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The colorful, contentious story behind health advocate Samuel Crumbine’s leadership

The leadership story behind the state’s most famous public health official – the physician who pioneered
“Don’t Spit on Sidewalk” bricks and likely saved thousands of lives – is more
colorful, contentious, troubling and inspiring than you ever knew.

By: Sarah Caldwell Hancock

 


Public health is tricky. Scientific advances are outstripping the average person’s understanding of reality,
and pockets of society are actively hostile to the insight science affords. Partisan divides make
policy progress difficult. Poor people and rural residents have less access to proper medical care, adulterated
drugs are a threat to the health of many, people engage in risky behaviors that
threaten their health and pandemics loom.
It’s 1888 in Kansas, and a young doctor has just arrived in Dodge City.


 

Samuel Crumbine is about to receive a crash course in Kansas beliefs related to health – that sassafras tea purifies the blood, that running streams or rivers purify themselves every seven miles and that “grannies” know more than the physician. As he travels the long distances (on horseback!) that his frontier practice requires, he has plenty of time to think. He diagnoses the situation: His patients need to be educated.

So he sets out to change things. What he accomplishes in Kansas gains national notice. By 1920, Kansas is No. 1 in life expectancy for white men, and in 1921, the average life expectancy of a Kansas child is more than five years longer than that in other states.

Kansas health has taken a hit since those heady days of the Progressive Era. Our state is now No. 32 in public health, according to a recent U.S. News & World Report Best States ranking. Looking back at Crumbine’s contributions can provide some valuable lessons and warnings for today’s health leaders. Crumbine brought ceaseless energy to the cause of public health: He energized others and raised the heat through effective public relations campaigns, and he gave work back to Kansas residents. Although politics often complicated his efforts, he worked across factions to make progress. He also made some mistakes and, finally, pushed some people too far.

Master of Public Relations

Crumbine witnessed many harrowing, unnecessary deaths from highly contagious diseases. Two common culprits were smallpox, a virus that causes a high fever, body aches and a disfiguring pustular rash; and diphtheria, a bacterial infection that attacks the respiratory system and renders victims – especially children –  struggling to breathand swallow, along with the desperately dirty conditions of everyday life during his time in Dodge City. Although he deeply respected the people he met on the frontier, calling them, in the autobiography he produced later in life, “kind, tolerant, generous to a fault and of endless assistance to their neighbors and to the physician when they finally called him,” his most difficult task was convincing them of proper approaches to sustaining good health and treating illnesses. “We doctors had difficulty getting people to observe modern rules of hygiene and even greater difficulty in persuading them that many of their beliefs concerning health and disease were age-old superstitions without any basis
in fact,” he wrote.

News of the 5-foot, 2-inch Crumbine’s competence spread, and he became known as the “fighting bantam rooster.” He was appointed to the fledgling Kansas State Board of Health in 1899. His actions to contain a smallpox outbreak earned him an appointment as the board chairman, and Crumbine moved his family to Topeka in 1904.

Crumbine acted quickly to take his case “straight to the people.” He started issuing a monthly Bulletin of the State Board of Health in 1905 to inform doctors, teachers, editors, legislators, manufacturers, food and drug merchants, leaders of social and civic groups, and residents of public health problems and solutions. An early target was sassafras tea, which was considered a necessary spring remedy to thin the blood. Crumbine wrote a sarcastic piece about the brew to debunk superstition. Newspapers found Crumbine’s repudiation of sassafras newsworthy, and heaped their own rejection on “old-fashioned folks” who thought herbs worn around the neck would prevent diphtheria and that sassafras relieved rheumatism.

Images courtesy of the Kansas State Historical Society.

The episode gave Crumbine a vital insight.
“Perhaps nothing is so effective against
superstitious custom and habits as subtle
ridicule and a robust satire. People may hold
out against scientific statement and learned
platitudes, but ridicule withers the branches
and satire dries the roots of superstition, so
they eventually shrivel and die,” he wrote.

The public health campaign was born.

Crumbine’s messages always had a scientific basis, but starting where people were became his recipe for success. “Swat the Fly” was one of his best-known campaigns. Crumbine published a story in his bulletin – and a special Fly Bulletin – that described conclusions of biologists who had studied the spread of typhoid in Tennessee during the Spanish-American War and proved that flies feeding on food in the mess tent carried lime from the latrines and accompanying fecal matter. But his most effective move was translating the science into doggerel and posters that captured imaginations.

Crumbine transformed a common elementary reader rhyme from:
Busy, timorous, thirsty fly
Drink with me, and drink as I;
Welcome freely to my cup–
Wouldst thou sup, come sip it up.

To:

Baby bye, here’s a fly
Let us swat him, you and I.
He carries filth upon his toes,
Which he wipes on baby’s nose.

By today’s standards, the campaign went viral. Crumbine gladly gave the work back to the teachers, scouts and community leaders who then cleaned up debris, refuse, manure and animal carcasses in their communities to remove the pests’ breeding grounds. He watched as his educational efforts resulted in national fly-killing contests and the spread of the flyswatter, and as women’s clubs delivered preprinted fill-in-the-blank notes to places of business enumerating how many flies the customer found on the premises.

Hearts and minds of legislators sometimes followed those of the public, with good results. Fighting tuberculosis, the second-leading cause of death in the U.S. in 1900, became a major priority. TB is a bacterial infection that usually attacks the lungs and causes severe coughing and weakness; when people in movies are coughing blood into their handkerchiefs, they have the dreaded TB, which spreads through the air via droplets.

To cut down on those infectious droplets, the Board of Health adopted the slogan “Don’t spit on the sidewalk,” and brick makers engraved the saying on bricks to be laid in sidewalks. Crumbine had already participated in national meetings and conveyed what he had learned to the Kansas governor, but the public slogan helped spur the Legislature to pass a law requiring notification of new tuberculosis cases and appropriating funds for sending supplies to affected individuals.

In another two years, the Legislature funded a state sanitarium to isolate and treat TB patients.

Enhanced data gathering led to greater understanding of the scale of the problem in southeast Kansas, southwest Missouri and northeast Oklahoma – a lead and zinc mining area rife with the crowded, poor conditions that spread the disease – and eventual creation of a Tri-State Sanitary District. Crumbine also criticized county commissioners for not enforcing relevant statutes and worked with state and national authorities to enhance testing and detection to prevent children from getting tuberculosis from contaminated cow’s milk.

Many other sources of illness caught Crumbine’s critical eye. He deployed more verses and images to convey the dangers of the public drinking cup (yes, people at the time actually drank from the same tin cup at water stations on trains, on city streets and in schools). He fought resistance with data from cups he had swabbed and tested, and with an education campaign that he persuaded the Legislature to fund. He also targeted adulterated and unsafe foods and medicines. In several instances, Crumbine was able to persuade industries to clean up and address problems; for example, he exposed contamination and safety issues in the shipping of oysters, and in time Kansas’ standards were adopted by all shippers on the East Coast.

Enemies

The path to reform was often less than smooth. Business owners didn’t appreciate the heat Crumbine raised with new rules and regulations, so his enemies were plentiful. He was satirized by editorials and cartoons that mocked his small stature or argued that he was overstepping his bounds. Trade organizations, county authorities and other groups tried to discredit him, and some public factions resisted the  information his agency provided. Despite his many successes, he was frequently at odds with the Kansas Legislature or with governors, usually over funding. Although his work was slowed at times, he usually prevailed in engaging the right voices to disarm factions.

In an effort to combat diphtheria, for example, Crumbine first had to fight those who were suspicious of diphtheria antitoxin – the equivalent of today’s anti-vaccinators – as well as swindlers offering false cures. Then he had to find funding to provide diphtheria antitoxin to the hard-hit poor in southeast Kansas after Gov. Arthur Capper turned him down. Newspaper legend William Allen White provided support in the form of a plea to his wealthy friends to donate funds to provide the antitoxin, which provided the motivation Capper needed to “find” the fundingThe 1921 success of the first countywide diphtheria immunization program in the state – Wabaunsee County had its last diphtheria death the next year – led other counties in Kansas and in other states to do the same.

Crumbine’s efforts to improve food and drug safety brought him numerous adversaries in the food processing and distribution, restaurant and drug sectors, where bottom lines had suffered. Efforts in the 1913 Legislature to remove him from office and to question his spending were spearheaded by these enemies. When questioned by a committee appointed to investigate him, Crumbine managed himself well: He responded to questions simply and quietly. The investigation ended in frustration for Crumbine’s accusers, and in another two years, Crumbine ran unopposed and was re-elected by the board as secretary.

Mistakes

If Crumbine was an advocate of some of the best ideas of his time, he was also susceptible to one of the worst. Eugenics, or the science of improving a human population by increasing the occurrence of supposedly desirable traits through controlled breeding, was consigned to oblivion when it was used by the Nazis as a defense for their acts of genocide. But as Crumbine was fighting for improved public health, breeding healthier children was an appealing idea.

Crumbine modeled a Kansas program on a successful effort in New York, and in 1915, the Legislature created the Division of Child Hygiene on the Kansas Board of Health to study infant mortality and institute preventative measures. Crumbine hired two different doctors, both women, to lead the division. The first, Lydia DeVilbiss,  developed an advice book for mothers, popular baby clinics and child hygiene exhibits, and a Healthiest County Award.

The second, Florence Sherborn, was known for her eugenics work. She wanted families to understand heredity as a way to improve their health. She used fairs to propagate the message that those with desirable traits were morally and physically superior. Attendees at large fairs and other events enjoyed fitter family contests in which doctors graded the traits of family members. Participants appreciated the medical examinations and information the contests offered and probably did not think about the darker implications: Designating what babies are best and what families are fittest implies that some babies and families are undesirable.

Eugenicists in Kansas and elsewhere didn’t hesitate to identify those they found undesirable. Kansas laws passed in 1913 and 1917 mandated and eased quarantine and sterilization of certain populations (habitual criminals, the mentally disabled or disturbed, epileptics and so on). Chris Lovett, a history professor at Emporia State University, says records show that Kansas sterilized more than 3,000 people between 1917 and 1961 and that Crumbine supported the policy – he personally conducted some sterilizations at the state  prison in Lansing.

Women paid a particularly high price. When the army built Camp Funston at Fort Riley, tuberculosis and alcohol were problems, but the spread of prostitution and sexually transmitted diseases were grave concerns. Crumbine’s solution, as documented in his autobiography, was to quarantine and treat the “soiled doves” who provided “services” to the troops. Lovett says many of the women were sterilized. In addition, a large number of the women who were swept up and incarcerated were neither prostitutes nor infected with sexually transmitted diseases. Some had yeast infections that were assumed to be symptoms of syphilis. Some were not women at all, but girls as young as age 11 who went to the camps with relatives or were sexually active or even married at such an early age. Women who visited doctors or pharmacists could find themselves arrested because medical personnel were obligated to notify public health officials if they suspected a sexually transmitted disease case. Of women who were infected, Lovett estimates 10 to 20 percent were infected by their husbands.

Lovett says these darker truths highlight the inadequacies of the era. In his unpublished research, Lovett says he has found only a few recorded objections to eugenics or forced sterilization during the period. “These were people that should have known better – lawyers, judges and doctors. They all failed!”

Scandal

If there is a defense of Crumbine in this situation, it is that he thought sexually transmitted disease was a serious threat to the health of Kansas youth. But it was his insistence on prioritizing a fight against syphilis and gonorrhea that would prompt his exit from Kansas, although not for the reasons readers in 2018 might expect. After helping the state weather the flu pandemic crisis in the waning days of World War I, during which time he worked across factions and with every type and level of authority – counties, state agencies, the military, church officials, local clubs, and regional and national agencies – Crumbine pushed some Kansans too far in the area of sex education.

He devised a plan to deliver “social hygiene” information to Kansas high school students, and although demand for the information was high and the effort proceeded for three years, what Crumbine called a “witch’s brew of scandal and vulgar falsification was spewed” in some communities. Simply put, some people were offended by the very existence of sex education because they thought it encouraged “loose sexual relationships,” and Crumbine’s old enemies seized on a chance to oust him.

Democrat Jonathan Davis was elected governor in 1922 and demanded a 40 percent turnover in the Board of Health, a direct challenge to Crumbine’s authority to appoint his officials. A political fight ensued, and the 1923 Legislature unceremoniously pulled the funding for the Board of Health’s Division of Venereal Disease Control. Crumbine was shocked and ultimately resigned. He accepted a position with the American Child Health Association. He left  Topeka for New York City in June 1923, ending his more than three decades of work in Kansas.

Crumbine continued to work for public health improvements in his national position, and although the association made progress in milk safety and midwifery licensing, it was slow, difficult and hampered by the Great Depression. In his autobiography, Crumbine characterized this phase of his career as “lighter work,” compared with practicing medicine on the frontier or running the Kansas Board of Health. He downplayed the viciousness of the people who essentially had driven him from his adopted state and told stories about hunting and fishing, but he couldn’t resist taking a shot at those opposed to tackling sexually transmitted disease near the end of his book. “Timidity and a fuzzy public sentiment have obstructed and hindered us hitherto in really grappling with the venereal disease problem as effectively as the seriousness of the situation demands. I have yet to be impressed with any argument or reason why we should not fight venereal disease with the same determination and under the same general rules and objectives with which we deal with other serious communicable diseases,” he wrote.

Losing this battle clearly stung. Crumbine missed the open spaces of Kansas, and he closed his book with lines from “Home on the Range” and a tribute to his son, Warren, who had died of pneumonia in 1916 at age 24 while living in Shanghai. But he took comfort in his legacy and the “interesting and hard work” he had done through the years. Despite his difficulties, his most important conclusion was “how much the health of each one of us depends on the health of all of us.”

How Crumbine acted on his guiding principle highlights the central tension in public health: balancing individual liberty with the greater good. The Kansas Health Institute, a Topeka-based research organization, recently honored Crumbine with a statue in a pocket park outside of their offices across from the State Capitol (KHI is funded by the Kansas Health Foundation, which also funds the Kansas Leadership Center, publisher of The Journal).

Robert St. Peter, president and CEO of the Kansas Health Institute, says Crumbine’s interest and passion to protect the masses saved many lives. But what about his methods? “When faced with uncertainty and devastating consequences, people look outside their comfort zone. You hope people have the moral compass to navigate those decisions,” St. Peter says.

Public Health Ethics and Today’s Challenges

The moral compass required to navigate public health decisions remains a sticking point locally and nationally. Kansas and the United States have yet to solve the issues of access to health care and the behavioral changes required to make continued progress in public health. Problems such as opioid abuse and obesity are particularly intractable. St. Peter says it’s because the next steps are “outside the tidy box of medicine or science.

“The separation of health and other aspects of people’s lives are being erased. You can’t deal with them without thinking about the home environment and neighborhood and the economic opportunity people have,” he says.

In addition to fully integrating medical care with behavioral health, St. Peter says we have to address the partisan third rails of health care: costs and access. St. Peter hopes that Crumbine’s example of taking information to the people can inspire the same action in today’s public health leaders.

“Compared to other countries, we’re way overspending on health, and we’re not getting the outcomes we should be getting for what we’re spending,” he says.

“Crumbine had to talk to people about things they didn’t understand, like the germ theory: People didn’t understand how flies could carry germs from the outhouse to the kitchen table. He had to convince a skeptical public about something to really move public health forward. In our case now, it’s getting people to understand the complexity and the interconnectedness of issues that aren’t in the health sphere to things driving the costs up,” he says.

Our situation is not so different from the one Crumbine confronted. People may not be relying on sassafras tea, but they often draw on the healing power of entrenched political positions to help them avoid the complexities of health policy. Crumbine was deeply knowledgeable about individual and group actions that were necessary to improve public health, but he was at his best when his communications were appealing to the people he needed to reach and when he took time to build relationships in affected communities. He demonstrated the power of having the humility to let your audience interpret and accept your ideas as well as the pitfalls of failing to do so. If we are to replicate Crumbine’s success in improving and saving lives without falling prey to his shortcomings, we need to avoid casting aside populations that are unhealthy or contagious or just distasteful.

Most important, we must listen to the people public health policies are designed to help.

The health of each one of us depends on the health of all of us, but maybe it works the other way, too.    

This article was originally published in the Winter 2018 issue of The Journal, a publication of the Kansas Leadership Center. To learn more about KLC, visit http://kansasleadershipcenter.org. For a subscription to the printed edition of The Journal, visit klcjr.nl/amzsubscribe.

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