Fighting for Life

by S. Josephine Baker

  The hospital laboratories speedily proved that Mary was as dangerous as Dr. Soper had suspected. Her bowel movements were a living culture of typhoid bacilli. Her blood and urine showed nothing abnormal. But, as a cook, Mary could contaminate every bit of food she cooked and every dish she touched. And, to me, the interesting part of it all was that if Mary had let me have the specimens I was sent to get, she might have been a free woman all her life. It was her own bad behavior that inevitably led to her doom. The hospital authorities treated her as kindly as possible, but she never learned to listen to reason. When they suggested removing her gall-bladder, the probable focus of infection, she was convinced afresh that this was a pretext for killing her. The only answer was to keep her in the custody of the Department, out of contact with other people’s food, and she was given quarters at North Brother Island in the East River.

  For three years she stayed there and then was released on a solemn promise given to Dr. Ernst Lederle who was then Health Commissioner, that she would never again take any position that involved handling food. But cooking was, after all, her trade and she was constitutionally incapable of believing all this mystery about germs. So she went back to it, with the inevitable consequences. When typhoid broke out suddenly in a New Jersey sanitarium, it developed that Mary had been working there and had then run away when the disease developed. A short time later, typhoid appeared in the Sloane Maternity Hospital in New York City, with two deaths out of twenty-five cases. Although I was no longer a roving inspector, I went up there one day and walked into the kitchen. Sure enough, there was Mary earning her living in the hospital kitchen and spreading typhoid germs among mothers and babies and doctors and nurses like a destroying angel.

  This time she had to go back under a life sentence, to North Brother Island. Until the other day she was still there and she still had her gall-bladder. She had threatened to kill me if she could get out, and during the years she was at large, that little doubt would stay in the back of my mind. But I could not blame her for feeling that way. From my brief acquaintance with Mary, I learned to like her and to respect her point of view. After all, she has been of great service to humanity. There have been many typhoid carriers recognized since her time but she was the first charted case and for that distinction she paid in a life-long imprisonment. Today, typhoid carriers are usually allowed their freedom, after they have pledged themselves not to handle other people’s food. And, so far as we have been able to discover, they have kept their word. It was Mary’s tragedy that she could not trust us.

  Typhoid Mary made me realize for the first time what sweeping powers are vested in Public Health authorities. There is very little that a Board of Health cannot do in the way of interfering with personal and property rights for the protection of the public health. Boards of Health have judicial, legislative and executive powers. They are the only public agencies that combine all of these powers. It all dates back to a bad cholera epidemic in New York almost one hundred years ago, when cholera and yellow fever were still potential menaces along the Atlantic seaboard. This outbreak was so serious that a petition was sent to the State Legislature asking that emergency police measures be created for proper protection against this invasion. A Board of Health was created and, in order that it might be fully effective in any emergency, the legislature granted it extraordinary powers to use as it saw fit. These laws still persist. Today practically all Boards of Health have the same wide powers, but it is to our credit that they have used them wisely.

  All of which made it strange that, in my early days, a huge municipality like New York was doing so little to control contagious diseases among children of school age. Doing anything at all was comparatively new. It was as late as the nineties that Boston and Philadelphia began pioneering in this field. I have already spoken of how pointless and sketchy school medical inspection was when I first began working for the Department. In 1902 a new administration had made an effort toward increasing the efficiency of this work, had employed additional inspectors and begun the huge task of attempting to examine each child periodically. The routine inspection for contagious eye and skin diseases was done in a way that seemed farcical and yet it yielded enough information to make it worth while. It was a rough way of finding the worst cases and brought many of the minor ones to light. My experience in this was the same as that of all the other medical inspectors and the same method is followed today in a large proportion of our school systems. When I entered the room the children all arranged themselves in a line and passed before me in solemn procession, each child stopping for a moment, opening his mouth hideously wide and pulling down his lower eyelids with his fingers. For our purposes it gave the doctor an opportunity of looking at the child’s hands (for skin diseases), his teeth, throat and eyes all at the same time. For the children’s purposes it was a beautiful opportunity for making a face at teacher unscathed and they made the most of it. It all seems very superficial and yet it was such a test for our quick and accurate diagnosis that we learned a great deal. After a year or two at this sort of inspection, I reached the place where I could pick out the undernourished children and those with other obvious physical defects almost as soon as the door was opened and before the children passed before me.

  We started out on the principle that any case of contagious eye or skin disease must be sent home at once to prevent the spread of any further infection. But the sheer numbers of such cases put a stop to that scheme before we were well started. We were literally depopulating the schools, for the results of this first real inspection were tragically astounding. Four out of five of these children, about 80 per cent, had pediculosis—the polite medical term for head-lice. One out of five, some 20 per cent, had trachoma, that highly infectious eye-disease which constitutes so serious a risk of blindness that the immigration authorities no longer allow any case of it to enter the country. You may remember that recently when they made an exception in favor of Kagawa, the Japanese people’s cooperative organizer, they stipulated that a doctor would have to stay by his side throughout his tour to guard others against infection. The infectious skin diseases—scabies, ringworm and impetigo—were almost as frequent. Those were not schoolrooms we inspected; they were contagious wards with all the different diseases so mingled it was a wonder that each child did not have them all. Many of them did: lice, trachoma, scabies, ringworm, all at once.

  When we started sending these children home with orders to stay away from school until the infections were well, the schoolrooms, in many schools, were practically deserted. The children’s parents were painfully astonished at finding that Giuseppe and Isador and Sonya were being kept out of school because of inconspicuous troubles to which no one had ever paid any attention in the old country. That was one of our chief handicaps, of course. Our present rigid restriction of immigration had not yet begun, physical examination of immigrants was hardly yet existent, and the famous melting-pot of Manhattan Island had long since become a huge germ culture. The Mediterranean and Balkan slums and southern Russia were emptying their underprivileged into Ellis Island and, on reaching their new country, these underprivileged were likely to be a definite medical and public-health problem. No one had told them what to do about these seemingly minor ailments and they had never known themselves that anything could or should be done.

  It was a thoroughly insane situation. Not the least ridiculous detail of it appeared when the truant-officers, finding the schools emptied of pupils, began going around and ordering these children back into school. Here was one city department prohibiting the children from attending school and another city department commanding the parents to send them to school. At that point, I suppose, the children’s parents concluded that, without exception, all government officials in this new country were crazy. It looked as though there were no solution. The answer came as answers will if one tries to find them. Dr. Ernst Lederle, who was then Commissioner of Health, consulted Miss Lillian D. Wald. Miss Wald, the well-loved and great-souled head of the
famous Henry Street Settlement, was ready to share her knowledge of social and public-health problems with all who might be helped. She had a solution. She would lend the Department of Health one of her best qualified nurses, a Miss Lina Rogers, whose common sense and wide experience might be a starting point in the right direction. Miss Rogers turned out to be a dignified, attractive person who exuded capability and adaptability and all of the other required qualities. She well merits the distinction of being the first public health nurse in this country as a result of this task.

  After Miss Rogers had carried out a few months of experimental work in a particularly bad school, we had evolved a scheme to check these minor infections. Our war on pediculosis in the New York City slums (aided by the restriction of immigration), for instance, has turned a matter-of-course condition into a disgrace. The method of attack was home-missionary work, teaching whole families that a shampoo and fine-tooth comb technique followed by soaking the hair in kerosene to kill the nits would accomplish our purpose. I can still see the lines of little girls with their pigtails pulled forward over their eyes so that the nurse could look through their hair. There were hazards about this job. All nurses periodically acquired lice themselves. Even I, who seldom had to do that work of inspection, have not avoided that infection on several occasions.

  For the care of the infectious skin diseases, we planned a readily applied protective treatment to keep the infection from spreading. When treated, the children could stay safely in school without danger of spreading the infection to others. We established a clinic in each school, supplied with simple remedies, and the children reported each day to the nurse for the appropriate treatment. We could not take any chance with trachoma; it was too serious a disease. So we solved that problem in a different way. Throughout the city we established special classes in the schools for these affected children. They could go on with their studies but were not allowed any contact with the other children in the schools. For the worst cases, we had special clinics where children who could not be allowed in school could have the specialized treatment necessary, or where operations that had to be done could be performed with safety and skill. These clinics were crowded for many years but were given up long ago as trachoma has now sunk to the vanishing point. That was another victory.

  As a result of Miss Rogers’ experiments, the Department installed her technique in other schools and employed several more nurses to carry it out. Eventually the school nurse with her equipment and medicines and shrewd willingness to go as far as was advisable without a doctor’s advice was known all over the city. Today, there is hardly a place in the United States that does not support a school nurse. The results were quite as astonishing to me as the appalling conditions the nurses were combatting. How much school nurses have accomplished was vividly brought home to me a few years ago when I was teaching a course in public health at Teachers College, Columbia University, and made a practice of taking my students down to a public school for a first-hand lesson in the technique of inspecting school children. Naturally I wanted plenty of cases of contagious eye and skin diseases for demonstration, so I asked the Superintendent of Nurses to have sent to me every available case of pediculosis, scabies, trachoma, ring-worm and impetigo to be found in the Borough of Manhattan. The response was breathtaking—because it was so meager. In all of the Borough of Manhattan they could never produce more than two or three cases of any given infection, whereas fifteen years before we had had them by the hundreds in every public school. Our care and treatment had been an overwhelming success—a magnificent tribute to the splendid and thorough work of the school nursing staff.

  By this time my attitude toward public health problems was approaching a definite plan. I did not yet know the exact answer I expected, but I had a feeling that it was just around the corner. It was. That corner was turned when I was assigned to work with a group from the Bureau of Municipal Research—a privately financed organization which was always looking into and checking up on details of city affairs where political administrations were too ignorant, too cautious or too lazy to bother to seek out the facts. At that time the Bureau was managed by Henry Bruere, now president of the great Bowery Savings Bank, William H. Allen, a well known investigator, and Paul Wilson, husband of Frances Perkins, the present Secretary of Labor—keen people, all of them. When they started investigating New York City’s scandalous death rate, I was assigned to cooperate with them as politely as possible.

  It might have been just another assignment. But in the course of their study, the Bureau turned up one set of facts that made me stop, look and listen. Of all the people who died in New York City every year, a third were children under five years of age and a fifth were babies less than a year old. It was the babies and small children who never really had a chance to live, who swelled the death rate to fantastically macabre proportions. Interesting figures beyond any doubt; perhaps they impressed me so particularly because they were not just cold statistics to me at all. I had served my time in that long, hot summer in Hell’s Kitchen when I walked up and down tenement stairs to find in every house a wailing skeleton of a baby, doomed by ignorance and neglect to die needlessly. I had interviewed mother after mother too ignorant to know that precautions could be taken and too discouraged to bother taking them even when you tried to teach her. If mothers could be taught what to do, most of these squalid tragedies need never happen. The way to keep people from dying from disease, it struck me suddenly, was to keep them from falling ill. Healthy people didn’t die. That sounds like a completely absurd and witless remark, but at that time it really was a startling idea; at any rate it seemed so to me. And I found that it was when I tried to convince the authorities that something might be done about teaching people how to stay well.

  Preventive medicine had hardly been born yet and had no portion in public-health work. People were speaking of Colonel Gorgas’ work in cleaning tropical diseases out of the Canal Zone as if he had been a mediaeval archangel performing miracles with a flaming sword instead of a brilliant apostle of common sense and sound information in combatting epidemics. The great campaign to prevent and combat tuberculosis with Dr. Herman M. Biggs as its fine leader was still in its infancy. At that time health departments went entirely on the principle that there was no point in doing much until something had happened. If a person fell ill with a contagious disease, you quarantined him; if he committed a nuisance you made him stop doing it or made him pay the penalty. It was all after-the-fact effort—locking the stable door after the horse was stolen; pretty hopeless in terms of permanent results. No, there was no preventive medicine in public health. The term “Public Health Education” had not been invented. Perhaps something might be done; I was not sure but I hoped it could be tried.

  The Bureau of Municipal Research group and I saw this at the same time. They had authority; I had none. And then they recommended to the Department that a division should be established to deal with the matter. Dr. Darlington and Dr. Bensel were favorable to the idea. Dr. Bensel called me into his office one day in the early summer of 1908 to tell me I might have a try at it. I came out of that office the proud and bewildered Chief of the newly created Division of Child Hygiene. I had no staff; I had no money; all I had was an idea. It was clear to the Commissioner that it was going to be a struggle to convince the Board of Estimate and Apportionment that money could be legally appropriated to care for well people. I could see that myself. A large part of being a successful government administrator consists of being able to keep the political powers-that-be appropriating funds for your pet projects; that is as true today as it always has been. You have to be a salesman as well as an executive. As a salesman I was going to need an impressive sample before I could get into our budget a sum large enough to pay for any such experiment. It had to be more than an idea: it must be something concrete and definite if the money was to be forthcoming.