Although there were several early attempts at organizing physicians and the establishment of statewide medical codes in Florida, those that were legally enacted were never viable, and private organizations were slow to take hold in the state.¹ The need for statewide organizations became more apparent in the 1870s, and during the period new hospitals were founded in municipal areas such as in Duval County and the City of Jacksonville.² At the same time as the national trend of increasing organization of the trade groups, establishment of business chambers, and the proliferation of civic associations—evident in Florida as well as the rest of the country—medical conditions were worsening in rapidly expanding urban centers. Meanwhile, diseases associated with rural isolation, inadequate nutrition, and poor hygiene continued to plague large portions of Florida's population. Successive epidemics of yellow fever, smallpox, typhoid, and other grave illnesses had taken a toll on not only Florida’s ever-growing population, but also on the state’s governmental, civic, and professional resources.

Florida physicians, led by A. S. Baldwin of Jacksonville, George W. Betton of Tallahassee, and others, established the Florida Medical Association in Jacksonville on January 14, 1874. The Association charged itself with maintaining high standards of professionalization throughout the state and developing interest in medical science and literature. It appointed delegates to the American Medical Association.³ Despite strong support from Association members, it would take another 15 years before a State Board of Health was founded.

The Florida territorial government established provisional boards of health within days of the ceding of Florida to the United States in 1821. How quickly this was done reflects the serious threat posed, and fear engendered, by yellow fever. Yellow fever is a viral disease that is transmitted to humans through the bite of infected mosquitoes. Severe infection can lead to liver failure. The resulting yellowing of the skin and eyes (jaundice) gives yellow fever its name.

Although physicians in established cities such as Pensacola and St. Augustine, as well as the other cities quickly sprouting around the state, recognized the need for professional organization, the need to control the spread of yellow fever superseded other issues. In Pensacola and St. Augustine, the local boards of health were granted enough power by Governor Jackson to quarantine sections of the cities and appoint health officers to meet and possibly quarantine incoming ships, attend to the hygiene of the cities by disposing of trash, and impose and enforce health regulations.⁴

Meanwhile, newspapers and city officials were often reluctant to publicize outbreaks of disease or otherwise draw attention to the health needs of the state. Despite further efforts by physicians to organize during the territorial and early statehood periods, and the establishment of a territory-wide Board of Health in 1824, efforts at health regulation failed, and after 1831 the territorial medical board was terminated. The responsibility of registering physicians was pushed onto county governments, and Florida witnessed the beginning of a long trend towards self-regulation, which medical historian E. Ashby Hammond describes as “a retrogression into a casual and haphazard system of health and medical regulation” that would persist until after the Civil War.⁵

Yellow Fever and the Founding of the Board of Health

Although the state of Florida was slow to embrace the need to create statewide agencies to coordinate efforts to protect the public health, years of severe yellow fever outbreaks created public and political will to eventually do so. Yellow fever, and other diseases believed to be brought to the state by ships engaged in trade with tropical areas, influenced the policy making of local governments. County boards of health and city governments felt tremendous strain because of the financial and logistical demands of confronting outbreaks, always on their own with the help of citizen volunteers in the early stages, until federal authorities and state assistance arrived. Without a state official charged with coordinating state efforts, the county boards regularly reported directly to the governor. This process of direct communication with the governor made it difficult for county boards of health to share information between themselves and hampered the vital need to communicate possible outbreaks with other states.

The inefficiency of county boards and lack of statewide organization brought criticism from other states, particularly those facing possible yellow fever outbreaks such as Texas and Louisiana, and became the most compelling evidence for the establishment of a State Board of Health. Newly elected Governor Francis Flemming established the State Board of Health in 1889 as his first official act. Fulfilling a promise made during the campaign, the establishment of the Board was largely in response to concern from the Florida public, not to mention other states and the federal government, that not enough was being done to combat outbreaks of the disease after the devastating fever season of 1888.

Letters from the Counties and the Local Demand for Broader Action

Correspondence from county officials to the Governor’s Office during the yellow fever outbreak of 1888 reflects the growing statewide concern for more coordinated health efforts and the strain epidemics placed on local infrastructure. Officials and private citizens asked the governor to intervene to prevent looting, and to be more aggressive in placing quarantines over larger areas of the state. They also detailed the expenses incurred by city and county governments in order to feed and house the sick and try to control the spread of the disease.

Cities like Apalachicola, which were dependent on trade for their very existence, but whose people were haunted by the annual prospect of epidemic disease, instituted stringent health regulations for their ports. The final establishment of the Florida Board of Health was a direct result of the need to coordinate efforts in combating yellow fever. During the yellow fever outbreak of 1888, 10,000 residents, nearly a third, of Duval County’s residents fled. Of those who remained, there were more than 5,000 recorded cases of the disease and more than 400 deaths. The next year, the first official act of the newly elected Governor was to convene a special session of the legislature to create a Board, dedicated first and foremost to tackling diseases such as yellow fever, smallpox, and cholera.

Dr. J. Y. Porter of Key West was appointed the first director of the Board and remained in the position for the next seven terms, 27 years. Among Dr. Porter’s priorities was the creation of quarantine stations at each of the state’s major ports, as well as the compilation of statistics related to diseases and the overall health of the state.

Yellow Fever, Epidemic Disease, and Health Policy Nationally

The understanding of and approaches to dealing with yellow fever were closely related to public health policy in the United States throughout the 19th century. Medical understanding of the disease changed during the century as well. Early on, most physicians believed it to be non-contagious. Then, it was understood to be at least “transportable,” as it appeared to spread from city to city, seemingly from tropical and subtropical areas northward during the warmer months of the year. In the last decades of the century, germ theory greatly influenced the treatment of yellow fever, and public health efforts, such as those in Florida, focused on disinfecting and fumigating in order to eradicate the germ.⁶

Because major outbreaks became more frequent after the development of larger urban areas in the United States, cleaning of entire neighborhoods or cities, quarantining ships and people, and the destruction of vast amounts of personal and public property resulted from the idea that the disease was in some way contagious or caused by filthy living conditions. Despite evidence that contradicted theories of yellow fever being contagious, efforts to clean up cities did seem to decrease the number of yellow fever incidents and the extent of outbreaks. However, this was a beneficial byproduct of the accidental destruction of the real culprit, mosquitoes, which were discovered as a vector in 1900 by Walter Reed and James Carroll.

In 1905, Pensacola experienced a yellow fever outbreak that was reportedly transmitted from New Orleans. After years of establishing screening procedures for quarantines and aggressively screening off infected persons, the outbreak was contained largely in Pensacola, and other cities where it appeared such as Tampa experienced very limited spreading. The Board coordinated the construction of small quarantine hospitals near population centers throughout the state for $2,000 each.

A State Health Officer for Florida

By the peak of the yellow fever outbreak of 1888, Dr. Porter was leading all government relief measures in Jacksonville. Porter had been invited by the Duval County Board of Health to coordinate government relief measures being made by the county and the Marine Hospital Service, as well as the donations of money, food, and other goods from private citizens. In 1889, he was appointed State Health Officer by the newly formed State Board of Health.

Efforts to eradicate disease, clean the cities, and allow people to return to homes or resume work impacted every level of government and communities across the south. Local groups craved assistance from the federal government, such as the Marine Hospital Service, as well as more assistance from the state. Controlling disease was a vital issue nationally. Federal and state agencies created and revised policies continually in order to protect public health while facilitating commerce.

The State Board of Health certified citizens as being immune to yellow fever, in addition to other epidemic diseases such as smallpox and cholera. Dr. Porter strongly believed that an attack of yellow fever made survivors immune, and that people who had lived in communities that were centers for outbreaks for significant lengths of time were also immune, although the practice of certification was criticized for being unreliable and subject to corruption and forgery. The acknowledgement by the state of immunity, also known as “Acclimation Certificates,” became a model for vaccination certification programs later adopted at ports of entry throughout the United States.7