winslow’s letter referred to the Milbank Foundation’s announcement on May 12, 1922 that it would seek three areas in New York State to undertake a similar project.

Despite the favorable results and publicity, it does not seem that Gunn reacted to that suggestion.

Towards the end of 1922 Gunn’s name came up in one of the regular retreats organized by Vincent to explore outstanding issues with his senior staff. The question under discussion was the possibility of the New York Academy of Medicine serving as a kind of facilitator for “graduate instruction and medical extension.” If such a program did develop, Gunn serving as its full time secretary would be “most helpful.” This history, too, suggests that Gunn may not have been fully honest in his communication with Winslow or perhaps he was not aware that his superiors were considering futures for him that might bring him back to America.

Gunn’s apparently firm wish to stay in Europe for the immediate future did not prevent him from receiving other job offers. In late 1922 he reported to Winslow about an offer that he had received for “an important position with the new Child Health Association” to which he expressed interest but regrets. The American Child Health Association aimed to improve health education largely by making it an integral part of schooling. Like Gunn’s work in France, it encouraged imaginative and original approaches in spreading the health message.

In June 1923 Gunn indicated to Winslow that he had decided against a position with the Committee on Municipal Health Department Practice, an APHA-led program that was deeply involved in promoting health center demonstrations. And finally, in February 1924, he wrote that he had turned down the position of Director of the National Health Council! His work in Europe was “constantly developing and it would be extremely difficult for me to give it up at the present time,” concluding “the development of modern public health work conditions in Europe are most promising, and I for one am not as pessimistic with regard to the general political situation as many of my friends.” No doubt Gunn was fully aware that the Council had failed to develop as hoped for. As noted by one of its leaders, it “ran out of steam.” Its’ budget for 1924 was a mere $8,000. None of its member groups had turned over any of their activities. Attempts to revive Vincent’s original vision of bringing together “a definite body of scientific knowledge, medical, statistical, and sociological” continued to fail. Not until 1941,
as discussed later, with the return of Gunn to America, would there be another serious effort to revive it.

Gunn’s reluctance to accept any position in America may also have been influenced by a number of trends – the increasing conservatism of America’s public and private leaders, including the medical profession, and (despite that) the acceptance on the part of public health leaders that a medical degree was a prerequisite for someone seeking a career in public health (as opposed to one of its constituent disciplines – nursing, sanitation, laboratory technician).

The conservative shift made itself evident in various ways. One issue that was always present, especially among those concerned with the prevention of tuberculosis, was the importance to be given to the social determinants of this disease. As reflected in their response to Gunn’s questionnaire, in 1913 the NTA gave top priority to improving of housing and working conditions. But this was for government to develop. As Farrand had noted in 1908, the major purpose of the voluntary tuberculosis movement in America was to arouse government to its responsibilities. This did not keep the NTA from initiating its own programs especially in the field of public education and extension services of all kinds. Even relief for patients and families was on the agenda developed by Folks before his departure for France, but at the lowest level of priority.

With the selection of Charles J. Hatfield to replace Farrand in 1917 the “social” approach to tuberculosis lost ground. In keeping with the changing times, he feared that any emphasis on the social would alienate physicians. This did not prevent social workers calling for housing control, relief programs and health insurance when given the opportunity at the NTA annual meetings. But these received less and less attention as Hatfield asserted the medical nature of the Association. While those who advocated a social approach to public health never openly split with their more medically-inclined colleagues, the trend was clear – downgrade the social in favor of well-defined medical interventions.