The contrast between public health programs based on the germ theory and those based on public education are exemplified by controversies over the effectiveness of diphtheria antitoxin and tuberculosis control. Evaluations of antitoxin treatment concentrated on the diphtheria bacillus and disregarded the patient, resulting in inaccurate and conflicting findings. Early tuberculosis control programs also emphasized the tubercle bacillus, but the lack of success led to greater concern with patient education and community involvement.

The Development of Urban Public Health Programs

Federal, state, and local governments undertook different types of public health activities in the first decades of the twentieth century. The federal government gathered statistical data, conducted many useful and some outstanding research studies, occasionally distributed limited funding to states, and provided some health care for veterans and merchant seamen. State governments operated mental hospitals, tuberculosis sanatoria, and similar facilities for specific groups, but undertook few health programs for the general public. States were unable to resolve the conflicts between their cities, which wanted public health programs, and their rural areas, which sometimes opposed even compulsory birth and death reporting as government intrusions into the privacy of citizens. Many states undertook local health initiatives only in response to conflicts among towns or cities, such as the pollution of one town's water supply by another town's sewage. State governments employed physicians, engineers, and bacteriologists in the 1880s to monitor the drinking water and sewage disposal of local governments, but forty years later only two-thirds of the states required state approval of all municipal water supplies and sewerage systems.