The Lower East Side of New York was one of the most densely populated square miles on the face of the earth in the 1890s. The photo-essayist Jacob Riis famously described it as a world of bad smells, scooting rats, ash barrels, dead goats, and little boys drinking beer out of milk cartons. Six thousand people might be packed into a single city block, many in tenements with sanitary facilities so foul as to repel anyone who dared approach. City health inspectors called the neighborhood “the suicide ward”; one tenement was referred to—in an official New York City Health Department report, no less—as an “out and out hog pen.”1
Diarrhea epidemics blazed through the slums each summer, killing thousands of children every week. In the sweatshops of what was then known as “Jewtown,” children with smallpox and typhus dozed in heaps of garments destined for fashionable Broadway shops. Desperate mothers paced the streets trying to soothe their feverish children, and white mourning cloths hung from every story of every building. A third of the children born in the slums died before their fifth birthday.
In the European farming villages where many of these immigrants came from, people spent most of their time outdoors in the fresh air and sunshine, and most never encountered more than a few hundred people in a lifetime. “Crowd diseases”—measles, dysentery, typhoid, diphtheria, trachoma, and so on—were rare, and the immigrants had little idea of how to prevent them. Some parents vainly tried to administer folk remedies; others just prepared the little funeral shrouds in silence.2
It was in the 1890s that Sara Josephine Baker decided to become a doctor. Not the Josephine Baker who would become celebrated as a cabaret star and dance at the Folies Bergère in a banana miniskirt but the New York City public health official in a shirtwaist and four-in-hand necktie, her short hair parted in the middle like Theodore Roosevelt, whom she admired. By the time Baker retired from the New York City Health Department in 1923, she was famous across the nation for saving the lives of 90,000 inner-city children. The public health measures she implemented, many still in use today, have saved the lives of millions more worldwide. She was also a charming, funny storyteller, and her remarkable memoir, Fighting for Life, is an honest, unsentimental, and deeply compassionate account of how one American woman helped launch a public health revolution.3
Born in 1873, Baker grew up in a modestly prosperous Poughkeepsie family and studied medicine at the Women’s Medical College in Manhattan, run by Emily Blackwell, the sister of the more famous Elizabeth, America’s first woman doctor. Baker graduated second in her class. The only course she failed was “The Normal Child,” taught by Dr. Annie Sturges Daniel, a pioneer health educator who also campaigned for better housing conditions for the poor. Baker had to retake the class and in studying for it became fascinated with “that little pest, the normal child” whom she would go on to make the focus of her career.
After graduation, Baker worked as an intern at the New England Hospital for Women and Children in Boston and then returned to establish a private practice in New York. She once examined the actress Lillian Russell, but most of her patients resided in the tin squatters’ shacks of Amsterdam Avenue and couldn’t pay her. In need of money, she applied for a job with the Department of Health and was hired in 1902.
Medicine in those days required a certain daring. While still in Boston, she almost killed a drunk who was beating his pregnant wife as Baker was trying to deliver their baby. As a New York City health inspector, she administered smallpox injections to snoozing hoboes in Bowery flophouses, fielded calls from Tammany politicians requesting that she hire their cast-off mistresses as nurses (she declined), and chased down the notorious cook Typhoid Mary through the streets of Manhattan. Baker had to sit on Mary all the way to the hospital to keep her in the ambulance.
Modern readers might be put off by Baker’s tendency—common in those days—to generalize about the various ethnic groups she encountered in the city’s variegated slums. Blacks come off well; the Irish all seem to have been slapstick drunks. However, she clearly understood that their misery and dissolution were part of a wider culture of official corruption and indifference to the poor, which afflicted even her own Health Department.
In the tenements of Hell’s Kitchen, Baker wrote, she “climbed stair after stair, knocked on door after door, met drunk after drunk, filthy mother after filthy mother and dying baby after dying baby.” Most of her fellow health inspectors didn’t bother to make rounds at all; they just forged their records and went on their way. Baker, who might well have been fired for making everyone else look bad, was lucky to have the support of the Tammany-affiliated but nevertheless reform-inclined mayor George McClellan, elected in 1903. He appointed a new health commissioner who dismissed the other inspectors and promoted Baker. In 1908, she was put in charge of the Health Department’s new Bureau of Child Hygiene, the first of its kind in the country.
There she changed the way we think about public health. Until then, the Health Department had sought to track down sick children and refer them to physicians, a mostly futile endeavor in the days before antibiotics and modern medicine. Baker decided that the new bureau’s mission would instead be prevention. The city had an established and efficient system of birth registration. As soon as a child was born, her name and address were reported to the Health Department. Baker reasoned that if every new mother were properly taught how to feed and care for a baby and recognize the signs of illness, the mother would have a much better chance of keeping the child alive.
In her first year at the Bureau of Child Hygiene, Baker sent nurses to the most deadly ward on the Lower East Side. They were to visit every new mother within a day of delivery, encouraging exclusive breast-feeding, fresh air, and regular bathing, and discouraging hazardous practices such as feeding the baby beer or allowing him to play in the gutter. This advice was entirely conventional, but the results were extraordinary: that summer, 1,200 fewer children died in that district compared to the previous year; elsewhere in the city the death rate remained high. The home-visiting program was soon implemented citywide, and in 1910, a network of “milk stations” staffed by nurses and doctors began offering regular baby examinations and safe formula for older children and the infants of women who couldn’t breast-feed. In just three years, the infant death rate in New York City fell by 40 percent, and in December 1911, The New York Times hailed the city as the healthiest in the world.
Articles about Baker’s lifesaving campaigns appeared in newspapers from Oklahoma to Michigan to California. In the late 1910s, she and other reformers drafted a bill to create a nationwide network of home-visiting programs and maternal and child health clinics modeled on the programs in New York. But the American Medical Association (AMA)—backed by powerful Republicans averse to spending money on social welfare—claimed the program was tantamount to Bolshevism. Baker was in Washington the day a young New England doctor explained the AMA’s position to a congressional committee:
“We oppose this bill because, if you are going to save the lives of all these women and children at public expense, what inducement will there be for young men to study medicine?” Senator Sheppard, the chairman, stiffened and leaned forward: “Perhaps I didn’t understand you correctly,” he said: “You surely don’t mean that you want women and children to die unnecessarily or live in constant danger of sickness so there will be something for young doctors to do?” “Why not?” said the New England doctor, who did at least have the courage to admit the issue: “That’s the will of God, isn’t it?”
Baker’s public health innovations were numerous. In addition to the home-visiting programs and community baby clinics, she established the position of the school nurse, developed special capsules for delivering silver nitrate to the eyes of newborns to prevent blindness due to congenital gonorrhea, invented a window board for improving ventilation in houses, and created a more efficient method of medical record keeping. She even designed a set of baby clothes that was more convenient and comfortable than the swaddling traditionally used in the immigrant ghettos.
The enormous declines in child mortality that Baker helped bring about are frequently attributed to improved nutrition and a general improvement in working and living conditions, and to the availability of vaccines and antibiotics. However, demographers who have studied the subject in detail have concluded that it had little to do with any of these things. Most vaccines and antibiotics weren’t available until after World War II and the “general uplift” in nutrition and living conditions occurred at the end of the nineteenth century, decades before the mortality decline. This may have set the stage for the drop in the death rate that followed, but the survival of babies didn’t substantially improve until safer milk supplies became widely available and, even more crucially, campaigns like Baker’s had helped women understand germs and how to avoid them, so that they could provide better care for their children.4
Safe milk and hygiene aren’t the only things children need to survive. Baker was the first to prove scientifically that they also need love. In an era when reliable birth control was unavailable and abortion was unsafe and illegal, hundreds of newborns were abandoned each year in New York City. Babies turned up in parks and alleyways or on the doorsteps of fashionable houses. These foundlings were assumed to be illegitimate and until 1870 weren’t even welcome at Catholic charity orphanages. Most ended up in squalid municipal almshouses with the paupers, drunks, and insane; nearly all of them died. But in 1915, a foundling hospital opened on Randall’s Island under the direction of Baker’s Bureau of Child Hygiene. There trained nurses provided the babies with state-of-the-art care and feeding. Nonetheless, close to half of them still died. In what Baker’s nurses referred to as the “hopeless ward,” where the most premature, sickly babies lay in tiny boxes lined with cotton wool, virtually none survived.
At the time, many doctors would have been unconcerned about this. While the deaths of older infants and children might be attributed to inadequate hygiene and nutrition and prevented accordingly, eugenically minded child health experts believed that the deaths of newborns, defined as children aged under a month or so, were due to their inborn “sub-normality”; there was nothing doctors could do for them. In order to prevent these babies from growing up and passing their sickly genes on to the next generation, it was thought preferable to let them die.
1 Jacob Riis, How the Other Half Lives (Scribner’s, 1890). ↩
2 Oscar Handlin, The Uprooted: The Epic Story of the Great Migrations That Made the American People (University of Pennsylvania Press, 2002). ↩
3 This essay will appear in somewhat different form as the introduction to a new edition of Fighting for Life, to be published by New York Review Books in September. ↩
4 Samuel H. Preston and Michael R. Haines, Fatal Years: Child Mortality in Late Nineteenth-Century America (Princeton University Press, 1991), chapter 6. ↩
Jacob Riis, How the Other Half Lives (Scribner’s, 1890). ↩
Oscar Handlin, The Uprooted: The Epic Story of the Great Migrations That Made the American People (University of Pennsylvania Press, 2002). ↩
This essay will appear in somewhat different form as the introduction to a new edition of Fighting for Life, to be published by New York Review Books in September. ↩
Samuel H. Preston and Michael R. Haines, Fatal Years: Child Mortality in Late Nineteenth-Century America (Princeton University Press, 1991), chapter 6. ↩