Laboratory Services Health Article

LABORATORY SERVICES

Even though the role of pathogenic bacteria and viruses in human health was defined in the nineteenth century, the first public health laboratories in the United States were called chemical laboratories and only performed elementary analyses of milk, water, and other substances. The Minnesota Board of Health established the first public health chemical laboratory in 1873, and in 1881 the New York legislature established the first state chemical laboratory. By 1869, most of the larger cities in Massachusetts had health boards that were actively involved in the area of sanitary engineering. The state's public health laboratory, established in 1886, was intended primarily to perform chemical analysis, though it was called a "hygienic" laboratory. Michigan followed Massachusetts' lead, moving into the regulation of food and water, and in 1887, the Michigan State Laboratory of Hygiene was established, with Dr. Victor C. Vaughn as director.

Both the Massachusetts and Michigan state hygienic laboratories began working on the connection between the public water supply and typhoid fever. This was probably the first application of bacteriology to sanitary science in the United States. By 1890 a number of state and local laboratories were established, with many of them doing both chemical and bacterial analysis.

The nation's first diagnostic public health laboratory was the result of work by Drs. Hermann M. Biggs and T. Mitchell Prudden. In 1887, these two physicians were able to isolate Vibrio cholerae, the bacterium that causes cholera, from the feces of ill passengers on an immigrant ship anchored in New York City harbor, and they were anxious to promote their technique as a routine diagnostic measure. It was not until a cholera scare in 1892, however, that they were able to convince the city health department of the need to establish a laboratory to develop and use diagnostic methods. On September 9 of that year, the New York City Department of Health's Division of Pathology, Bacteriology, and Disinfection was created, with Dr. Biggs as the director.

Biggs soon had a second disease upon which to focus his attention. Cases of diphtheria peaked in the 1890s in New York City, and Biggs was ready with a bacteriological diagnostic technique. He used this technique to demonstrate that half the patients in the New York City diphtheria hospital had been misdiagnosed. Because of this high rate of misdiagnosis, he stressed that laboratory testing to confirm a diagnosis would be cheaper than disinfecting and quarantining the homes of every case of suspected diphtheria. The health board agreed, and the first official medical bacteriologist in the United States, Dr. William H. Park, was appointed. Meanwhile, Biggs continued the expansion of the laboratory's diagnostic capabilities. He began routine laboratory bacteriological testing on every suspected tuberculosis case, despite his colleagues' skepticism of its value. In 1895, Biggs added vaccine production to the laboratory. He and his assistant, Park, refined the methods for production of the smallpox vaccine, and of diphtheria and tetanus antitoxins.

The New York City public health laboratory became a model for other public health departments. Within a few years, the diagnostic public health laboratory had become an essential component of an effective health department.

HISTORICAL SCOPE

The laboratory added a new dimension to public health department activities. The ability to isolate and identify disease-producing organisms immeasurably strengthened the prevention and control role of the department. However, this new health department tool of diagnostic bacteriology was not readily accepted by the general medical profession. Duffy, in "The Sanitarians," quoted from an 1884 JAMA journal article on Robert Koch and the tuberculosis (TB) bacillus that concludes a "too ready acceptance of the bacillus doctrine" was likely to do more harm than good and that "neither phthisis nor any form of tuberculosis (was) contagious."

Biggs and his associates in New York City met strong resistance from physicians to the city's board of health requirement to report all cases of tuberculosis. The attitude of New York physicians was duplicated around the country as more and more health departments instituted this requirement. Through perseverance and laboratory expertise, health departments were eventually able to convince the public and physicians that tuberculosis was communicable and not an hereditary disease related to environmental conditions.

As the diagnostic expertise of the laboratories grew, the ability of the public health dpeartments to control disease was bolstered. The ability to culture disease-causing organisms from asymptomatic people led to recognition of the carrier state and a reexamination of isolation practice. Laboratory-supported disease control efforts resulted in significant reductions in disease mortality by the early twentieth century.

By mid-century, most of the laboratories had evolved in service provision to the same general scope provided today: testing support of the communicable disease programs, chemical and bacteriologic testing of drinking water, analysis of food and milk, and limited non-communicable disease testing. As continuing advances in technology enhanced the diagnostic capabilities of the laboratories, the public health department core functions of assessment, policy development, and assurance were significantly strengthened.

Development of federal public health laboratories was slower than at the state level, although the nucleus of what would evolve into the National Institutes of Health was established in 1887. In that year Joseph Kinyoun founded the Laboratory of Hygiene, a bacteriology research laboratory at the Marine Hospital on Staten Island. In 1891, this laboratory was moved to Washington, D.C., where it expanded into what became the National Institutes of Health (NIH) forty years later. The NIH laboratories still focus primarily on research and are not usually considered front line public health laboratories. The Centers for Disease Control and Prevention (CDC), which is the acknowledged apex of the public health laboratory system, was established even later than the NIH. In 1942 the Office of Malaria Control in War Areas (MCWA) was established. In 1946 the MCWA was converted to the Communicable Disease Center. It was renamed the Centers for Disease Control in 1980, and in 1992 became the Centers for Disease Control and Prevention. The CDC has since matured into a collective group of laboratories and programs that is dedicated to preserving the health and wellbeing of the public. The testing performed by CDC, in conjunction with local and state laboratories, has been essential to the provision of safe drinking water, an increased awareness of the importance of environmental health issues, and the decline of communicable diseases such as syphilis.