Dr. Sara Josephine Baker of the New York City Health Department, circa 1912

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.

Drawing by Edward Lear

But Baker didn’t agree that the fate of these infants was inevitable. She had noticed that though infant mortality had plummeted in the slums thanks to the bureau’s efforts, it hadn’t budged in wealthier neighborhoods. “Sometimes,” she writes, “it really looked as if a baby brought up in a dingy tenement room had a better chance to survive its first year, given reasonable care, than a baby born with a silver spoon in its mouth and taken care of by a trained nurse who knew all the latest hygienic answers.” Intrigued, she decided to experiment. She boarded out the sickliest newborns in the hopeless ward to a corps of gushing Italian mothers on the Lower East Side who had been trained in child care by the bureau’s visiting nurses. “Offhand it sounds like murder,” Baker confesses. “Moving these poor little potential ghosts out of this ward where everything was light and sterile and spic and span, into tenement rooms on Hester and Orchard streets.”

Once again the results were astonishing: the death rate of these vulnerable babies was cut in half. Baker had hit upon a truth that we now take for granted. At the time, medical opinion held that mothers should train their babies early to be independent by feeding them at regular intervals and ignoring their cries and babbles. Doing otherwise was thought to damage them psychologically. We now know the opposite is true. Emotionally sensitive and responsive human contact is essential for normal child development. Without such care, children may be physically stunted, mentally retarded, or even die.5 Baker had no children of her own, but she saw clearly that though a baby

may still be unable to talk, walk or do anything but feed and cry and kick,…he nevertheless needs that sense of being at home in a new world…. Even more than he needs butterfat and fresh air and clean diapers…he also needs the personal equation to give him a reason for living.

That Baker’s decisive work is so little known today is probably due to its great success: much of what she taught us now seems self-evident. She also died in 1945, when the mystique of technology was at its height. The extraordinary burst of technical innovation that occurred in midcentury brought us not only the horror of the atom bomb but also better vaccines, pesticides, antibiotics, and such mass-produced labor-saving devices as vacuum cleaners and washing machines and the first plastics and computers. These new technologies changed the world forever. But demographic studies show clearly that Baker’s methods of common sense and compassion, dispensed not by machines but by real human beings, probably saved more American children’s lives than anything else.6

The neglect of Baker’s contributions to public health may also be political. In the 1950s and 1960s, America once again faced the challenge of integrating millions of disenfranchised citizens into its systems of public education, health, and social welfare, but this time those citizens were impoverished blacks, most of whom had been left behind by the public health revolution of the early twentieth century. They occupied, in demographer Samuel Preston’s words, “a separate caste” in US society. Their living conditions were much worse than those of whites, they had poorer access to whatever medical care was available, and black women with infants were much more likely to work outside the home—and for much longer hours and in much worse conditions than white women. This would have made it difficult for them to take advantage of the new health education and provide the kind of care their children needed.

Civil rights legislation and new programs like Medicare, Medicaid, and Head Start helped many people, both black and white, but they could not shield children from the steadily worsening poverty of the 1970s and 1980s. In 1971, a group of Washington officials and their allies in the civil rights movement drafted the Comprehensive Child Care and Development Act, which would have created a nationwide system of high-quality day-care, preschool, and home-visiting programs that resembled the national system of child health programs envisioned by Baker and other reformers fifty years earlier. It passed both houses of Congress with strong bipartisan support, but right-wing Republicans, using language similar to that used to quash the mother and baby care programs, pressured President Nixon to veto it.7

As described in the excellent forthcoming documentary series The Raising of America: Early Childhood and the Future of the Nation, Nixon’s adviser Pat Buchanan encouraged conservative journalists to write commentaries with headlines such as “Child Development Act—To Sovietize Our Youth,” which Buchanan would then present to Nixon in his morning press digest, as if it represented mainstream conservative opinion.8 Even though polls suggested that most Americans supported the bill, large numbers of letters denouncing it—some even comparing it to the Hitler Youth programs—poured into the White House.

Edward Zigler, head of Nixon’s Office of Child Development and one of the main architects of the bill, read through many of them. Most seemed to him to be form letters, and he suspected that the campaign had been orchestrated by a small number of conservative opponents. Nevertheless, the president got the message and vetoed the bill. This campaign gave rise to the “Family Values” movement, which has since attempted to thwart just about every legislative proposal to support American families. Today, nearly every other industrialized nation on earth provides some form of guaranteed support to families with young children. That America still does not is considered by many to be a national disgrace.

After the veto, some experts continued to pursue the vision of comprehensive child care services. During the 1970s, David Olds, now a professor of pediatric psychiatry at the University of Colorado, was working in a Baltimore day-care center for preschoolers. Many of the children came from homes wracked by poverty, drug abuse, domestic violence, and other problems. Realizing that there was only so much the center could do to help them, he eventually went on to create the Nurse Family Partnership, a home-visiting program in which trained nurses taught poor mothers how to provide a safe, secure, stimulating environment for their children, and helped them envision a better future for themselves.

Twenty years later, Olds found that the children of mothers who received the visits were not only healthier but were also less likely to have been abused or neglected and more likely to finish school, get jobs, and stay out of jail than a similar group of children whose mothers had not received the visits. Economists now estimate that every dollar invested in high-quality home-visiting, day-care, and preschool programs results in $7 in savings on welfare payments, health care costs, substance abuse treatment, and incarceration, plus higher tax revenues due to better-paying jobs.9

In the early 1930s, Baker toured Soviet Russia. Unlike the United States even now, the Soviets already had a comprehensive system of day-care centers and preschools. Maternal and child health care were free and pregnant women were given paid leave from their jobs. Baker was well aware of the purges, labor camps, deliberate mass starvation, and other horrors of the Soviet system, but the national dedication to the care of the young impressed her. Still, as she toured these programs, she noticed something odd. None of the children ever seemed to fight or cry, and she never saw children laughing, except on propaganda posters. “They just sat and looked at you like so many little Buddhas,” she writes. Play activities were rigidly organized and even potty behavior seemed to be governed by Soviet methods of synchronized regulation.

Since its inception, the Soviet Union had been preparing for another world war, and Baker suspected that there was a connection between this and the child development programs. “You could not talk to any Intourist guide for ten minutes without hearing something about the Red Army and impending war,” she wrote, “and, from sickening experience, I know it is no accident that, in 1934, the two groups of Russians that looked really well fed were the soldiers and the children.”

In some respects, contemporary America is not all that different. It turns out that there is one group of Americans that receives high-quality government-subsidized child-care services, including day care, preschool, home-visiting programs, and health care: the US military. Unlike the Soviet version, these comprehensive programs aren’t designed to create obedient little soldiers. Instead, they use a play-oriented approach to help bring out children’s individual cognitive and social capacity. This may help explain why military children score higher on reading and mathematics tests than public school children, and why the black/white achievement gap is much lower in military families than it is in the general population.10 Since the military child-care program was created in 1989, the government has repeatedly declined requests to fund an in-depth evaluation, perhaps because if the effects were known, all Americans would demand these programs for their children too.

Baker appears to have destroyed all her personal papers, so little is known about her life except what’s in her memoir. After retiring from the Bureau of Child Hygiene, she lived in Princeton, New Jersey, with the novelist and Hollywood scriptwriter I.A.R. (Ida) Wylie, who was the author of more than a dozen romantic novels, many of which were adapted for film, including Torch Song with Joan Crawford and Keeper of the Flame with Spencer Tracy.

The witty, detached, sometimes hilarious but always morally decent tone of Fighting for Life resembles Wylie’s own memoir, My Life with George.11 Although the books tell totally different stories, some phrases, including “fighting for life,” appear in both, and it’s likely that Wylie ministered to Baker’s prose. Their third roommate was Louise Pearce, a Rockefeller University scientist who helped invent the cure for sleeping sickness and then traveled alone to the Belgian Congo in 1922 to test it. Around Princeton they were referred to as “the girls,” but otherwise, gossip appears to have been restrained. They must have been wonderful to know. Read the first page of Fighting for Life and you’ll see.