Public Health

The historian Edward H. Beardsley concluded that the story of public health in South Carolina is a “history of neglect.” Indeed, since 1914, when data on vital statistics in South Carolina were first collected, the state’s residents have been significantly less healthy than most Americans. A confluence of poverty, racism, close alliances between government and industry, and adherence to states’ rights and limited government worked to prevent significant improvements in public health throughout much of South Carolina’s history. When improvements finally came, they did so for the most part due to federal largesse and changes in the workplace (air conditioning in textile mills, for example) undertaken largely to increase efficiency (machinery broke down less often and could be run at higher speeds with less humidity).

South Carolina’s doctors enforced medical segregation, ignored occupational health issues, and fought perceived encroachments on private practice by public health officials who offered free or low-cost clinics and vaccinations. Public health officials rarely questioned the legacy of paternalism and social practices that led to ill health among both whites and blacks. Even the state’s few black physicians were slow to challenge medical segregation and second-class care. The advent of the civil rights movement of the 1950s and 1960s pushed most southern black physicians into the battle for health and medical equality, although most did so as followers, not leaders.

Despite the history of neglect, South Carolina’s public health history contains its share of heroic practitioners and public-spirited health officers who fought against great odds to improve the health of their communities. As early as 1796 a Charleston ordinance permitted any one of three commissioners of health to order ships removed, cleaned, aired, and fumigated if deemed dangerous. Residents of the city established quarantine stations shortly after the turn of the nineteenth century and a Board of Health in 1815. Beginning in 1813 a Ladies Benevolent Society provided nursing services for “such persons as suffer under the anguish of disease and penury.” Early public health efforts in Charleston focused on the removal of decomposing animal and vegetable matter that was thought to spread disease. According to popular beliefs that attributed illness to “marsh miasmas,” disturbing the soil led to epidemics of yellow fever and malaria. As late as 1910 critics condemned the city’s health department for digging sewer lines during hot South Carolina summers. Still, under the direction of Dr. John Mercier Green, Charleston built a water-filtering plant, piped clean water into the city from Goose Creek, and inspected food and milk by the 1910s.

The delivery of public health services in the rest of the state was slowed by the dominance of plantation-based agriculture. Large landholders controlled the scope and quality of medical services provided to those in their employ as well as to those held as slaves. Small farmers and their families were left to fend for themselves. As was the case with public schools, statewide public health efforts did not begin until after the Civil War. The General Assembly established a State Board of Health in 1878. From the beginning it was poorly funded and overextended–its four employees were charged with developing and implementing a thorough sanitary program for the state. Early efforts of the State Board of Health included campaigns to encourage smallpox vaccinations, school sanitation, and ventilation.

By the twentieth century working-class whites and blacks had separate profiles of poor health. Due in large part to laws that excluded blacks from most categories of textile work, whites had higher rates of industrial diseases associated with hot, dusty environments, especially byssinosis (“brown lung”). Textile hands also suffered more from hookworm and pellagra than did blacks. African Americans incurred venereal disease and tuberculosis at higher rates than whites, and black maternal and infant mortality rates were among the highest in the nation throughout most of the twentieth century.

Securing state appropriations proved to be an ongoing obstacle to public health efforts. In 1915 the Red Cross agreed to pay the salary of one supervising field nurse, grants from the Rockefeller foundation gave impetus to the establishment of county health departments and initiated efforts to eradicate hookworm, and the U.S. Children’s Bureau sent a physician and a nurse to conduct a survey of infant and child health problems in Orangeburg County. Ruth Dodd, the Children’s Bureau nurse in South Carolina, authored a 1919 report that recommended the establishment of a Bureau of Child Hygiene. The legislature appropriated $10,000 to do so, making Dodd its first director and hiring two additional nurses. The same session of the General Assembly created a Division of Venereal Disease Control.

Between 1922 and 1929 federal funds made available under the Sheppard-Towner Act added a midwife supervisor and a nutritionist to the State Board of Health’s payroll, financed a demonstration unit in child health education, employed four traveling public health nurses, and sponsored midwife training institutes, nutrition camps, and child health conferences. The Federal Maternity Infancy Fund sponsored clinics for diphtheria immunization throughout the state. In counties where there was no health department, public health nurses helped private physicians give the inoculations.

Congress discontinued Sheppard-Towner funding in 1929. Since the South Carolina General Assembly made no appropriations for child health and private donations were not forthcoming during the Great Depression, the Bureau of Child Hygiene was abolished in 1933. According to the State Board of Health, infant and maternal mortality rates and tuberculosis rates increased in South Carolina for the first time since 1915.

Many of South Carolina’s public health programs suffered from a lack of state support, however, well before the onset of the Great Depression. The tuberculosis sanatorium program failed to serve many of those in need throughout the 1920s due to insufficient funding and racism that limited access by African Americans to treatment. By the end of the decade, ninety percent of the 230 patients at the Columbia facility were white. Despite the prevalence of tuberculosis among black children, white youngsters at the sanatorium outnumbered black children by fifty percent. Routinely, blacks waited longer for treatment and when finally hospitalized died at close to four times the rate of whites.

Federal funds for venereal disease control stopped in 1923. Within a year state appropriations ended and programs designed to prevent and treat venereal diseases were shelved. Despite the appeals of public health officers, the General Assembly refused to resume funding venereal disease work. When the State Board of Health presented venereal disease programs again fourteen years later, it was supported with federal funds released as part of the Social Security Act.

South Carolina was seen as a poor risk by Public Health Service officials, who viewed federal dollars as seed money. In addition to recalcitrant politicians, James A. Hayne, who served as the state’s health officer between 1911 and 1944, refused to advocate for programs that would assist blacks disproportionally. Like most of the state’s private physicians and public health officials, Hayne was a South Carolina native who did not question segregation and believed that the state’s embarrassing health record was due to the presence of so many blacks. After Hayne’s retirement, Dr. Hilla Sheriff was able to parlay her position as director of the Division of Maternal and Child Health (between 1941 and 1967) and connections in the U.S. Children’s Bureau into increased funding for pre-natal clinics, well-baby clinics, toxoid distribution, midwife training and supervision, nutrition programs, postgraduate scholarships for physicians in obstetrics and pediatrics, mortality studies, dental clinics for indigent schoolchildren, motion pictures on public health topics, and a rural home project to decrease the likelihood of premature births. Sheriff’s reports emphasized that state services were meant for all citizens: “the aim of the Division is to have every woman under medical care as early in pregnancy as possible and to see that she has a safe delivery in an environment that offers the least risk possible to both mother and baby.” Sheriff made presentations to mixed-race audiences of public health nurses, physicians, and teachers, and the number of clinics in primarily black areas increased under her tenure.

After World War II public health programs expanded to include vision screening, accident prevention, a migrant laborers’ project, PKU (phenylketonuria) testing for all infants born in hospitals, child abuse prevention programs, school nurses, and statewide family planning services. Still, much of the increased work was paid for with federal funds. In relatively prosperous times and with infant and maternal mortality rates still well above national averages, the State Board of Health’s budget increased by just over $500,000 between 1950 and 1960 (from $3,355,115.52 to $3,891,503.75). Federal grants for venereal disease control and hospital construction and improvement, however, totaled more than $3.5 million– almost as much as the Board of Health’s entire annual budget.

In 1968 public health services provided by county health departments were consolidated into thirteen statewide health districts. Both Sheriff and the new state health officer Kenneth Aycock had experience as county health officers and understood that programs dependent on federal funds could be more efficiently administered at a district level by a generation of public health officials less opposed to integrated programs and facilities. The establishment of state health districts motivated some veteran county health officers to retire and hastened South Carolina’s dismantling of segregated public health and medical services.

Calls for limited government still prevailed in South Carolina, and public medicine remained suspect at the start of the twenty-first century. Despite significant improvements in the past thirty years, South Carolinians compared poorly to residents of other states in most health categories–a legacy of the state’s history of neglecting the health care needs of those unable to afford or without access to private physicians.

Banov, Leon. A Quarter Century of Public Health in Charleston, South Carolina. Charleston, S.C.: Charleston County Department of Health, [1945?].

Beardsley, Edward H. A History of Neglect: Health Care for Blacks and Mill Workers in the Twentieth-Century South. Knoxville: University of Tennessee Press, 1987.

Free, Mary Louise. “History and Development of Services to Mothers and Children in South Carolina.” Typescript in Hilla Sheriff Papers, South Caroliniana Library, University of South Carolina, Columbia.

Hill, Patricia Evridge. “Hilla Sheriff (1903–1988).” In Doctors, Nurses, and Medical Practitioners: A Bio-Bibliographical Sourcebook, edited by Lois N. Magner. Westport, Conn.: Greenwood, 1997.

Sheriff, Hilla. Papers. South Caroliniana Library, University of South Carolina, Columbia.