Fighting for Life

by S. Josephine Baker

  When Dr. William H. Park, then director of the Bureau of Laboratories of the Department of Health, wished to start a drive to make the Schick test as nearly universal as possible, he asked my staff to cooperate in carrying on the actual work. We started by giving the test to the school children after having obtained the parents’ permission in each instance. When a child was found to be non-immune to diphtheria we immunized him with routine injections of toxin-antitoxin. Today toxin is used for this purpose. We knew we were wrong from the scientific and statistical points of view. It may be more spectacular to immunize the children of school age but they are not the ones who need it most nor is their age the one when this immunization will do the most good. We should have concentrated on babies, for that is the susceptible period for diphtheria. The time of highest non-immunity lies in the period between six months and two years of age after the baby has lost his mother’s adult immunity and before he has had a chance to acquire it for himself. But preventive public health work, as well as the group we should have reached, was then in its infancy and we had to prepare the way in a devious fashion. We parted company with sense and science here. We knew we should have a fearful battle inducing mothers to let us test their babies, whereas permission to test older children was more easily gained. When a mother had once known her older child to come through such a test unharmed and when, after the subsequent injections of toxin-antitoxin she was convinced that her child was protected against diphtheria, it was not too difficult for her to let her baby have the Schick test too.

  The Bureau of Child Hygiene did its share in reducing the toll of the general contagious diseases. We had only a vague relationship with the home quarantine of these cases; our function was to protect the child while he was in school. When we began our work, measles, scarlet fever, chicken pox, mumps and whooping cough were all familiarly known as “school diseases.” At least we have changed that designation. They may still be called “diseases of the school age” but the school itself has lost the stigma of being responsible for their occurrence and spread. As a matter of fact, with any adequate system of health control in the schools, they may well be the safest places where a child can go during any epidemic. The teachers cooperated with us nobly in this campaign. In groups, they were instructed, not in diagnosis of the various diseases, but in the detection of “something wrong” physically. Each morning, each teacher looked over the children in her class. If any showed any symptom of flushed face, obvious cough, listlessness or a rash, that child was sent at once to the doctor’s office in the school and told to wait there until he came and could decide whether the child might go back to the classroom or must be sent home. A report to the Department office in each suspicious case brought another inspector who might at leisure make the final diagnosis and enforce quarantine if a contagious disease was found. Simple enough, but surprisingly effective in its results. It is interesting to know how the character of some of these diseases has changed. Years ago, scarlet fever was considered a deadly disease; today it is almost innocuous. On the other hand measles, which was formerly thought of as a necessary part of child life and of little consequence, is now a serious disease. The virulency of these two childish ailments has changed places.

  One of the most important incidents that proved the value of the properly supervised school as an aid in preventing infections, came about during the wartime epidemic of influenza. There was a frightful sweep of the disease and there were not enough doctors or nurses to care for the cases nor enough undertakers to bury the dead. Theaters and moving-picture shows were closed by order of the Health Department which took charge. By their orders, also, all business had to function under a “stagger” system, certain groups of employees going to work at stated hours so that the subways, elevated railways and surface cars might not be overcrowded at any one time. The schools came in for their share of attention. All over the country schools were closed and the children allowed to play in the streets unsupervised and ready victims of the disease. One morning Commissioner Copeland sent for me. He told me that all public schools were to be closed at once. I do not know where I got the courage to remonstrate but youth gives one reckless strength of purpose. Anyway, I did protest and asked him a question:

  “If you could have,” I said, “a system where you could examine one fifth of the population of this city every morning and control every person who showed any symptom of influenza, what would it be worth to you?”

  “Well, that would be almost priceless,” he replied, “but we haven’t got anything of the sort and why talk about it?”

  “But of course we have,” I said. “Won’t you let me try out the idea I have in mind for a week or so? I want to see if I can’t keep the six-to-fifteen-year age group in this city away from all danger of the ‘flu.’ I don’t know that I can do it but I would awfully well like to have a chance.”

  “All right,” he said, “I’ll give you that chance but, remember, the responsibility is on your head.” And as I was leaving the room, he casually added, “By the way, I am changing the name of German measles. Hereafter it will be known as ‘Liberty measles’.” And it did bear that extraordinary title for the duration of the war. War psychosis is a fearful and wonderful disrupter of horse sense.

  But the schools were kept open. All of the inspectors and nurses were assigned solely to the care of this one disease. Every morning every school was visited by one of the doctors and the children were given a hurried inspection. The children went directly to their classrooms when they arrived at the school and directly home when the school was dismissed for the day. No class came into contact with any other class. So far as humanly possible, we watched those children. Not only were cases of influenza almost non-existent among the children but the teachers kept well too. When the epidemic was over (incidentally, nothing more was said about closing the schools), we found that we had accomplished our purpose. The number of cases of influenza among children of school age was so small as to be negligible. There was no evidence at all, in this age group, that there had been any epidemic of influenza in the city. The number of children absent from school because of illness was lower than it had been for the same period the previous year. So far as I know, New York was the only large city that kept its schools open. That fact, and its results, received wide publicity and it was generally agreed that this method was the safe and sure one. It scored heavily for organized child hygiene work and was a great tribute to the doctors and nurses of the Bureau’s staff.

  When the great wave of propaganda for better teeth struck the United States, the Bureau of Child Hygiene plunged enthusiastically into the toothbrush war, of course. The incidence of bad teeth among the school children is so high that it baffles any corrective measures. We could not even try to fill one percent of the teeth that needed this care. Why not try to prevent tooth decay and have a campaign for clean mouths? We started in with all the enthusiasm of the convert. We installed a few dental clinics, staffed by dentists, for the more needy cases and we went in in a wholesale way for dental hygiene. Dr. Alfred C. Fones of Bridgeport, Connecticut, had started a training school for young women with the idea of teaching them the fundamentals of preventive dental care. Upon graduation, they were to be known as “dental hygienists” and were supposed to know all about how decay could be prevented so far as humanly possible. We took all of his graduates he could supply and soon afterward similar schools were opened in Boston, Rochester and in New York City. We established toothbrush drills in the classrooms. Any morning, a casual visitor to a school was apt to come upon an army of children all earnestly brushing their teeth. We spent a great deal of money on equipment and toothbrushes; we worked hard and long; we believed in the idea and certainly it was given every chance, but after years of trying to make toothbrushing a universal habit, we ended up just about where we began, which is only another way of saying that the results proved nothing at all and that part of our work was an absolute failure. Of course, the reason for our debacle is obvious. Denti
sts know more today about the reason for tooth decay than we did then. Keeping the teeth clean may be a hygienic habit just as washing the face is, but that the clean tooth does not decay is an exploded theory. We were, quite naturally, inundated with requests to use all kinds of dental cream and powder. We resisted them all and from the best inside information we could obtain, we invented our own dental powder which might be bought, in pound lots, for fifteen cents. It kept the teeth clean but it did not prevent decay. As selling propaganda, I can smile tolerantly at the claims made by manufacturers for their pastes and powders. Few of them are as honest as the firm which offered me six thousand dollars for my picture and a signed statement that merely said: “The sole function of a toothpaste is to clean the teeth. It has no medicinal properties whatever”; to be used for advertising, of course. I was quite willing to make the statement for the purpose of debunking the claims of grotesque advertising. But, upon consultation, I found that I was likely to be expelled from my various medical societies if I lent my name to any such purpose and I was not yet ready for this expulsion then. It does seem a pity that organized medicine can defeat its own purpose in so asinine a way. In all events they, meaning the manufacturers of dental pastes and powders, have gone back to their original fantastic claims. Someone may find out, some day, how dental decay may be easily prevented, but the great discoverer is not yet articulate.

  But we had tried, and we tried again in the matter of bad eyesight, which is on the way to being the great American defect if one may judge by the number of people who wear glasses. We examined the children’s eyes as nearly annually as we could. We fought for duller paper in textbooks, better spacing of the print and better classroom lighting in order to avoid eye-strain. But the incidence of defective eyesight is just as high as it ever was, possibly higher. I do think we got a note of sanity into the whole question of adenoids and enlarged and diseased tonsils, but there was little we could do with heart disease, besides establishing special classes for these children; and tuberculosis and orthopaedic defects seemed hopeless. We did manage to meet the challenge of undernourishment among these children. Here it was largely a matter of right feeding at regular hours, decent hygiene in the home and freedom from undue late hours and excitement. Public health education could go a long way along this road and we followed it with enthusiasm. It really meant altering the living habits of an entire population and that is a large order. But we did get results in the prevention of undernourishment even if they came slowly and were not spectacular. At any rate the proportion of cases showed a decline though it took an inordinate amount of work to bring this about.

  Shortly before I retired, I found that a working lifetime of coping with this insanely complicated and probably hopeless matter of physical defects in school children was forcing me to make one last effort to find a way out. Again, I studied all the available facts, looking for an indicative pattern in them. Presently I began to think I saw some light. The New York Association for Improving the Condition of the Poor (another of those check-discouraging names) had some important figures, laid out in age groups, which were worth considering. They showed that the percentage of physical defects in children increased from 8.2 to 9.1 between six and eight years of age, rapidly declining thereafter to 1.7 at sixteen years. In order to check this and produce more detail, the Bureau rigidly examined 139,000 school children by age groups.

  The results were more illuminating that I had hoped they could be. Sex had nothing to do with it. Both boys and girls had defects in the same proportion. And it was indubitably plain that the defects which we could hope to prevent or correct were present in largest force when the children were very young; that is, at the entering-school age of six years. Lung diseases, heart disease and nervous troubles stayed at about the same level throughout the groups at all ages, which probably meant that school life affected them not at all. Eye defects went up steadily until at the age of fourteen there were twice as many sufferers. Malnutrition, adenoids, enlarged and diseased tonsils and decayed teeth, all very popular difficulties, were at the height of their incidence at the entering-school age. It all resulted in a clear showing that if school health control was to evidence any symptom of sanity, most of our effort should be spent on examining and securing treatment for the child entering school for the first time. And so I made the following statement in my printed report: “This study seems to show that the expenditure of time and money to make annual physical examinations of all school children is unwarranted and unnecessary.” I believed that then and I believe it now. But the pressure was too great. I could not induce the Health Department to make any such revolutionary change. They preferred the shapeless, pointless, fragmentary round of haphazard examinations year after year. Even today I go to meetings of school health authorities and hear the same old figures, the same old complaints, the same old helplessness and the same old routine which never made sense or produced any worth-while results and which to me, today, sounds as archaic as an ox-cart.

  It would have been even more revolutionary to follow out the furthest implications of my figures and to try to convince the powers that were that the only really sensible thing to do would be to put the school child in the background, except for contagious diseases, and concentrate on the pre-school child. For it is the neglected, unhappy, misfit stepchild, known technically as “the pre-school child,” who is our logical point of attack. Day nurseries and nursery schools touch only the surface of this problem, and yet in it undoubtedly lies the solution of the health problem in schools. But I have been enough of a heretic in my day to avoid any more such trouble in my resting years. Perhaps, some day, the millennium will come. I can only hope so.

  People who write books about how much progress human beings have made are always telling us that the day of experimentation without a scientific background is past. Working in the public health field is apt to make one think twice about that dictum. No doubt the same is true of any other field where well established procedures make humans reluctant to reinspect their premises and contemplate change. In the days when I was trying to establish simple modification of whole milk, we used to have great arguments at the meetings of various medical societies. It was not because these doctors had found that my ideas were wrong; it was simply that they could not part from tradition. They had been told that certain procedures were correct and the simplest way was to continue them. In the face of my simple figures, they could only protest and deny. I had no scientific background for my proposed methods; they had plenty of what they thought was scientific background and they saw no reason to change their minds. And yet my whole-milk modification was a great success and is common practice today.

  There was the time when I grew quite bothered about the open-air classrooms in the schools. Not that they were bad in themselves: far from it. They were almost too good. The difficulty seemed to be that there were too few of them and that they were set apart as a sort of shrine not to be approached by the common herd. Why, I pondered, should we limit the advantage of fresh air to a chosen few? Why should we select only the most tragic cases for life in the out-of-doors? Why should we breed more candidates for fresh-air classes than we could possibly accommodate?

  In going about the schools, I was struck with the pale and anaemic appearance of the children kept in badly ventilated classrooms with closed windows and then contrasted their appearance with the twenty or thirty children who were in the one open-air classroom in the same building. Only the most undernourished children, the most anaemic and the most fragile children were considered candidates for the open-air class. Once established in it, their cheeks became redder, their appetites improved, they gained weight and made miraculous recoveries. It was all very dramatic but wholly wrong from the point of view of one who had to think in terms of the masses. Indoors, there would be too many small bodies, too closely contained in their clothes, perhaps not literally sewn in for the winter, but semi-permanently garbed just the same. The empty desks where children were absent with
colds were numerous, the children’s faces were pale, their eyes dull. Mine would have been the same way if I had had to stay in such a room six hours each day for five days each week. The Elizabeth McCormick Memorial Foundation in Chicago used to publish a poster which went to the heart of the matter, although I always suspected that much of the irony in it was by no means intended by the artist. It was a picture of a ragged, undersized, shivering boy looking up into the face of a healthy man standing outside of a door labelled “Open Air School.” “Mister,” he was saying, “how sick do I have to be to get in there?”

  It was just one of those vague worries which you try to forget and which will persist in the back of your mind. One day, about that time, it became necessary for me to write a thesis for New York University in connection with my being awarded a degree of Dr.P.H. (Doctor of Public Health). The ventilation of school buildings was a thoroughly appropriate and not well explored subject. There were so many possible aspects of it that I narrowed my study down to The Relation of Classroom Ventilation to Respiratory Diseases Among School Children. Under the circumstances, the subject matter of the thesis had to be beyond challenge. With the aid of the New York Committee on Ventilation who kindly cooperated with me in checking up on all of the ventilating apparatus and temperatures, I worked on this for two years, and the results were highly interesting.