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Martha May Eliot
PROFILES IN PEDIATRICS II
This profile of Martha Eliot honors a pediatrician whose career influenced children and pediatrics in a different way from the others in the series. As so well described by Dr. Lesser, her career options were shaped in large part (perhaps completely) by the sociologic pattern prevalent at the time. The "subspecialty" that she turned into a major force for children is the field of preventive-administrativegovernmental pediatrics. The scope of her contribution has particular significance as we enter what promises to be the next era of support for children's health issues at the federal level, As much as any in our series of outstanding pediatricians, she led the way to a new plateau of concepts and new ways of doing things for children's health.--Laurence Finberg, MD, Guest Editor
Martha M a y Eliot W r i t i n g biographic notes a b o u t someone who was born 100 years ago provides an impressive view of the striking changes in A m e r i c a n society and culture t h a t have taken place in this century. T h e career of M a r t h a M a y Eliot ( 1 8 9 1 - 1 9 7 8 ) is characteristic of the experiences of m a n y women whose a m b i t i o n was to enter professional or public life. Dr. Eliot was a d e s c e n d a n t of two distinguished New England families, Eliot and May. A seventeenth-century ancestor t r a n s l a t e d the Old T e s t a m e n t into the Algonquian Indian language; a n o t h e r was president of H a r v a r d University; her g r a n d f a t h e r was a founder of W a s h i n g t o n University, in St. Louis, Mo.; and a c o n t e m p o r a r y cousin won the Nobel prize for literature. Because H a r v a r d Medical School did not accept women, Dr. Eliot studied medicine at Johns Hopkins, in Baltimore, Md. However, she was not accepted as an intern at the H a r r i e t L a n e H o m e because J o h n H o w l a n d believed t h a t women would m a r r y and not continue to be pediatricians. In her H o w l a n d A w a r d Address in 1967, Dr. Eliot said of her rejection: This was just as well--for my lines lay in different directions, and I was forced to reach out at once to what to me were basically more appropriate foundations for what I was searching for in pediatrics. It was from the vantage point of my subsequent association with Francis Peabody in Boston, Ned Park and Grover Powers in New Haven that I took off in 1924 to join the staff of the Children's Bureau. It was from Grace Abbott, who was then Chief of the Children's Bureau, that I learned the breadth and depth of the meaning of public responsibility for children and the role that could be played by pediatricians together with social workers in setting high standards of performance for, and in stimulating, supporting and expediting public programs of, child health and child welfare services. 1
THE JOURNAL OF PEDIATRICS 1993;123:162-5.
Copyright 9 1993 by Mosby-Year Book, Inc. 0022-3476/93 $01.00 + .10 9/20/40811 162
Preceding her move to New Haven, Dr. Eliot spent a year at the Peter Bent B r i g h a m Hospital, Boston, Mass., in general medicine and a year at St. Louis Children's Hospital, St. Louis, Mo., with Williams M c K i m M a r r i o t t . In St. Louis, she carried out her interest in child health and preventive health services by devoting part of her time to the city's child health clinics, an interest t h a t continued on her r e t u r n to Boston. W h e n Yale Medical School, N e w Haven, Conn., developed its d e p a r t m e n t of pediatrics (previously a part of the
The Journal of Pediatrics Volume 123, Number 1
department of internal medicine), Edwards Park left Johns Hopkins to become chairman at Yale. He invited Martha Eliot to become a resident at the New Haven Hospital and a member of the Yale faculty, an invitation she accepted on the day the letter arrived. She later commented that her years in New Haven were among the happiest of her life. While at Johns Hopkins, Edwards A. Park demonstrated that rickets in rats could be prevented by cod liver oil. In 1923 the U.S. Children's Bureau asked Park to carry out a community-wide demonstration in New Haven to determine the effectiveness of cod liver oil in the prevention of rickets in children. He asked Martha Eliot whether she was interested, and thus she became a staff member of the Children's Bureau and designed and carried out the study. The study was significant not only because the effectiveness of cod liver oil was demonstrated but also because the study included control groups of children and because public health nurses of the New Haven city health department participated, visiting homes of the study children and demonstrating to their mothers, among other things, how to give cod liver oil. 2 The statute establishing the Children's Bureau in 1912 authorized the Bureau to "investigate and report upon all matters pertaining to the welfare of children and child life among all classes of our people." This was the first recognition that the federal government has a responsibility to promote the welfare of the nation's children. The studies of infant and maternal deaths showing the relationship of social and economic factors to the causes of death provided the Bureau with the basis for proposing and justifying a grants-in-aid program to assist state agencies in establishing and improving services to promote the health of mothers and children. The Sheppard-Towner Act, passed in 1921, was the first continuing federal-state grants-in-aid program for health services. Its primary effect was educational. Many people came to understand for the first time the help they could receive through prenatal and well baby clinics, from home visits by public health nurses, and from the systematic programs designed to teach the principles of good maternity care to the large numbers of untrained midwives then practicing in many states. 3 The 1912 statute and the Sheppard-Towner Act were not enacted without sharp controversy that included nasty and bigoted expressions of opposition, perhaps characteristic of the period. During the Congressional debate, a Mr. Reed, of Missouri, said of the Children's Bureau, "It seems to be the established doctrine of this bureau that the only people capable of caring for babies and mothers of babies are ladies who have never had babies [laughter]. ''4 After listing the names of Bureau staff, all preceded by "Miss," he said: At the very threshold therefore we are confronted by the remarkable and amusing fact that we are asked to turn over questions of
Pediatric profile--.Eliot
16 3
infant bearing and infant care to an aggregation composed almost exclusivelyof spinsters. . . . I repeat, I cast no reflection on unmarried ladies, Perhaps some of them are too good to have husbands.4 The Illinois Medical Journal had this to say: This bill is a menace and represents another piece of destructive legislationsponsored by endocrine perverts, derailed menopausics and a lot of other men and women who have been bitten by that fatal parasite Upliftusputrifaciens, all of whom are workingovertime to devise means to destroy the country.~ Women also opposed the extension of the SheppardTowner Act. The Woman Patriot stated: "Children are now the best political graft in America. They furnish the best possible screen behind which to hide cold-blooded calculated socialist feminist political schemes to raid the United States Treasury to supply new fat jobs. ''6 Although there was strong support as well, particularly among citizens' groups, pediatricians, social workers, and other professionals, authorization for the Sheppard-Towner Act was not renewed in 1929. The congressional hearings on extending the authorization of the Sheppard-Towner Act provided Dr. Eliot with an introduction to the hearings on the Social Security Act and other challenges to come, challenges that she usually met head-on. She occasionally recalled these experiences, not emotionally, but objectively, as though one must expect them in public life. By now a full-time staff member of the Children's Bureau in Washington, she was devoting most of her time to working with state committees on children and youth and with other citizens and professional groups in preparation for the 1930 White House Conference on Children and Youth. The conference was called by President Herbert Hoover "to study the present status of the health and well-being of the children of the United States and its possessions, to report what is being done, to recommend what ought to be done and how to do it." Particularly impressive about this conference were the large number of participants and the nationwide collection of factual information about children and youth, gathered well in advance, that enabled the conference to carry out the President's stated objectives. Its final reports were included in 32 volumes of facts and recommendations. The timing of the conference could not have been better; its reports provided the necessary background information and support for President Franklin D. Roosevelt's proposed Social Security Act, of which Title V authorized grants-in-aid to states for maternal and child health programs, services for crippled children, and child welfare services.* Dr. Eliot, now the associate chief of the U.S. Children's Bureau, wrote the statutory language for the crippled chil*For a discussionof the forces that led to the enactment of Title V of the Social Security Act, see Lesser AJ. The origin and development of maternal and child health programs in the United States. Am J Public Health 1985;75:590-8.
16 4
Pediatric profile
Eliot
dren's program, and it is a model of comprehensiveness and clarity. It was original, without any precedents that could have offered guidance. As she interpreted the statute: It required a State's program to include servicesfor findingchildren who are crippled or who are suffering from diseases that lead to crippling and to provide them with medical, surgical, and corrective services and care, and facilities for diagnosis, hospitalization, and aftercare. No partial programs leaving out, for example, adequate diagnostic or follow-upcare were to be approved3 [pp. 13940]. Subsequent policies were basic to medical care administration and included, for example, the requirement that state plans describe their standards of personnel, including those engaged in providing care, and the requirement that diagnostic services be available without charge or a means test. The point of the latter, of course, is that, until a diagnosis is made, it is not possible to estimate the cost of medical care and what treatment is needed. With regard to payment for medical and hospital care, when the parents had insurance or could otherwise be considered able to pay a share of the costs, the Children's Bureau policy required that the decision about payment be made by the state agency that had authorized the care; furthermore, payments to physicians and hospitals were payments in full and additional charges could not be made to the parents. Beginning in 1939, some of the federal funds that did not require matching were reserved for grants for special projects of regional or national significance, enabling the states to develop demonstration programs for children with problems not hitherto included (initially the crippled children's programs were predominantly orthopedic). Project grants also helped to support specialty graduate training in institutions of higher learning for professional personnel. These special projects enabled state agencies to broaden the diagnostic groups, beginning with rheumatic fever programs and neonatal care for premature infants, and then proceeding to congenital heart disease, hearing impairment, and epilepsy. The experience gained in the development of policies for the crippled children's program were useful in 1943, when the wartime Emergency Maternity and Infant Care (EMIC) program was iniated by the U.S. Congress. The purpose of this program was to provide complete maternity care, without charge, for the wives of servicemen in the four lowest pay grades, as well as health supervision and medical care for their infants up to 1 year of age. These services actually started in 1941, when the commanding officer of Fort Lewis, in Washington State, requested help from the state health department in providing care for the increasing number of pregnant wives of enlisted men in the area, exceeding the capacity of the fort hospital. The health department's request for project grant funds was approved by the Children's Bureau, which soon began receiving similar requests
The Journal of Pediatrics July 1993
from other states. By December 1942, twenty-five states initiated such programs and it was clear that a new appropriation was needed. An Act of Congress made the first special appropriation of $1,200,000 available in March 1943, with provision for extension to other states as needed. The enactment of this legislation and the rapid growth of the EMIC program became a matter of great concern to physicians' organizations, particularly the American Medical Association and the American Academy of Pediatrics. First, they were concerned that the Children's Bureau, in its administration of the EMIC program, had established standards of care and fee schedules for payment for care in private practitioners' offices. Second, many physicians believed that the program was a prelude to a postwar national health care program. The American Academy of Pediatrics Executive Board stated: The Academy and the physicians of America have demonstrated in many ways their willingnessto give full support to any measure that will help win the war. It cannot approve, however, of measures established by a governmentbureau which, under the guise of war effort or necessity, arbitrarily control medical practice, and which are in reality plans for the control of postwar medical practice.* Because of the way in which the Children's Bureau has tended to turn away from the purpose for which it was founded,.., we feel the time has come when the Academy and the pediatricians of the U.S. must withdraw their support from the Children's Bureau] The report then recommended that all health care activities be placed in the U.S; Public Health Service. This would have removed Dr. Eliot from the child health care programs of Title V of the Social Security Act. The report concluded with the statement that because "we are a nation at war" the pediatricians are "eager and willing to cooperate to the fullest extent with the EMIC program. ''7 The EMIC program was, however, strongly supported in the Congress and by many citizen's organizations. By the end of the program in 1949, about 1,500,000 maternity patients and infants had received authorization for care. In 1945, 92% of the EMIC babies were born in hospitals, compared with 79% of all births in the United States. Despite criticism and opposition, at the height of the program 48,000 physicians and 5000 hospitals cooperated. 8 Nathan Sinai and Odin Anderson, in their extensive study of the administration of the EMIC program, wrote: EMIC serves as a striking demonstration of joint effort and of administrative resilience. It would be hard to find another wartime *The Academy's worry about plans for a postwar national health program was not groundless. President Harry S Truman sent special messages to the Congress in 1945, 1948, and 1949, recommending compulsory national health insurance. In 1939, Senator Robert Wagner had introduced his proposed National Health Act. Subsequently the Academy renewed its support for the Children's Bureau.
The Journal of Pediatrics Volume 123, Number 1
program that grew to such comparatively huge proportions and still remained within the framework of existing national, state, and local peace time administration. The accomplishments in meeting the problems, disregarding the antagonisms, conflicts, and fears are a monument to the combined contributions of medicine, public health, and the hospitals. 9 The war in Europe and particularly the bombing of London caused much concern in Washington regarding the need for the development of a plan for civil defense in this country. General George C. Marshall appointed a committee that included the surgeon general of the U.S. Public Health Service and the chief of the Children's Bureau to study the situation in England. Katharine Lenroot could not leave the country at this time; Martha Eliot substituted, and the group arrived in London in January 194l. She devoted particular attention to the arrangements for the evacuation of children, with its many complications, and for maternity care and medical care of children. The committee's report provided the basis for civil defense preparations in this country. After the war, Dr. Eliot participated in the work of the United Nations Relief and Rehabilitation Administration ( U N R R A ) and then in the United Nations Children's Fund ( U N I C E F ) , which replaced U N R R A . As vice-chairman of the U.S. delegation, she participated in the first International Health Conference in 1946 and in subsequent activities. The following year she was offered a position with U N I C E F for the purpose of carrying out a study of the needs of children in the war-ruined countries of Europe. She accepted, taking a leave of absence from the U.S. Children's Bureau. Her comprehensive report followed months of travel. Dr. Eliot continued her international work with the World Health Organization until 1951, when she was appointed chief of the U.S. Children's Bureau by President Harry S Truman, replacing Katharine Lenroot, who had retired. She found that the federal government had grown considerably, with the Children's Bureau still a small agency that had become a component of a large department. One of her first activities as chief was to start a juvenile delinquency program with the assistance of the Field Foundation and other voluntary organizations. It was subsequently supported with congressional appropriations. However, General Dwight D. Eisenhower was elected president of the United States in 1952, and the new political era was in sharp contrast to the New Deal programs of the previous 20 years. It has been said that "a true writer can never be other than what he is. But in our imperfect world his living light will shine among men only if it appears at the right time." W h a t is true for writers is true for others as well. Dr. Eliot's appointment as chief could not have come at a worse time for her. President Eisenhower's views of government were similar to those of the preceding generation.
Pediatric profile--Eliot
16 5
It was soon made clear to Dr. Eliot that the President preferred to make his own selection for the position of chief of the Children's Bureau. After a few frustrating years, Dr. Eliot came to the conclusion that the Children's Bureau would be better off without her. She left in 1956 to become professor of maternal and child Health at Harvard. She later continued her activities as chairman of the Massachusetts State Committee on Children and Youth. I would see her on my annual visits to Boston, and she always maintained her interest in the program developments of the Children's Bureau. She died in 1978. Martha Eliot was one of a number of remarkable women who were active in the latter part of the nineteenth and first half of the twentieth century, including Jane Addams, Lilian Wald, Florence Kelley, Julia Lathrop, Grace Abbott, Katharine Lenroot, and Frances Perkins. Their lives and careers were the expression of the hopes that most people have for their children, as President Truman said in his address to the 1950 White House Conference on Children and Youth: We cannot insulate our children from the uncertainties of the world in which we live or from the impact of the problems which touch us all. What we can do--and must do--is to equip them to meet these problems, to do their part in the total effort and to build up those inner resources of character which are the main strength of the American people. Arthur Lesser, MD, M P H Washington, DC 20015-1524
REFERENCES
I. Eliot MM. The United States Children's Bureau [John Howland Award Address]. Am J Dis Child 1967;114:565-73. 2. Eliot MM. A demonstration of the community control of rickets. In: Bremner R, ed. Children and youth in America; vol II. Cambridge Massachusetts: Harvard University Press, 1971: 1074-6. 3. Eliot MM. The children's titles in the Social Security Act. Children 1960 July-Aug, pp. 136, 139-40. 4. Reed. Quoted in: Brenner R, ed. Children and youth in America; vol II. Cambridge, Massachusetts: Harvard University Press, 1971:1013-4. 5. Illinois Medical Journal. Quoted in: Brenner R, ed. Children and youth in America; vol II. Cambridge, Massachusetts: Harvard University Press, 19711019-20. 6. Woman Patriot. Quoted in: Brenner R, ed. Children and youth in America; vol II. Cambridge, Massachusetts: Harvard University Press, 1971:1024. 7. American Academy of Pediatrics Executive Board. J PEDIATR 1944;25:88-91. 8. Five decades of action for children. Washington, D.C.: U.S. Children's Bureau, 1962:22, 68. 9. Sinai N, Anderson O. Emergency Maternity and Infant Care [program of U.S. Children's Bureau]. Ann Arbor: School of Public Health, University of Michigan, 1948.
This profile of Martha Eliot honors a pediatrician whose career influenced children and pediatrics in a different way from the others in the series. As so well described by Dr. Lesser, her career options were shaped in large part (perhaps completely) by the sociologic pattern prevalent at the time. The "subspecialty" that she turned into a major force for children is the field of preventive-administrativegovernmental pediatrics. The scope of her contribution has particular significance as we enter what promises to be the next era of support for children's health issues at the federal level, As much as any in our series of outstanding pediatricians, she led the way to a new plateau of concepts and new ways of doing things for children's health.--Laurence Finberg, MD, Guest Editor
Martha M a y Eliot W r i t i n g biographic notes a b o u t someone who was born 100 years ago provides an impressive view of the striking changes in A m e r i c a n society and culture t h a t have taken place in this century. T h e career of M a r t h a M a y Eliot ( 1 8 9 1 - 1 9 7 8 ) is characteristic of the experiences of m a n y women whose a m b i t i o n was to enter professional or public life. Dr. Eliot was a d e s c e n d a n t of two distinguished New England families, Eliot and May. A seventeenth-century ancestor t r a n s l a t e d the Old T e s t a m e n t into the Algonquian Indian language; a n o t h e r was president of H a r v a r d University; her g r a n d f a t h e r was a founder of W a s h i n g t o n University, in St. Louis, Mo.; and a c o n t e m p o r a r y cousin won the Nobel prize for literature. Because H a r v a r d Medical School did not accept women, Dr. Eliot studied medicine at Johns Hopkins, in Baltimore, Md. However, she was not accepted as an intern at the H a r r i e t L a n e H o m e because J o h n H o w l a n d believed t h a t women would m a r r y and not continue to be pediatricians. In her H o w l a n d A w a r d Address in 1967, Dr. Eliot said of her rejection: This was just as well--for my lines lay in different directions, and I was forced to reach out at once to what to me were basically more appropriate foundations for what I was searching for in pediatrics. It was from the vantage point of my subsequent association with Francis Peabody in Boston, Ned Park and Grover Powers in New Haven that I took off in 1924 to join the staff of the Children's Bureau. It was from Grace Abbott, who was then Chief of the Children's Bureau, that I learned the breadth and depth of the meaning of public responsibility for children and the role that could be played by pediatricians together with social workers in setting high standards of performance for, and in stimulating, supporting and expediting public programs of, child health and child welfare services. 1
THE JOURNAL OF PEDIATRICS 1993;123:162-5.
Copyright 9 1993 by Mosby-Year Book, Inc. 0022-3476/93 $01.00 + .10 9/20/40811 162
Preceding her move to New Haven, Dr. Eliot spent a year at the Peter Bent B r i g h a m Hospital, Boston, Mass., in general medicine and a year at St. Louis Children's Hospital, St. Louis, Mo., with Williams M c K i m M a r r i o t t . In St. Louis, she carried out her interest in child health and preventive health services by devoting part of her time to the city's child health clinics, an interest t h a t continued on her r e t u r n to Boston. W h e n Yale Medical School, N e w Haven, Conn., developed its d e p a r t m e n t of pediatrics (previously a part of the
The Journal of Pediatrics Volume 123, Number 1
department of internal medicine), Edwards Park left Johns Hopkins to become chairman at Yale. He invited Martha Eliot to become a resident at the New Haven Hospital and a member of the Yale faculty, an invitation she accepted on the day the letter arrived. She later commented that her years in New Haven were among the happiest of her life. While at Johns Hopkins, Edwards A. Park demonstrated that rickets in rats could be prevented by cod liver oil. In 1923 the U.S. Children's Bureau asked Park to carry out a community-wide demonstration in New Haven to determine the effectiveness of cod liver oil in the prevention of rickets in children. He asked Martha Eliot whether she was interested, and thus she became a staff member of the Children's Bureau and designed and carried out the study. The study was significant not only because the effectiveness of cod liver oil was demonstrated but also because the study included control groups of children and because public health nurses of the New Haven city health department participated, visiting homes of the study children and demonstrating to their mothers, among other things, how to give cod liver oil. 2 The statute establishing the Children's Bureau in 1912 authorized the Bureau to "investigate and report upon all matters pertaining to the welfare of children and child life among all classes of our people." This was the first recognition that the federal government has a responsibility to promote the welfare of the nation's children. The studies of infant and maternal deaths showing the relationship of social and economic factors to the causes of death provided the Bureau with the basis for proposing and justifying a grants-in-aid program to assist state agencies in establishing and improving services to promote the health of mothers and children. The Sheppard-Towner Act, passed in 1921, was the first continuing federal-state grants-in-aid program for health services. Its primary effect was educational. Many people came to understand for the first time the help they could receive through prenatal and well baby clinics, from home visits by public health nurses, and from the systematic programs designed to teach the principles of good maternity care to the large numbers of untrained midwives then practicing in many states. 3 The 1912 statute and the Sheppard-Towner Act were not enacted without sharp controversy that included nasty and bigoted expressions of opposition, perhaps characteristic of the period. During the Congressional debate, a Mr. Reed, of Missouri, said of the Children's Bureau, "It seems to be the established doctrine of this bureau that the only people capable of caring for babies and mothers of babies are ladies who have never had babies [laughter]. ''4 After listing the names of Bureau staff, all preceded by "Miss," he said: At the very threshold therefore we are confronted by the remarkable and amusing fact that we are asked to turn over questions of
Pediatric profile--.Eliot
16 3
infant bearing and infant care to an aggregation composed almost exclusivelyof spinsters. . . . I repeat, I cast no reflection on unmarried ladies, Perhaps some of them are too good to have husbands.4 The Illinois Medical Journal had this to say: This bill is a menace and represents another piece of destructive legislationsponsored by endocrine perverts, derailed menopausics and a lot of other men and women who have been bitten by that fatal parasite Upliftusputrifaciens, all of whom are workingovertime to devise means to destroy the country.~ Women also opposed the extension of the SheppardTowner Act. The Woman Patriot stated: "Children are now the best political graft in America. They furnish the best possible screen behind which to hide cold-blooded calculated socialist feminist political schemes to raid the United States Treasury to supply new fat jobs. ''6 Although there was strong support as well, particularly among citizens' groups, pediatricians, social workers, and other professionals, authorization for the Sheppard-Towner Act was not renewed in 1929. The congressional hearings on extending the authorization of the Sheppard-Towner Act provided Dr. Eliot with an introduction to the hearings on the Social Security Act and other challenges to come, challenges that she usually met head-on. She occasionally recalled these experiences, not emotionally, but objectively, as though one must expect them in public life. By now a full-time staff member of the Children's Bureau in Washington, she was devoting most of her time to working with state committees on children and youth and with other citizens and professional groups in preparation for the 1930 White House Conference on Children and Youth. The conference was called by President Herbert Hoover "to study the present status of the health and well-being of the children of the United States and its possessions, to report what is being done, to recommend what ought to be done and how to do it." Particularly impressive about this conference were the large number of participants and the nationwide collection of factual information about children and youth, gathered well in advance, that enabled the conference to carry out the President's stated objectives. Its final reports were included in 32 volumes of facts and recommendations. The timing of the conference could not have been better; its reports provided the necessary background information and support for President Franklin D. Roosevelt's proposed Social Security Act, of which Title V authorized grants-in-aid to states for maternal and child health programs, services for crippled children, and child welfare services.* Dr. Eliot, now the associate chief of the U.S. Children's Bureau, wrote the statutory language for the crippled chil*For a discussionof the forces that led to the enactment of Title V of the Social Security Act, see Lesser AJ. The origin and development of maternal and child health programs in the United States. Am J Public Health 1985;75:590-8.
16 4
Pediatric profile
Eliot
dren's program, and it is a model of comprehensiveness and clarity. It was original, without any precedents that could have offered guidance. As she interpreted the statute: It required a State's program to include servicesfor findingchildren who are crippled or who are suffering from diseases that lead to crippling and to provide them with medical, surgical, and corrective services and care, and facilities for diagnosis, hospitalization, and aftercare. No partial programs leaving out, for example, adequate diagnostic or follow-upcare were to be approved3 [pp. 13940]. Subsequent policies were basic to medical care administration and included, for example, the requirement that state plans describe their standards of personnel, including those engaged in providing care, and the requirement that diagnostic services be available without charge or a means test. The point of the latter, of course, is that, until a diagnosis is made, it is not possible to estimate the cost of medical care and what treatment is needed. With regard to payment for medical and hospital care, when the parents had insurance or could otherwise be considered able to pay a share of the costs, the Children's Bureau policy required that the decision about payment be made by the state agency that had authorized the care; furthermore, payments to physicians and hospitals were payments in full and additional charges could not be made to the parents. Beginning in 1939, some of the federal funds that did not require matching were reserved for grants for special projects of regional or national significance, enabling the states to develop demonstration programs for children with problems not hitherto included (initially the crippled children's programs were predominantly orthopedic). Project grants also helped to support specialty graduate training in institutions of higher learning for professional personnel. These special projects enabled state agencies to broaden the diagnostic groups, beginning with rheumatic fever programs and neonatal care for premature infants, and then proceeding to congenital heart disease, hearing impairment, and epilepsy. The experience gained in the development of policies for the crippled children's program were useful in 1943, when the wartime Emergency Maternity and Infant Care (EMIC) program was iniated by the U.S. Congress. The purpose of this program was to provide complete maternity care, without charge, for the wives of servicemen in the four lowest pay grades, as well as health supervision and medical care for their infants up to 1 year of age. These services actually started in 1941, when the commanding officer of Fort Lewis, in Washington State, requested help from the state health department in providing care for the increasing number of pregnant wives of enlisted men in the area, exceeding the capacity of the fort hospital. The health department's request for project grant funds was approved by the Children's Bureau, which soon began receiving similar requests
The Journal of Pediatrics July 1993
from other states. By December 1942, twenty-five states initiated such programs and it was clear that a new appropriation was needed. An Act of Congress made the first special appropriation of $1,200,000 available in March 1943, with provision for extension to other states as needed. The enactment of this legislation and the rapid growth of the EMIC program became a matter of great concern to physicians' organizations, particularly the American Medical Association and the American Academy of Pediatrics. First, they were concerned that the Children's Bureau, in its administration of the EMIC program, had established standards of care and fee schedules for payment for care in private practitioners' offices. Second, many physicians believed that the program was a prelude to a postwar national health care program. The American Academy of Pediatrics Executive Board stated: The Academy and the physicians of America have demonstrated in many ways their willingnessto give full support to any measure that will help win the war. It cannot approve, however, of measures established by a governmentbureau which, under the guise of war effort or necessity, arbitrarily control medical practice, and which are in reality plans for the control of postwar medical practice.* Because of the way in which the Children's Bureau has tended to turn away from the purpose for which it was founded,.., we feel the time has come when the Academy and the pediatricians of the U.S. must withdraw their support from the Children's Bureau] The report then recommended that all health care activities be placed in the U.S; Public Health Service. This would have removed Dr. Eliot from the child health care programs of Title V of the Social Security Act. The report concluded with the statement that because "we are a nation at war" the pediatricians are "eager and willing to cooperate to the fullest extent with the EMIC program. ''7 The EMIC program was, however, strongly supported in the Congress and by many citizen's organizations. By the end of the program in 1949, about 1,500,000 maternity patients and infants had received authorization for care. In 1945, 92% of the EMIC babies were born in hospitals, compared with 79% of all births in the United States. Despite criticism and opposition, at the height of the program 48,000 physicians and 5000 hospitals cooperated. 8 Nathan Sinai and Odin Anderson, in their extensive study of the administration of the EMIC program, wrote: EMIC serves as a striking demonstration of joint effort and of administrative resilience. It would be hard to find another wartime *The Academy's worry about plans for a postwar national health program was not groundless. President Harry S Truman sent special messages to the Congress in 1945, 1948, and 1949, recommending compulsory national health insurance. In 1939, Senator Robert Wagner had introduced his proposed National Health Act. Subsequently the Academy renewed its support for the Children's Bureau.
The Journal of Pediatrics Volume 123, Number 1
program that grew to such comparatively huge proportions and still remained within the framework of existing national, state, and local peace time administration. The accomplishments in meeting the problems, disregarding the antagonisms, conflicts, and fears are a monument to the combined contributions of medicine, public health, and the hospitals. 9 The war in Europe and particularly the bombing of London caused much concern in Washington regarding the need for the development of a plan for civil defense in this country. General George C. Marshall appointed a committee that included the surgeon general of the U.S. Public Health Service and the chief of the Children's Bureau to study the situation in England. Katharine Lenroot could not leave the country at this time; Martha Eliot substituted, and the group arrived in London in January 194l. She devoted particular attention to the arrangements for the evacuation of children, with its many complications, and for maternity care and medical care of children. The committee's report provided the basis for civil defense preparations in this country. After the war, Dr. Eliot participated in the work of the United Nations Relief and Rehabilitation Administration ( U N R R A ) and then in the United Nations Children's Fund ( U N I C E F ) , which replaced U N R R A . As vice-chairman of the U.S. delegation, she participated in the first International Health Conference in 1946 and in subsequent activities. The following year she was offered a position with U N I C E F for the purpose of carrying out a study of the needs of children in the war-ruined countries of Europe. She accepted, taking a leave of absence from the U.S. Children's Bureau. Her comprehensive report followed months of travel. Dr. Eliot continued her international work with the World Health Organization until 1951, when she was appointed chief of the U.S. Children's Bureau by President Harry S Truman, replacing Katharine Lenroot, who had retired. She found that the federal government had grown considerably, with the Children's Bureau still a small agency that had become a component of a large department. One of her first activities as chief was to start a juvenile delinquency program with the assistance of the Field Foundation and other voluntary organizations. It was subsequently supported with congressional appropriations. However, General Dwight D. Eisenhower was elected president of the United States in 1952, and the new political era was in sharp contrast to the New Deal programs of the previous 20 years. It has been said that "a true writer can never be other than what he is. But in our imperfect world his living light will shine among men only if it appears at the right time." W h a t is true for writers is true for others as well. Dr. Eliot's appointment as chief could not have come at a worse time for her. President Eisenhower's views of government were similar to those of the preceding generation.
Pediatric profile--Eliot
16 5
It was soon made clear to Dr. Eliot that the President preferred to make his own selection for the position of chief of the Children's Bureau. After a few frustrating years, Dr. Eliot came to the conclusion that the Children's Bureau would be better off without her. She left in 1956 to become professor of maternal and child Health at Harvard. She later continued her activities as chairman of the Massachusetts State Committee on Children and Youth. I would see her on my annual visits to Boston, and she always maintained her interest in the program developments of the Children's Bureau. She died in 1978. Martha Eliot was one of a number of remarkable women who were active in the latter part of the nineteenth and first half of the twentieth century, including Jane Addams, Lilian Wald, Florence Kelley, Julia Lathrop, Grace Abbott, Katharine Lenroot, and Frances Perkins. Their lives and careers were the expression of the hopes that most people have for their children, as President Truman said in his address to the 1950 White House Conference on Children and Youth: We cannot insulate our children from the uncertainties of the world in which we live or from the impact of the problems which touch us all. What we can do--and must do--is to equip them to meet these problems, to do their part in the total effort and to build up those inner resources of character which are the main strength of the American people. Arthur Lesser, MD, M P H Washington, DC 20015-1524
REFERENCES
I. Eliot MM. The United States Children's Bureau [John Howland Award Address]. Am J Dis Child 1967;114:565-73. 2. Eliot MM. A demonstration of the community control of rickets. In: Bremner R, ed. Children and youth in America; vol II. Cambridge Massachusetts: Harvard University Press, 1971: 1074-6. 3. Eliot MM. The children's titles in the Social Security Act. Children 1960 July-Aug, pp. 136, 139-40. 4. Reed. Quoted in: Brenner R, ed. Children and youth in America; vol II. Cambridge, Massachusetts: Harvard University Press, 1971:1013-4. 5. Illinois Medical Journal. Quoted in: Brenner R, ed. Children and youth in America; vol II. Cambridge, Massachusetts: Harvard University Press, 19711019-20. 6. Woman Patriot. Quoted in: Brenner R, ed. Children and youth in America; vol II. Cambridge, Massachusetts: Harvard University Press, 1971:1024. 7. American Academy of Pediatrics Executive Board. J PEDIATR 1944;25:88-91. 8. Five decades of action for children. Washington, D.C.: U.S. Children's Bureau, 1962:22, 68. 9. Sinai N, Anderson O. Emergency Maternity and Infant Care [program of U.S. Children's Bureau]. Ann Arbor: School of Public Health, University of Michigan, 1948.