The many functions of the Department of Health and Mental Hygiene began separately and developed at different rates, according to the State's recognition of a need to safeguard public health, the perceived urgency of that need, the potential for scientific solutions, and later, federal mandates for funding. Baltimore City usually led the way, due to the caliber of the City's medical professionals and the acuteness of urban health problems. Also, the growth of Baltimore City was parallelled by the accumulation of immense fortunes, and philanthropists often intervened to meet the urgent needs of sick, poor and insane citizens before the State assumed these responsibilities.
Health in colonial Maryland was precarious, but if a settler survived exposure to various malarial fevers, the settler was likely to be healthier than his European counterpart due to better diet, less crowding, and a cleaner environment. Epidemic diseases flourished in the squalidness of some European cities where they had become endemic and, with the growth of Atlantic seaports, Americans began to suffer too. Citizens of seaports, Philadelphia and Charleston especially, were ravaged by recurring epidemics of smallpox and yellow fever in the eighteenth century, while diphtheria decimated the children of New England. Maryland was not free from the dreaded diseases, as evidenced by the legislative record showing the General Assembly either did not meet (1747) or convened in Baltimore (1757) due to the report of smallpox in Annapolis. As Baltimore port grew in prominence, so too did the threat of epidemics increase. Little was known about the source or treatment of the diseases, but clearly they arrived by ship.
The Role of Baltimore City. Epidemics played a role in the formation of public health agencies in Maryland. The first health office in the State was created in Baltimore to cope with yellow fever epidemics beginning in 1792 (Chapter 56, Acts of 1793), and in 1797, after Baltimore was incorporated as a city, the State's first local health department came into being. Baltimore physicians had ample opportunity to study yellow fever, since more than a century would elapse before the mosquito was identified as the carrying culprit. Baltimore doctors, however, were among the first to vaccinate for smallpox, and by 1802 had set up their own Institute to vaccinate the poor free of charge, a duty later assumed by the City Health Department. In 1809, the General Assembly authorized a lottery to support the Vaccine Institute, but did not create the State Vaccine Agency, the first statewide health agency, until 1864 (Chapter 269, Acts of 1864).
The Baltimore City Health Department performed many tasks before 1850: inspecting and quarantining ships, transporting paupers to the almshouse, burying paupers, cleaning streets, removing snow and ice, and vaccinating the public against smallpox. The Department kept mortality tables showing age and cause of death; ran a hospital for contagious diseases to which sufferers could be forcibly removed; abated nuisances, such as stagnant ponds; and maintained public fountains and sewers. In 1875, it began registering births and deaths, functions the State, despite repeated efforts, did not perform adequately until 1898.
Department of Health. The first impetus for State involvement in the health of Maryland citizens came from a group of physicians, mostly from Baltimore, who were chartered in 1798 by the General Assembly as the Medical and Chirurgical Faculty of Maryland (Chapter 105, Acts of 1798). Their initial concern was to diffuse medical knowledge and protect Marylanders from ignorant medical practitioners and quacks, who abounded in the absence of an adequate supply of trained doctors. The law authorized the Faculty to license doctors. The Faculty was instrumental in founding the first medical school in the State in 1807 and, even after the Faculty lost its licensing power, it often petitioned the legislature for improvements in health care facilities and regulation.
Maryland created a State board of health in 1874, the sixth state to do so (Chapter 200, Acts of 1874). Overcoming rumors of the purported unhealthiness of certain areas of the State was seen as a necessary boon for immigration, and accurate data was required for that purpose. At first, the State Board of Health was primarily an advisory body with no regulatory authority. In 1876, the Board reported that it had surveyed physicians throughout the State regarding health concerns, investigated nuisances in mining towns, analyzed public drinking water in Baltimore City, and examined conditions in county jails and almshouses. The Board additionally had lectured to citizens on public hygiene, collected information on the prevalence of malarial diseases, investigated a smallpox epidemic in Cumberland, and evaluated the deleterious effects of Jones Falls and the Basin on health in Baltimore City. The Board lamented the lack of any local health structure, which made it difficult to acquire information about public health. Also, although towns might call in the Board when health problems arose, the Board had no authority to mitigate nuisances. The Board's report showed that the only two significant public health laws on the books were failing dismally. The first had created the State Vaccine Agency, and required smallpox vaccination prior to enrollment in school (Chapter 269, Acts of 1864). Doctors were supposed to vaccinate infants and other patients in their practice, and the law provided for vaccination of those unable to pay. The smallpox epidemic in Cumberland, however, made it clear that vaccination was not widespread in 1876. The second was the long-advocated law for registration of births, deaths, and marriages, which were to be reported to the Secretary of the Senate by the clerks of court (Chapter 130, Acts of 1865). Vital statistics were a major concern of the new State Board of Health in 1876 since few statistics had been forthcoming under the 1865 law.
In 1880, the State Board was reorganized, empowered to establish local boards and deal with emergencies. The Secretary of the Board acquired the additional title of Superintendent of Vital Statistics. Beginning in 1894, Baltimore City physicians from the Johns Hopkins Hospital led a public health movement calling for sanitary conditions in food processing from "stable to table." They worked for laws to pasteurize milk, assure pure food, and prevent the ancient scourge of tuberculosis. The State Board of Health benefited from this public interest, and in 1910 was reformed as the State Department of Health, overseeing five bureaus with clearly defined duties: Bureau of Communicable Diseases; Bureau of Bacteriology; Bureau of Chemistry; Bureau of Sanitary Engineering; and Bureau of Vital Statistics (Chapter 560, Acts of 1910).
In 1939, the Medical and Chirurgical Faculty urged the State Planning Commission to look into the availability of health care for the poor. The specter of socialized medicine loomed, and physicians were interested in developing an alternative plan. The General Assembly enacted a law in 1945 to provide health services to the indigent and medically indigent of the counties and later extended the plan to Baltimore City. The 1945 law also authorized the Department of Health to operate State-owned hospitals for persons with chronic diseases (Chapter 91, Acts of 1945).
Department of Mental Health. Maryland had assumed some responsibility for the fate of its insane by 1797 when the Maryland Hospital in Baltimore City was established as "a hospital for the relief of indigent sick persons, and for the reception and care of lunatics" (Chapter 102, Acts of 1797). Care and custody of the mentally ill suffered from the prevailing belief that insanity was not curable. Families kept their insane members at home; those who were violent could be locked up in the local jail or almshouse. The legislature perpetually was besieged with petitions for relief, and many private acts authorized a county to levy a minimal amount to support an insane or feeble-minded individual at home. Early in the nineteenth century, the so-called "moral" method for the care of the insane came into vogue, and physicians claimed that early treatment by that method made insanity more curable than most diseases. The Maryland Hospital seems to have used the method. In 1817 the county levy courts were authorized to commit their insane to the Maryland Hospital upon payment by the county of $100 per year (Chapter 78, Acts of 1817). Since it was cheaper to keep the mentally ill chained in the county almshouse with no care at all, probably the most difficult cases, those least susceptible to a cure, were sent to the Maryland Hospital. It became primarily a hospital for the insane in 1838 though it lacked sufficient space.
Dorothea Dix, outspoken advocate for the mentally ill, pointed out in her 1852 address to the Maryland legislature that the 1850 census showed 946 insane and idiot inhabitants of the State. Of these, 133 were in the Maryland Hospital, 74 in Mount Hope Hospital, 123 in the Baltimore Almshouse, and 8 in the Maryland Penitentiary, leaving 598 either in private homes, county jails, or almshouses. Only those in the Maryland or Mount Hope Hospitals were undergoing curative treatment. The General Assembly did appropriate funds that year for a new hospital for the insane with capacity for 200 to 250 patients (Chapter 302, Acts of 1852), but by 1872 it was still under construction. Even when patients from the old Maryland Hospital were moved into the new hospital, the State needed additional accommodations and in 1894 began the Second Hospital for the Insane of the State of Maryland (Chapter 231, Acts of 1894).
For most of the nineteenth century, feeble-minded, idiotic and alcoholic citizens often shared the fate of the insane, locked in local jails or almshouses. The Board of Directors for the Maryland Inebriate Asylum reported in 1864 that they were still without a building but some inebriated persons were being treated in a lunatic asylum (Maryland Documents A, 1865). In 1883, the Medical and Chirurgical Faculty petitioned the legislature on behalf of the feeble-minded, and, in 1888, the Asylum and Training School for the Feeble-Minded was authorized (Chapter 183, Acts of 1888).
At the turn of the century, the private sector was ahead of the State in providing space for the mentally ill, and county jails and almshouses served as a last resort. To safeguard legal rights and protect against abuses, the legislature created the Lunacy Commission in 1886 (Chapter 487, Acts of 1886). The Commission was mandated to visit and inspect all places, public or private, where insane persons were kept. Duties of the Commission were transferred to a Board of Mental Hygiene in 1922, and the State's five mental institutions were placed under the Department of Welfare (Chapter 29, Acts of 1922). Wartime austerity cut back spending on State institutions, and public concern after the war about treatment of the mentally ill led to creation of the Department of Mental Hygiene in 1949 (Chapter 685, Acts of 1949). The Department was charged to administer the State's mental institutions, coordinate State psychiatric research, and oversee education and training of personnel working in mental institutions.
State Board of Health and Mental Hygiene. Mental health and public health functions became officially entwined in 1961 under the new State Board of Health and Mental Hygiene which assumed responsibility for the health interests of Marylanders; State facilities for care of the chronically ill, mentally ill, mentally retarded, and tuberculous persons; and the medical care program for the indigent and medically indigent. The two departments, Health and Mental Hygiene, continued to administer programs and facilities as directed by the new Board (Chapter 841, Acts of 1961).
Department of Health and Mental Hygiene. Through executive reorganization in 1969, the Board and the two departments were superseded by the Department of Health and Mental Hygiene, which encompassed not only the programs and facilities inherited from its two predecessors, but also all the medical professional licensing boards, the Comprehensive Health Planning Agency, the Commission on Physical Fitness, the Advisory Board on Hospital Licensing, the Advisory Council on Hospital Construction, the Radiation Control Advisory Board, the Air Pollution Control Council, the Air Quality Control Council, and the Juvenile Services Administration (Chapter 77, Acts of 1969). Boards and councils relating to radiation and air quality, as well as environmental health programs, were transferred to the Department of the Environment in 1987; the Juvenile Services Administration became an independent agency in 1987 and an executive department in 1988.
The Department of Health and Mental Hygiene has evolved into a complex agency which continues to protect the physical, mental and social health of Marylanders. Through a comprehensive and accessible system of health services, the Department promotes health and prevents disease and disability.
Many health care programs are, by their nature, public functions and cannot be performed effectively by the private sector. Prime among these is the responsibility for dealing with epidemiological hazards to health, such as communicable diseases, and the organization of community efforts to prevent or control their impact.
Local health departments are the focal point in the delivery of services. Overseen by the Department of Health and Mental Hygiene, twenty-four local health departments report to the Deputy Secretary for Public Health Services and have access to all Department officials as well.
The Department also provides or purchases direct care services. These primarily include residential and outpatient care for the mentally ill; the mentally retarded; the chronically ill, including those with tuberculosis; the impaired elderly; and persons with addictive conditions. Several health services for the community as well as comprehensive health care services for the indigent and medically indigent are provided directly by the Department.
July 18, 2000
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