There is a lot of talk during the current pandemic about healthcare and hospitals. All during the political campaigns of let last dozen or so years, we have argued and fought over how we should manage and administer healthcare in our country. Lots of ink has been spilled on the merits and problems of public versus private medicine. Few people really consider how we got to the place that we are and why the “American Experience” of healthcare is so from other nations. A lot of the stigma for “public medicine” and the reverence for private practice comes from the history of how this profession developed very differently in America than in Europe.
The first hospital in America was constructed in 1503-1508 by order of Nicolas de Ovando, Spanish soldier, knight, and Governor of the Indies. Only a few years had passed since Columbus was removed from governorship of the island in chains, accused of gross abuses of power.
Although this first hospital was founded under his rule, Ovando was no gentle ruler. He is remembered for his ruthless and violent suppression of native uprisings, and for forcing those who survived into a kind of indentured servitude. Patients at the Saint Nicholas hospital received treatments principally so that they could return to military service or complete their indenture. It was not a kind place.
In the British Colonies, hospitals in the United States emerged from institutions, notably almshouses, that provided care and custody for the ailing poor. Rooted in this tradition of charity, the public hospital traces its ancestry to the development of cities and community efforts to shelter and care for the chronically ill, deprived, and disabled. The almshouses did not focus on medical care, and served the public good principally by getting the homeless and mentally ill off the streets.
A six-bed ward founded in 1736 in the New York City Almshouse became, over the course of a century and more, Bellevue Hospital. Similarly, Charity Hospital was established in French New Orleans in 1736, from a grant from Jean Louis, a French shipbuilder, and sailor, who had died a year before. According to his will, he was to finance the building of a hospital in New Orleans from his estate. The hospital was initially named the Hospital of Saint John. These are our first PUBLIC hospitals.
In contrast, the Pennsylvania Hospital in the city of Philadelphia was founded in 1751, by Benjamin Franklin and Dr. Thomas Bond. Originally founded with the aim of receiving and curing the sick free of charge, this hospital’s main focus was teaching physicians. The Philadelphia Hospital offered space for those with curable maladies who were unable to afford care privately but this was also a vehicle to ensure that medical students had a variety of patients to practice on. About thirty percent of the beds were also devoted to the insane, but these patients were confined to the basement without any real medical care. Colonial Americans commonly believed insanity to be a demonic affliction brought on by an “evil visitation.” The insane were seen as incurable, subhuman creatures doomed to a life in shackles and chains at a poor house or squalid jail cell for the mad.
Colonial physicians served as important medical and intellectual authorities in frontier communities. Yet they were businessmen, too. Paying for medical care was an expense that could be afforded primarily by members of the growing professional class. The ledger of James Lloyd, a Boston doctor from the 1770’s, shows patients who were merchants, lawyers, a wine cooper, chair maker, cabinet maker, rope maker, shop keeper, painter, sail maker, and baker. Most of these patients could afford to pay Lloyd in cash, and did so that they could avoid being referred to the hospitals where the mortality rate was often as high as fifteen percent.
While hospitals in Colonial America treated an economically and racially diverse range of patients, private physicians primarily focused on the elite. For example, David Townsend attended to the medical needs of Massachusetts governor John Hancock, his family, and his “servant,” Eunice. For a fee of two dollars, he also assisted with the labor of Sappho Henshaw, a “black girl.” While such care may appear to indicate equivalent treatment of white and black patients, one should remain attentive to the larger social context, in which people of color were frequently enslaved. Those who paid for medical treatment for servants or enslaved people may have done so out of economic self-interest.
This dichotomy of care will continue to expand as the medicine matures into its current form. Patients with the means to care for themselves will receive the best care. Patients whose economic value is deemed important enough will be granted care either by a patron or, as in modern times, insurance. Those who cannot afford care, or who have conditions that the society choses to castigate on “moral grounds” will be ushered into the public institutions where they will be treated like livestock and used to train and educate future physicians. If we ever want to have a better system, we must change these assumptions.