Between Public Health and Social Welfare: Saving Mothers and Infants in the United States and Japan in the Early Twentieth Century

Abstract

Throughout most of human history, maternal and infant mortality rates were appallingly high. The early twentieth century witnessed unprecedented state interventions in maternal and infant health that laid the groundwork for modern states to improve public health and promote social welfare. This dissertation examines this understudied process of state-building, asking why mothers and infants were treated differently despite a high political and social consensus to protect both mothers and infants.

I make a paired comparison between the United States and Japan, two rising military powers in the twilight of European hegemony. They both learned from the European experience of great power rivalry, particularly World War I, that future wars would be total wars requiring the mobilization of their whole population, and they must prepare. Although the two countries were anxious to reduce both maternal and infant mortality, the health outcomes of mothers and infants diverged in both countries in the late 1920s. The United States performed well in reducing the infant mortality rate but fell far behind in reducing the maternal mortality rate. Public health officials mourned that the United States was one of the world’s most dangerous places to birth a baby. Japan’s situation was exactly the opposite—Japan had one of the world’s lowest maternal mortality rates but fell far behind in reducing their infant mortality rate.

This dissertation shows how the politics of public health interventions uncoupled the otherwise naturally connected maternal and infant health. In both countries, maternal and infant health were regulated under two very different health regulation discourses, which I term the public health and social welfare approaches to health. The social welfare approach regards health as an important component of social welfare and emphasizes that health interventions should be conditioned on the economic/class backgrounds of individuals or families. It is a historical and narrow version of today’s health regulation that highlights upstream social determinants of health. The public health approach regards health as an independent entity, emphasizing building the public health workforce and infrastructure while isolating high-level socioeconomic factors. Ideally, the two approaches are complementary. Historically, however, the two approaches conflict since they were promoted by competing historical actors. I find that in an early stage of public health interventions, health regulations guided by the public health approach were more effective than those guided by the social welfare approach at reducing maternal or infant mortality rates.

I then show how the jurisdiction competition between the expanding public health and social welfare bureaucracies, professional conflicts among public health professions and social workers, together with women’s organizations, medical groups, and traditional local charities led to the adoption of different approaches to protect mothers and infants.

My dissertation lies at the intersection of state-building, the welfare state, and public health. It makes theoretical contributions to the existing literature on state formation and the welfare state. It also contributes to today’s debate on public health interventions.