Wednesday, September 3, 2014

Suffrage and Immunizations – Major Public Health Tools

North Dakota has been dramatically changed by the oil boom in the state’s Williston Basin. The influx of people to work in the Bakken oil fields has generated numerous social, economic, and public health issues.  While environmental concerns, violence, prostitution, housing shortages, and railroad safety have garnered most of the attention, it is the potential disruption of a core public heath function that prompted the North Dakota Department of Health to ask for help from the Centers for Disease Control and Prevention (CDC) and the Association of State and Territorial Health Officials (ASTHO). The issue? How to keep track of the immunization status of the thousands of people moving to North Dakota from all over the country.
To address this issue, experts in immunization registries and health informatics and immunization program staff from state health departments in the five states from which most oil workers emigrate came together last week in Minneapolis. The focus was how, within federal and state programmatic and legal frameworks, to share immunization information between state immunization programs. As the health commissioner in one of those states, I was invited to attend.
I have long-believed that immunization programs are a prototype for our health care system. If the public and private sectors can collaborate to get the right vaccines into the right people at the right time in a high quality and affordable way and can track and monitor the effectiveness of those efforts, we would have a model for the rest of our health care system.  The presentations and discussions at the Immunization Information Systems meeting reinforced that opinion. 
Yet, that was not the main lesson I learned from the meeting. Given that this meeting was held on August 26, the anniversary of the enactment of the 19th amendment to the U. S. Constitution, what struck me was the impact that an engaged, passionate, and organized constituency of nearly a century ago was still having on the health and wellbeing of today’s society. Without the 19th Amendment, our immunization discussion would most likely have been much different.
The 19th amendment, which gave women the right to vote, was the result of decades of effort by dedicated individuals and organizations committed to empowering women to have equal rights in shaping the future of our country.  Women’s suffrage didn’t come easy but, when achieved, made a significant difference in all aspects of society.  To me, enactment of the 19th amendment in 1920 was the greatest public health achievement of the 20th century. 
With women having the right to vote, elected officials recognized the need to address the issues important to women. High on that list of concerns was the heath of mothers and children. In response, congress passed the Sheppard-Towner act in 1921 with the goal of reducing maternal and infant mortality. The Maternity and Infancy (Sheppard-Towner) Act (PL 67-97) created a state/federal partnership around public health that continues to the present. It established the first public grants-in-aid program in the U.S., which led to the development of full-time Maternal and Child Health (MCH) programs in every state health department and provided training and support for public health nurses. In addition, recognizing the need for data to support research and program evaluation, the Act expanded Birth Registration/Vital Records systems to all states.
[As an aside, the Sheppard-Towner Act was opposed by the American Medical Association, which led some members to establish a new physician organization, the American Academy of Pediatrics. There was also discussion about who should be responsible for implementing the Act. The decision was to make it part of the Children’s Bureau, which was in the Department of Labor rather than in the Public Health Service.  Perhaps this was the beginning of a Health in All Policies perspective and a new narrative about what creates health.]
Although the Sheppard-Towner Act was repealed in 1929 because it was considered too “socialist,” it was the model for Title V of the 1935 Social Security Act, which continues to influence public health today. Without the existence of the federal/state partnerships, state MCH programs, and an accurate vital records system developed through the Sheppard-Towner Act, MCH activities and the immunization delivery and tracking systems of today would be much different. We can thank the Suffragettes for their influence on today’s immunization and public health system. 
As a post script:  Women’s Equality Day is celebrated each year on August 26, the anniversary of the enactment of the 19th Amendment. Although women have made great progress toward equality since 1920, major inequities remain. Similarly, even though all adult citizens theoretically were able to vote after 1920, it took the Voting Rights Act of 1965 to enforce the voting rights guaranteed by the 14th and 15th amendments and ensure the enfranchisement of racial minorities throughout the country. Despite all these laws, there are still efforts to limit the advancement of women and access to voting. Voting is a powerful public health tool because it helps shape public policies that profoundly influence our health. Along with all of our other Health in All Policies activities, empowering people to vote should be part of our Advancing Health Equity efforts.
Ed