Fighting for Life

by S. Josephine Baker

  The hospital heads were understandably frantic. The only thing that occurred to me, as I turned this paradox over and over in my mind, was that the missing element, whatever it was, obviously had nothing to do with care from the hygienic point of view. Then something which had been vaguely in my mind for some time began to take definite form, something deriving from the curious fact that, although you could make big dents in the infant death rate in tenement districts, there did not seem to be much to do about the rate in wealthy districts. Sometimes 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. If you put those two together, you arrive at the same answer I did. I cannot say I exactly believed in it myself, but there was no other way of making sense of this foundling-hospital situation, so we tried it out.

  We started taking these foundlings, every other one of whom was doomed to die before the year was out, and boarding them with tenement mothers—actually removing them from the admirable conditions of the hospital and exposing them to the hazards of slum conditions. Poor mothers, who had already had experience in raising families under supervision of the Bureau of Child Hygiene, were paid ten dollars a month to become foster mothers of foundling babies until they were well started on the problem of staying alive. We chose our foster mothers carefully and gave them the necessary supervision and aid of a trained staff of doctors and nurses, but even so we did not expect the results we got. In four years we had only one foundling in three dying where one in two had died before, and the decrease would probably have been much sharper if we had had funds and facilities for boarding them all out.

  When we saw how successful this plan was, we really went looking for difficulties and worked on the problem of the hopeless ward in the foundling hospital, the place where prematurely born and obviously moribund babies were put and given the best of care. Thoroughly futile it was: the death rate in that ward was actually one hundred percent. Any scrawny, bluish, half-alive baby that went there, to be wrapped in cotton wool and fed with a medicine dropper, was morally certain to fade out after a little while, and through nobody’s fault at all. There was no possible harm in trying the foster-mother system on these unfortunates, because they were all going to die anyway. I went to the Russell Sage Foundation and induced them to furnish an additional five dollars a month as pay for foster mothers taking these difficult cases, and we began moving these poor little potential ghosts out of this ward where everything was light and sterile and spick and span, into tenement rooms on Hester and Orchard streets. Offhand it sounds like murder. In actual practice, however, the foster mothers worked miracles. We reduced the death rate among these hopeless cases from practically one hundred percent to a little over fifty percent in one year.

  It was just a guess on our part, an effort to alter an environment in order to give something better a chance to happen. But the more I reflected on the kind of alteration we had made, the closer I came to an idea which is, from the orthodox medical point of view, pretty heretical. There were the rich children, beautifully taken care of by white-starched professionals, dying with uncanny readiness as soon as something went wrong with them. There were the slum children who, given halfway proper feeding and care, could stand up under diseases that would have killed the rich children. There were the wretched little foundlings dying wholesale under fine hygienic conditions and flourishing, relatively anyway, when conditions were much worse—but, very significantly, when they began to get personal care from a maternally minded woman.

  That was the chief difference and it meant something. The rich baby’s nurse, who never picked him up and crooned to him, merely fed him the right thing at the right time and kept him properly aseptic, was in the same category as the foundling hospital’s nurse who turned the foundling over at the right time and gave him the best of care with all the impersonal efficiency of a well-intentioned machine. That was why I became and still am a firm believer in mothering for babies: old-fashioned, sentimental mothering, the kind that psychologists decry. It should not be carried to excess and it should not be continued too long, but there is little doubt in my mind that many a baby has died for lack of it. He may still be unable to talk, walk or do anything but feed and cry and kick, but he nevertheless needs that sense of being at home in a new world which only fond personal attention from his mother or the psychological equivalent can give him. He needs it even more than he needs butterfat and fresh air and clean diapers. Modern medicine learned a good while ago to give him material things in greater quantity than ever before. But that he also needs the personal equation to give him a reason for living is the only answer I could ever find in that experience with the doomed foundlings.

  Not that this is the only assignable reason for the relatively high mortality among the children of the well-to-do and the wealthy as opposed to those in the lower income brackets. The nearer the family income gets to $3,000 a year, the better chance a baby in that family has of living. The moment the family income crosses the $3,000 mark, the baby’s chances of dying increase until the family income gets appreciably above that amount. This may well be because the lower income families are eligible for the kind of supervision and care that is given them by organizations like the Bureau of Child Hygiene. With sixty thousand babies a year under our care, we had a right to feel that this was true. The very wealthy mother can well afford to have proper prenatal care and careful supervision of her baby’s life. I am tempted to say that she can afford to have the same care that is given freely to the poor. But the middle-class mother, neither rich nor poor, can seldom afford such care and is too proud to ask for it free. In this, as in nearly all other medical matters, the “white collar” class is unable to obtain the best of medical care or advice and the baby death rate tells the tale.

  Another reason is that babies and children in the tenements acquire an immunity to disease from the very fact of their environment. This is not true of the better protected children of the rich. The whole question of this acquired immunity is a fascinating problem in medicine. Too much protection and care in avoiding the normal hazards of life can be a grave mistake. Three stories come to my mind which may help toward a better understanding of this complex immunity problem. The first is a personal experience. In my student days part of our experience came from work at Bellevue Hospital. Once, during the late spring, with other students, I was in the wards there making “rounds” with Dr. Alexander Lambert. It was just after Admiral Peary had returned from the North Pole and he had brought back with him a number of Eskimo men. Our pneumonia season was well over in New York and yet soon after their arrival, practically every one of these Eskimo men came down with a particularly virulent type of pneumonia and was being cared for in the hospital. So far as I can remember, nearly all of them died. They were not immune to this disease; it was unknown where they came from and so they were so susceptible that they succumbed at once.

  The second and third stories are equally interesting. One was told me by Dr. William H. Welch of Johns Hopkins. He said that during the first months after the United States went into the World War, our soldiers in Europe consisted only of troops of the regular army, all men in splendid physical condition and with absolutely no trace of tuberculosis. These troops were quartered with troops from French Africa and soon afterward practically all of these Africans came down with tuberculosis in an acute and almost malignant form. They had never had tuberculosis at home; it was an unknown disease there. The mere contact with large numbers of men from a country where tuberculosis was endemic was sufficient; they were non-immune to this disease while the white men had acquired immunity by long contact with the infection. The last incident concerns the time of the World War also. When the troops from the small towns began coming to New York to be placed in camps nearby, these boys were promptly brought to the contagious disease hospitals of the New York
City Department of Health suffering from the minor contagious diseases which we associate with childhood: measles, mumps, chicken pox and occasionally scarlet fever. Practically all of these country boys were our patients; they too had no immunity while our city boys either had had these diseases or had acquired immunity long since from living in a city where such diseases were always rampant.

  So I do not think that anyone can take an undue share of credit for reducing the baby death rate when it takes place in the poorer districts. Still it had to be done and much to my surprise it was not at all difficult. The point that had to be stressed was its utter simplicity. Given a group of babies who were largely immune to the common infections and almost immune to conditions that would kill carefully brought-up children, we soon found that simple changes in diet, plenty of fresh air, simple clothing, adequate bathing and regular schedules worked wonders. Breast feeding alone is responsible for a large part of the reduction of the diarrhoeal diseases. Prevention of disease was not too difficult. It was extraordinarily easy to keep these babies well and the lowering death rate proved that this simple way was the right one to follow. We were helped enormously by the fact that we had to work out the right methods by trial and error. There was nothing that we could follow; we had to make our own way and evolve our own procedure, without precedents to help or to bother us. We had to go confidently into the practice of new techniques, had to improvise our own methods of midwife control and baby care. Our goal was to keep well babies well, so that they would not become sick and probably die, and we had to defy all orthodox methods when they did not bring us the desired results. Again it seems strange that the methods we evolved could ever have been new and untried.

  We concentrated upon babies at first because reducing the baby death rate was, and still is, the most spectacular, the quickest and the easiest part of the whole field of child hygiene. When that was well established we moved on to the finally complete supervision of the whole cycle of child life.

  CHAPTER VII

  BABY HEALTH STATIONS, AS WE CALLED THEM, were among the Bureau’s earlier achievements and, as I look back on our work, were the place at which we first dug deep into the problems we had wished on ourselves.

  At this point elder readers must cast their minds back thirty years or so and remember that in that short interval the whole milk supply of New York, and nearly all other big cities, has been revolutionized. The pasteurizing process was already known, but the great bulk of milk consumed by the poorer people was “grocery,” or “loose” milk, unpasteurized, originating from all sorts and conditions of dairies, sold in dubious containers, and undoubtedly one of the most prolific sources of babies’ and children’s diseases. It came into New York City from six different states, all with different sanitary regulations and standards of enforcement, and was never less than twenty-four hours old when it entered the grocery store, to be dipped into for bulk sale. Under those circumstances telling a tenement mother to give her child so much milk a day was like telling her to give him a diluted germ-culture daily.

  Then there was the other problem of how to get the tenement mother properly to modify cow’s milk for the human baby. No modern mother needs to be told that the differences in protein and butter-fat content and other details between cow’s and human milk are extremely important to the baby that drinks it. But that was new in our time too and had to be sold to the tenement mother, as only one of a number of things she must learn if she was not going to kill her baby even with the best intentions in the world.

  In the baby health stations we were definitely building on the experience of others. France had developed private institutions called the Goutte de Lait and the Consultation des Nourissons which supplied milk for babies whose mothers had abandoned the idea of breast-feeding, making some attempt to teach modification, and in the United States, establishments generously subsidized by Nathan Straus and others were distributing modified and pasteurized milk free in some thirty large cities. (The Straus stations were gallant battlers in the cause of pasteurization and did a great deal to combat the public’s unhappy prejudice against “cooked” milk.) But I think we were the first to use milk-distribution as a way of coming into contact with mothers in order to educate them in scientific child care—always modified by common sense as the cow’s milk was modified for human babies’ consumption. We early developed the idea that, if we sold whole milk just enough below standard prices to tempt mothers to come to us, we could teach these mothers a great deal about baby care in the process of milk-buying. “Women and children first” was our natural motto, and since young babies are helpless by definition, it was the women we campaigned for, first, last and always.

  So we decided to set up in all of the poorer neighborhoods, Bureau establishments which would combine the education of mothers with the distribution of whole milk for young babies with instructions as to home modification. The eventual success of the scheme showed that it was thoroughly sound. But, when we put the idea up to the city fathers, they would have none of it. A fine notion, no doubt, but the tax rate was already at high-water mark and where would they get the money? Two years as head of the Bureau of Child Hygiene had already given me a lifetime of experience with municipal financiers, so I did not try to argue the point. If the city would not supply public funds, we would have to get private funds. With splendid public spirit Mrs. J. Borden Harriman formed a committee to raise enough money to start thirty baby health stations and keep them open for a few months. She raised about $165,000 from her wealthy friends and people in Wall Street, and this mechanism for supplying the babies of the poor with the necessity of life started to function on strictly capitalist money. Then, when the money ran out, I put it squarely up to the shrinking city fathers. Either the next budget included enough to keep these institutions going or they closed down, just when the wives and babies of thousands upon thousands of voters were beginning to value them and, which was probably even more pertinent, just when the newspapers were waxing most enthusiastic about the stations’ good work. Due in great measure to the influence of George McAneny, who was President of the Board of Aldermen under the reform administration of Mayor Mitchel, the city fathers managed to see the point. When all the parliamentary rubbish was cleared away we had an appropriation large enough for all our old stations and ten additional new ones. We all smiled at one another and started in to lease new premises and paint them blue, yellow and white—nice clean colors which also happened to be the colors of the city flag. They were well equipped and furnished.

  Like everyone else in the medical profession of the day, I had been trained in the then unimpeachable Rotch school of milk-modification, which was based on consideration of the baby’s age, health, complexion, nationality, color of eyes and numerological and astrological data—or at least so it seemed when you started working with it. Pediatricians insisted that no tenement mother, lacking accurate instruments and technical training, could do anything at all with milk-modification, and with that method they were quite right, so private milk stations of the Straus type had previously modified the milk for each mother, establishing a special laboratory for that purpose. But with our overcrowded facilities that method would have been like trying to serve a nine-course banquet for five hundred people out of a kitchenette. So I risked my professional reputation and all my hopes of getting cooperation from the medical profession, who were already quite sufficiently upset about the possible effects of our free service upon private practice, by starting a scheme for modifying milk which threw out all the higher mathematics and complications of the Rotch method and put the addition of water, lime-water and milk-sugar on the simple basis of what the baby weighed. I was not so presumptuous as to do it alone. Three eminent pediatricians sat in on the preparation of these formulae. But they were so apprehensive about it that they solemnly pledged me to keep their names out of it when the storm broke. It broke. Once again high and mighty medical associations called me a murderer and once again I was able to demonstrate with
figures that the babies I was murdering were much livelier little ghosts than the city had ever known before. Today that system of milk-modification is standard practice everywhere for well babies.

  But that is by the way. The emphasis was on the fact that Mrs. Slivowitz was coming to the baby health station —with her baby—having it given a careful examination and receiving a cheerily disguised lesson in how to care for it, and then taking her quart of milk home to modify it herself. I remember one tenement mother who confessed to a visiting nurse that her baby, a poor little wretch with all kinds of skin ailments, had never been bathed since she had left the hospital with him. When she was asked why: “I can’t bathe him,” she said, “I haven’t got any marble slab at home.” And then it came out that the only time the poor soul had ever seen her child bathed had been in the hospital on a marble slab, which, she had concluded, was as essential a part of the procedure as soap and water. Everything you taught had to be simple and standardized enough to fit that kind of mentality.

  That was a fairly successful job of hewing to the line, and the chips had not wrought any permanent damage, no matter how angry they made people for the moment. All during the development of our organization the Department of Health had also been working on the problem of the milk supply. When the smoke had all cleared away, New York City had established the familiar A, B and C standards of milk grading which now make it practically certain that the consumer gets pure milk for his money. A milk is either certified raw milk, free from all suspicion of contamination, or the richest kind of pasteurized milk. B is a perfectly respectable pasteurized milk, which makes up the bulk of present-day consumption, and it must be bottled before delivery to store or customer. C is not necessarily pasteurized or bottled and so can be used only for industrial purposes; it is against the law to sell it for drinking purposes. As I mentioned before, the public was vaguely hostile to the idea of pasteurized milk, and I must confess that, before the dairies perfected the process, pasteurizing the milk did make it taste as though it had been boiled. It hardly needs to be mentioned that the big milk companies were against pasteurization because the process was expensive and called for an installment of new equipment and eternal care. But the public was gradually sold on, and the companies gradually forced into, the idea. In no time the public was drawing huge dividends of health. (I do not mean that all this was due to the work of the Bureau of Child Hygiene. We were only one of hundreds of organizations in the campaign for safe milk.) Our supply was early arranged with the Sheffield Company, from a specially selected creamery out beyond Port Jervis. This milk was of Grade A quality, pasteurized and bottled at the dairy, brought into the city on ice in special cars, and delivered each morning only a few hours after the milking. They established a price which enabled us to sell Grade A to our mothers at the same price they would have paid for Grade B at the store.