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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Nurs Hist Rev. Author manuscript; available in PMC 2011 December 1.
Published in final edited form as:
Nurs Hist Rev. 2011; 19: 29–52.
PMCID: PMC3057500
NIHMSID: NIHMS195006

Life and Death in Philadelphia’s Black Belt: A Tale of an Urban Tuberculosis Campaign, 1900–1930

Abstract

The poor health status of black Americans was a widely recognized fact during the first third of the twentieth century. Excess mortality in black communities was frequently linked to the infectious disease tuberculosis, which was particularly menacing in densely populated urban settings. As health authorities in large cities struggled to keep pace with the needs of citizens, private charities worked to launch community-oriented attacks against the deadly disease. In 1914 a novel experiment to address excess mortality among blacks was launched in Philadelphia. The success of the health promotion campaign initiated by the Henry Phipps Institute and the Whittier Centre, two private charitable associations, has been attributed primarily to the presence of black clinicians, in particular public health nurse Elizabeth Tyler. This study suggests that community health efforts also rest on partnerships between like-minded organizations and coalition building.

Tuberculosis (TB) is an infectious disease with deep historical roots. For many centuries, “ the white plague,” known also as “phthisis” or “consumption,” had wrought havoc both in the United States and in Europe, striking its victims during the most productive years of life, leaving them with little hope for cure.1 During this period, TB was viewed primarily as a disease of here dity, preying on those of susceptible predisposition. By 1882, the pathogen responsible for TB, Mycobacterium tuberculosis, was isolated by bacteriologist Robert Koch, who established the disease as communicable, passed from person to person through respiratory secretions.2 During the decades following Koch’s discovery clinicians slowly acknowledged that TB was spread through close contact and prolonged intimate exposure. This concession came despite early resistance to the veracity of the germ theory and its less than auspicious reception.

By the turn of the twentieth century, ideas about TB had further evolved so that the disease once regarded as “ the captain of death” was also recognized as a “social problem” brought on by environmental conditions.3 This shift in scientific understanding helped shape the campaign for disease prevention, placing greater emphasis on environmental reform and personal responsibility.4 According to one early twentieth-century writer, “ the part played by social conditions in the propagation of the disease is twofold. First, the presence of the specific cause depends on … the duties of the individual [emphasis mine]. In the second place, the individual organism exposed to the danger of infection resists or succumbs to the invasion of the bacillus tuberculosis … as it has been predisposed by inheritance and environment.”5 In other words, though inheritance continued to be considered a factor in the development of the, individuals were increasingly expected to play a role in lowering their risks by increasing their health awareness and changing their lifestyles. Disease outcomes were now viewed as modifiable if environmental changes such as improved sanitation and ventilation were employed.

Turn-of-the-century Philadelphia was no stranger to TB or to this evolving discourse.6 As in other northern cities such as New York, Baltimore, and Boston, Philadelphia’s tenement housing, dense overcrowding, and poor sanitation served as breeding grounds for infectious illnesses like consumption.7 Records of the Department of Public Health and Charities reveal elevated TB rates among all Philadelphian residents in the late nineteenth and early twentieth centuries, though blacks were hit especially hard. In 1900, TB mortality for black Philadelphians was two-and-a-half to three times that for native whites.8

The persistent high rate of TB among blacks, coupled with the risk of contagion to the city at large, prompted several civic groups to consider alternative methods to prevent the disease and attract black patients to clinics for treatment. The most familiar example of antituberculosis work among black Philadelphians is the work of the Henry Phipps Institute (HPI), which in 1914 hired a black nurse, Elizabeth Tyler, and a black physician, Henry Minton, to initiate antituberculosis efforts among black community residents. The HPI, established in 1903 by Lawrence Flick, was one of the nation’s premier institutions for the prevention, research, and treatment of TB. Despite its prominence and its proximity to the black community, in its first eleven years, the institute largely failed to attract black patients. After the introduction of black clinicians this trend reversed and the numbers of black patients grew.

The HPI TB campaign in Philadelphia’s black community was the subject of the early research of Sadie Mossell in 1923, and later twentieth-century historians David McBride and Barbara Bates.9 These studies describe the work of the HPI among blacks as roughly involving three phases. During its first eleven years, the institute saw little participation from blacks; in 1914, the introduction of a black nurse and physician attracted blacks to the institute; and from 1914 to the 1930s black patient participation increased. This chronological summary largely attributes the efficacy of the HPI’s antituberculosis campaign to the inclusion of racially concordant nursing and medical professionals.

While this assertion has much to recommend it as a plausible explanation for the increase in black patient attendance at the HPI, an alternative argument suggests that the accomplishment of the HPI antituberculosis efforts was more complex and involved the involvement of influential neighborhood civic associations within the black community. Looking toward other community institutions and key stakeholders adds important details to our understanding of the successful TB campaign. This level of inquiry is particularly relevant because the campaign was in reality a joint effort between the HPI and the Whittier Centre, an influential civic association. Scholars have generally recognized the Whittier Centre’s role in providing the salary of the HPI’s first black nurse, but little substantive consideration has been afforded to its function as a mediator between the black community and the HPI.

The Whittier Centre was established in 1912 with the mission to address the social, health, and housing needs of the black community. Its early work focused on members of two predominately black benevolent societies, the Co-operative Coal Club and the Rainy Day Society, both with roots dating to the preceding century. For many years Whittier Centre leaders worked closely with Co-operative Coal Club and Rainy Day Society members, and over time the strength of these contacts grew. Concerned with the pervasive threat of TB, Whittier Centre organizers partnered with the HPI to address TB in the black community. The hiring of a black nurse was the byproduct of this venture. While Elizabeth Tyler’s addition to the HPI staff was of tremendous value, equally critical to the joint effort was the Whittier Centre’s long- standing presence in the black community; its ability to leverage its relationship with black community members led to increased buy-in when antituberculosis measures were introduced.

The role of the Whittier Centre, while acknowledged by earlier scholars, has not previously been explored. Examining its mediating function between the black community and the HPI becomes increasingly important as we explore private sector organizations and their role in providing community level health resources. This study reexamines the renowned HPI TB campaign and the influence of collaborative partnerships between HPI and the Whittier Centre. The article begins with an overview of TB mortality among blacks in Philadelphia during the first three decades of the twentieth century, a synopsis of ideologies by scholars of the time to explain elevated mortality rates in blacks, and the available treatment options. The efforts of the Whittier Centre and HPI and the response of black residents are explored in detail.

Death by Numbers: The Rise and Fall of TB in Blacks in Philadelphia

At the opening of the twentieth century, TB had long been recognized as a deadly menace in the city of Philadelphia. Efforts to eradicate the disease were taken up by the public and private sectors and included educating city residents on the importance of prevention and isolation to avert the spread of the disease. Whether due to the activities of the antituberculosis campaign, or to other factors such as improvements in nutrition or increases in per capita income, in the first decade of the twentieth century, TB rates started to decline precipitously.10 The notable exception was the case of black Philadelphians, who experienced an overall but much slower decrease in mortality.11

Vital statistical records for 1900 show the death rate in Philadelphia due to TB as 197.3 per 100,000 for whites versus 447.0 per 100,000 for blacks.12 Census records reveal continued elevated mortality for the next decade, so that by 1910 deaths due to TB in blacks were 57 percent greater than for native-born whites, and 44 percent higher than for foreign-born whites.13 In 1908, TB mortality in blacks dipped significantly, but spiked in 1914 and continued to climb until 1918 (see Figure 1).14

Figure 1
Death rate from pulmonary TB in Philadelphia, 1900 –1921.

Numerous factors may contribute to the variation in these death rates. Sharp elevations of TB among blacks at the opening of the century may have resulted from newly arriving blacks during the decades after the Civil War. Some scholars have argued that upon entering the city these blacks may have lacked acquired immunity, increasing their susceptibility to the disease.15 So the higher TB mortality among blacks at the opening of the century might reflect more recently infected individuals. The drop in 1908 – 1913 is more difficult to explain; it may be attributed to city-wide improvements in sanitation or the natural peaks and troughs of the disease.

During the next seven years, TB rates again began to climb steadily, peaking in 1918. The elevation in mortality during this period has been attributed to the arrival of rural migrants between 1916 and 1920.16 As newcomers entered the city, the combined effects of lack of acquired immunity, poverty, poor housing, and overcrowding likely led to increased susceptibility to the disease.17 Other factors might include the 1918 influenza outbreak and the transient city population due to the upheavals of World War I.18 Between 1912 and 1922, the rates of TB steadily declined in whites. Rates for blacks began to decrease between 1919 and 1921, though more slowly, and continued to fall throughout the remainder of the 1920s.19

Theoretical Considerations

Several theories have been proposed to explain why blacks incurred higher rates of TB. Many early twentieth-century scientists and reformers linked elevated TB rates to specific occupations such as domestic service, which required long, taxing hours; and jobs with high exposure to dust, such as marble, stone, plaster, wood, and textile work.20 The nature of these jobs and the low wages connected with them suggest a relationship between income limitations and higher rates of TB. While there is limited empirical data for the early decades of the twentieth century to link actual income to TB mortality, occupation undoubtedly served as a reasonable proxy for economic status. Accordingly, individuals with better jobs were believed less likely to contract the infectious disease.

In a 1906 report of the HPI, TB expert Lawrence Flick noted that middle-class city residents with jobs such as teachers, bookkeepers, or saleswomen were at lower risk for contracting TB. These people typically lived in modern homes and if they did get ill, had access to the comforts necessary to insure improvement.21 For blacks trapped at the lower end of the occupational spectrum, the hazards of their vocations and low wages weighed heavily on their health.

Other rationales for excessive rates of TB in blacks pointed to what were referred to as so-called racial handicaps.22 It was believed that blacks inherited racial defects that left them physically and constitutionally weaker. Theories of racial inferiority relied partially on the field of physical anthropology, which used measurements of anatomical features in an effort to explain variances in disease frequency between racial groups.23

With the passage of years, other theories emerged, such as the “virgin soil” theory, which proposed that blacks were more prone to consumption due to their lack of exposure to infectious diseases while living in African villages, and led to a lack of inherited or acquired immunity.24 Other members of the scientific community countered that “ the Negroes as a race in the United States have long been in contact with the virus of TB. They are probably as well or nearly as well tuberculized as the white race.”25 These scholars contended that racial (inherited) differences in TB did not exist and that any increase in susceptibility was attributed to the same factors which caused increased rates among whites —“unwholesome” living conditions.26 By the mid-1930s, most clinicians conceded that both racial and environmental factors played roles in the TB death rate among blacks; little could be done about racial differences, hence concerted efforts needed to focus on correction of the physical environment.27

Treatment Options: Fears and Limits

During the pre-antibiotic era, options to treat TB included isolation, bed rest, fresh air, and nutritious food, including milk in plentiful amounts. Many of these treatments were initiated in the home or dispensaries for incipient TB patients, or in hospitals or sanitariums for more advanced cases. The existence of treatment options did not, however, ensure accessibility to blacks. Several studies pointed to the lack of treatment facilities and hospital beds reserved for black patients.28 In her 1923 study of TB in Philadelphia, Sadie Mossell reported that blacks were able to receive care for TB at only six facilities in the city.29 Philadelphia General Hospital saw 96 percent of the total number of black TB patients, though the facility suffered from poor accommodations, overcrowding, and long waiting lists.30 The two black hospitals in the city did not have beds for tubercular patients due to lack of funds.31 Mossell ended her study with recommendations for more beds and dispensaries for black residents because the number of facilities at which blacks could receive care was inadequate.32

Options for blacks to enter sanitariums for treatment were also limited due to admission restrictions at both private and state sanitariums.33 Some black residents refused removal from their homes for fear of the treatment they would receive on arriving at the sanatorium and placing themselves under the care of strangers. One black physician discussed these concerns, “ the question for travel for the negro of some means and intelligence, seeking health in a sanatoria, is not worth consideration at this time; for a sick man traveling without civil rights, not knowing where he will be permitted to shelter his weakened body and quench his parching tongue, had better, yes far better, remain at home with his family and trust God for the rest.”34 Fear of mistreatment and the unknown left many blacks with the belief that they were indeed better off at home.

Low black patient utilization of the services that were available added to the problem of limited facilities. The HPI, established in 1903, was a well-regarded dispensary for TB treatment. Located for many years at 238 Pine Street, the institute was in the heart of the city’s historic black district. Yet, despite its close proximity to black residents, “colored people did not avail themselves of the benefits of dispensaries, or if they did, made but a few visits, often but one, and then ceased coming.”35

HPI and Black Patient Attendance

Named after its benefactor, steel magnate Henry Phipps, the Henry Phipps Institute for the Treatment and Prevention of Tuberculosis was the nation’s first endowed center aimed at curtailing the infectious disease.36 Dr. Lawrence Flick, a nationally recognized authority on consumption and founder of the nation’s first TB society, the Pennsylvania Society for the Prevention of Tuberculosis (1892), was the institute’s first medical director, serving in this capacity for seven years.37

In 1910, the University of Pennsylvania took charge of HPI, and the Institute’s mission shifted largely from clinical services to research.38 After the turnover, founder Lawrence Flick departed and soon after, Charles Hatfield was appointed executive director.39 In 1913, HPI moved to Seventh and Lombard Streets.40

HPI originally inhabited a modest space in the midst of one of the city’s poorest ethnically and racially mixed communities. Bare floors and walls, a few chairs, a clerk, and three physicians constituted the staff and equipment.41 The dispensary was located on the first floor, with wards on the second, third, and fourth floors. The front room was divided into a consultation room and office, and the back room into a consultation room, waiting room, and drug store.42

Dispensary services grew rapidly, quickly outpacing the number of physicians and nurses available. At the end of the first year, the nursing staff consisted of five trained nurses and five student nurses; clinical staff increased as more patients entered the dispensary and wards.43 During the first year, 1,903 patients were seen at the dispensary; of these, 904 made one visit only. Several reasons account for the low number of returning patients: some entered the hospital, some were deemed “unsuitable,” some did not have TB, and others merely came for an opinion.44 The racial composition of HPI patients during the opening year is particularly telling: 1,846 were white and 131 black.45 These numbers are especially striking given the high TB mortality in the black community and the large number of blacks who lived near the clinic.

Flick recognized that the low number of blacks seeking treatment at the clinic did not reflect the rate of TB in the black community. He noted, “the vast preponderance of white people over colored people among the patients registered is no indication of the relative amount of tuberculosis in the races, nor of their relative poverty. The colored people are more prone to tuberculosis than white people. There probably is as much poverty among colored as there is among whites.” Blacks, however, were “loath to become a public charge and are more disposed to help themselves. They will not go into a public institution if they can manage to crawl around.”46 Flick’s observations held true: the number of patients grew steadily over first eleven years, but the number of black patients did not.

Clinic attendance patterns for HPI patients reveal interesting differences between blacks and whites. Henry Robert Murray Landis’s 1923 study of TB in blacks compared individuals in the district of the HPI and those attending the dispensary. In 1903, there were 46 black patients; the numbers dropped to 11 in 1908 and 27 in 1913, then rose to 96 in 1918 and 427 in 1922.47 There were 587 white patients in 1903, 566 in 1908, 1,253 in 1913, 1,408 in 1918, and 1,541 in 1922. Thus, from the clinic’s opening whites tended to seek treatment there more frequently.48 The figures also reflect a shift in black clinic attendance; blacks were a small fraction of the patients seen in 1903, but by 1921 they were nearly 30 percent of new patients.49

These numbers, while reflecting only a sample of those patients attending the clinic and living near the institute, are telling as they reflect trends in black and white patient clinic attendance over a span of time. The low turnout of black patients in the early years is striking, while the increase in attendance in 1918 and 1922 certainly reflects the purposeful outreach into the black community.

Other demographic information pertains to gender differences between racial groups. In 1903, black patients were 65 percent male and 35 percent female; in 1908, 55 percent male and 45 percent female; in 1913, 52 percent male and 48 percent female; in 1918, 47 percent male and 53 percent female; in 1922, 39 percent male and 61 percent female.50 Clinic attendance according to gender in whites reflected a different pattern: in 1903, white patients were 60 percent male and 40 percent female; in 1908, 48 percent male and 51 percent female; in 1913, 54 percent male and 46 percent female; in 1918, 49 percent male and 51 percent female.51

These results taken together reflect interesting racial and gender differences in clinic attendance. In 1903 more black men attended the HPI clinic than did white and black women. Male/female patterns of attendance remained fairly even among blacks in 1913 and 1918, but the number of black men dropped significantly in 1922. After 1903, there appeared to be little gender difference in white attendance, while in 1922 the downward shift in black male attendance and increase in female attendance is quite notable.

It is difficult to attribute the dramatic shift in black male/female attendance in 1922 to any particular factor; several causes may have produced it. Possible shifts in work obligations during the war years may have made clinic attendance more difficult. A plausible rationale for the increase in black female clinic attendance may have been the types of outreach efforts, which, often occurring in the home, may have focused more on women than men. Landis’s results take on more value when considered in connection with the health work among blacks beginning with the efforts of the Whittier Centre and the hiring of nurse Tyler.

The Whittier Centre –HPI Plan

Named after nineteenth-century poet and abolitionist John Greenleaf Whittier, the Whittier Centre’s mission was to create solutions to the social and health problems plaguing black Philadelphia residents. The association’s leadership were from the local community, including social progressive Susan Parrish Wharton, who served as the organization’s first secretary, and physician Henry Landis, its first president. The other members of the board were a diverse group of black and white civic activists, including five physicians, five female volunteers, and a member of the clergy. Another group of eighteen individuals made up the Whittier Centre Advisory Board. Situated at 712 South Eighteenth Street and 510 South Seventh Streets, its geographical location placed it within the heart of the growing black community.

In its first year, the association focused its efforts toward the members of two black benevolent societies located in South Philadelphia, the Co-operative Coal Club and the Rainy Day Society. They had deep historical roots in the black community and together boasted a membership of over 1,000 individuals.52 The Co-operative Coal Club (see Figure 2) was formed in 1893 and served as a way for blacks to work collectively to buy coal, which was then used as a fuel source for cooking and heating homes.5 The Rainy Day Society, established in 1905, was similar to many other sick benefit societies operating in cities across the country; it served as a safety net to its members by providing financial assistance in the event of unexpected illness. Members paid annual dues that they were able to withdraw in times of illness, or the total savings could be pulled at the beginning of each year for other purchases. By 1913, both groups were well-recognized entities within the black community. Though the Whittier Centre itself was new, many of its board members had served in the community for decades and brought to the Whittier Centre long-standing relationships with black club members.

Figure 2
Co-operative Coal Club.

These relationships prompted Whittier Centre organizers to discuss means to address poor health among black community residents, primarily through combating the excessive TB rates.54 One early annual Whittier Centre report summarized the organization’s goal, stating that: “No movement for the betterment … of the Negro, from a social as well as health standpoint, demands more attention than the one having as its object the prevention and arrest of tuberculosis.”55 Drawing on its knowledge of specific black neighborhoods, and by now having intimate acquaintance with members of the black community, the Whittier Centre thought it wise to provide funding for a black nurse to work in the community. It planned to carry out its mission by working co operatively with the HPI. This partnership was solidified through Henry Landis.

With his dual affiliations with the Whittier Centre and the HPI, Landis was perfectly suited for oversight of the new program to reduce the high rate of TB in the black community. Born in 1872, Landis was a leading clinician and researcher in the field of TB. After graduating with an AB from Amherst College in 1894, and completing medical school at Jefferson Medical College in Philadelphia in 1897, he launched a career specializing in the treatment of TB; he later founded the National Tuberculosis Association and presided over the Pennsylvania Tuberculosis Society in 1928 –1932. In addition, Landis was one of the original HPI clinicians, beginning his work there in 1903; he was assistant professor of medicine and director of clinical and sociological services, and served as visiting physician to the Commonwealth of Pennsylvania White Haven Sanatorium.56 Landis’s affiliations extended to civic organizations, including the presidency of the Whittier Centre, a position he held for more than 15 years. As such, he was influential in setting the center’s organizational agenda toward consistent commitment to prevention and treating of TB.57

Under Landis’s direction, the Whittier Centre executive board met in May 1913 to discuss the ongoing dilemma of TB plaguing the black community. Members resolved to provide funding for the salary of a black nurse, who would work on the HPI clinic staff to provide health services to members of the black community. Landis believed a black nurse could more easily gain access to the homes of other blacks, that she could “go with immunity, day or night, into districts in which it would not be safe for a white woman.” Moreover, she could establish a “greater degree of confidence with the residents in the community.”58 In a notice outlining the center’s plan for public health reform, Landis explained the tripartite role of the nurse: visiting nurse, sanitary inspector, and social worker. To fill this auspicious position, the Whittier Centre board hired Elizabeth Tyler as nurse and “medical social worker.”59 See Figure 3. She would begin her work in a limited area (one or two blocks) at a salary of sixty-five dollars per month. She was also expected to live in the district and establish the beginning of a “neighborhood house.”60 As a community resident, she would work to strengthen bonds of racial and residential identification with hopes to increase her influence on the health practices of community residents.

Figure 3
Elizabeth Tyler.

Tyler’s educational and past professional background had prepared her well for her new position. A graduate of the Freedmen’s Hospital Training School in Washington, D.C., Tyler had a first-class education. After graduation, she worked as a private-duty nurse in Northampton, Massachusetts, caring primarily for students at Smith College. Hearing of employment opportunities in Alabama, Tyler traveled south, where she worked first at A&M College in Normal, Alabama, as the resident nurse and then as an instructor teaching physiology and hygiene. In a move to further her nursing education, she moved to New York City and attended Lincoln School for Nurses for a postgraduate course. In 1906, she accepted a position as the first black public health nurse of the well-known Henry Street Settlement.61

TB Work in the Black Belt

Tyler began her new post on 1 February 1914, focusing her attention primarily on the area surrounding HPI, known as the “Black Belt” of Philadel phia. This area and its adjacent neighborhoods housed a large number of blacks, including more than 1,000 members of the Co-operative Coal Club and Rainy Day Society.62 Club members had ties to the Whittier Centre, so many of Tyler’s initial home visits were with families of which the center had “intimate knowledge.”63 In the Whittier Centre annual report for 1 November 1913 to 1 October 1914, Tyler provides a detailed report of her visits. The number of families visited totaled 327; families averaged 3 1/2 individuals; the total number of all individuals visited was 1,084.64

Tyler began her work by assessing the living conditions of each family, and found that about 62 percent required medical or social service. For Tyler, this meant offering advice, making referrals to other civic agencies, or recommending treatment at the HPI. Of the total number of families visited, 263 persons (24.5 percent) were ill “from one cause or another.” About 12 percent of Tyler’s visits found TB or symptoms of it.65 For these individuals, Tyler recommended clinical treatment or hospital care; these suggestions were accepted voluntarily by nearly 75 percent.66

After Tyler’s arrival, black patient visits increased rapidly at the HPI. In one of her early reports, Tyler noted that “it is gratifying to know that the number of colored people attending the Phipps Institute has been greatly increased as a direct result of these house-to-house investigations.”67 In the first year, more than twelve times as many black patients visited the clinic than during the first eleven years of the institute’s history.68 More advanced cases were referred to sanatoria, and sanitation measures were taught to remaining family members.69

Despite her overall success in attracting patients to the HPI clinic and increasing health awareness, some black patients did not take to receiving health advice from a nurse. Tyler recognized that she was “just scratching the surface,” and that there were “gaps and leaks in the system which caused failure in too many cases.”70 Many cases refused to leave their unhygienic surroundings from fear or preference; others failed to improve under any circumstances. One of Tyler’s early case notes reveals this paradox. During a routine investigation, Tyler came across a man, ill with a “bad cold.” She persuaded him to go to the HPI for treatment, where his case was diagnosed as TB. Shortly thereafter, he became bedridden and hospital care was necessary. Despite his declining condition, he refused hospitalization until the woman with whom he was lodging could no longer provide food for him. After much coercion, the man was finally admitted to Philadelphia General Hospital, where he died three weeks later. The Bureau of Health fumigated the premises, but despite this action, the woman of the house soon became ill with TB; she was probably infected by the lodger. In homes such as these, Tyler believed that there was no protection for nontubercular members of the household. “Had the man been discovered earlier the woman might have been in good health today.”71

Tyler pointed to early detection as the surest way of preventing further spread of the disease. This case, however, illustrates something else, perhaps more profound. As a visiting home nurse, Tyler surely recognized that understanding an individual’s response to illness started with assessing the person’s contextual reality. The woman in this case relied on this boarder to supplement her income, not realizing perhaps that there were risks involved — not only loss of family privacy, as some feared, but also threats to her own well-being. For many blacks, taking in boarders opened a de facto contractual relationship where economics and personal space overlapped. This exchange of living space for money, however, left both parties vulnerable to the health practices or non-practices, of one another. Pressing economic needs often forced blacks to think first of their livelihoods, but these choices often cost them their lives.

Tyler’s health efforts were hugely successful, and while her work began with home visits, it quickly spread to a wider audience and included talks on sanitation, hygiene, and TB prevention to large crowds at local churches, “as it was the best way to reach the people en masse.”72 See Figure 4. An additional black nurse, Cora Johnson, was hired that same year, her salary provided for by the Whittier Centre and the Pennsylvania Society for the Study of Tuberculosis.73 A black physician, Henry Minton, was added to the HPI staff in 1914, his salary provided by the Pennsylvania Department of Health.74

Figure 4
Coal Club “Ready for the Lecture to Begin.”

Minton, like Landis, served as both a staff member at the HPI and a board member of the Whittier Centre. His professional and civic background had much to recommend him for both. Minton is perhaps best known for his long-time affiliation with Mercy Hospital, the second of two black hospitals in Philadelphia. He was born in Columbus, South Carolina, on 25 December 1870. His father was head accountant in the office of South Carolina’s state treasurer at the time. Minton received his elementary education in the public schools of Washington, D.C., and an academy at Howard University before entering the prestigious Phillips Exeter Academy in New Hampshire, where he graduated in 1891. He briefly studied law at the University of Pennsylvania, but withdrew after his first year. Soon after, he entered the Philadelphia College of Pharmacy and Science, receiving his degree in 1895. Two years later, he opened what is believed to be the first black-owned pharmacy in Pennsylvania. In 1902 he entered Jefferson Medical College, where he received his MD in 1906. In 1904 he served as a charter member and founder of Sigma Pi Phi, the first black fraternity.75

Like many black physicians who graduated from white medical schools, Minton could not intern at the hospital associated with the school. To expand his clinical experience, Minton did his residency at Frederick Douglass Memorial Hospital and Training School. He left Douglass in the summer of 1907 to cofound Mercy Hospital, where he served as medical director until 1944.76 Due to his professional standing, Minton was well respected throughout Philadelphia by both blacks and whites; he was also renowned as a TB expert, serving on the staff of HPI from 1914 until 1946.77

After working with the HPI and the Whittier Centre for more than seven years, in 1922 Minton was able to gather the fruits of his labor. In its formative years, the work of the institute was largely confined to black residents in South Philadelphia. By 1921, due to the large increase in patient volume, the number of black clinicians at the HPI had grown to six graduate nurses, one student nurse, and three physicians.78 In March 1923, a new clinic was established at Ridge Avenue and Twentieth Street, allowing for expansion into northeast Philadelphia.79

During his musings, Minton reminisced on the many different collective strategies used by members of the nursing and medical staff to improve the health of the black community. First, he pointed to the work of black nurses, praising them for their hard work and noting that “the success of these clinics is largely dependent upon the efficiency and faithfulness of the nurse. Without proper follow up visits to the homes of the patients to see that they carry out the instructions of the physicians … the work of the clinic would scarcely be satisfactory.”80 Minton also recognized that information in the black community was disseminated in several ways: for example, through the church and word of mouth. In the winter of 1914, Minton and Tyler worked together on a church campaign, in which health information was provided for members of congregations.81 Minton also solicited the support of other black physicians and ministers to aid in the health work. Of all the strategies used to attract blacks to TB clinics, probably none were more powerful than word-of mouth referrals through the social networks in the black community.

In a case note, Minton described Mrs. A., a twenty-three-year-old black woman who reported to the clinic with physical symptoms of incipient TB and a protracted cough. She was given medical treatment and instructed in proper methods of physical exercises, division of labor, rest, fresh air day and night, and nourishment. She diligently followed the instructions of both Minton and the medical social worker. The social worker made house visits to ensure that the instructions were followed. In subsequent visits, the young woman was free of her cough, she had gained twenty pounds, and her general condition was described as excellent. Mrs. A.’s progress prompted her to encourage her mother to visit the clinic for examination and treatment, along with a sister and two brothers. They all showed physical signs of incipient TB, were treated, and remained in close contact with the institute for three years.82

Revisiting the HPI “Experiment”

This article revisits a triumphant epoch in urban health history. Many health practitioners in the early part of the twentieth century did not understand why rates of TB in black American communities were much higher than in white American communities. This article reviews the many-faceted theories from that time, and more important, it revisits one of the better-known campaigns against TB in a black community and challenges previously held assertions that attribute the increase in HPI clinic attendance simply to the role of black clinicians. Rather, as is made clear here, the early success of HPI with blacks was due to a variety of different, though related, factors.

First, the Whittier Centre was not simply the benefactor providing “funding for the first black nurse.” The center was the driving force and sustaining fire behind the initiative to combat TB in the black community. It had a longstanding commitment to the ideals of social justice and equality, and hoped to fight the burden of excessive illness in blacks through increasing access to health resources. The first effort toward this end was to hire a black nurse.

The success of this endeavor is undeniable. Tyler was skilled and adept, bringing with her years of experience in community nursing. Yet her early efforts were aided by the longstanding ties already established between the Whittier Centre organizers and black community residents. Due to the Whittier Centre connection with the community, they were able to leverage their ties with black families and introduce new health initiatives to an audience with whom they were already familiar. Hence, during the early and critical months of her employment, Tyler was exposed to an immediate pool of more than 1,000 actively engaged individuals. These families were familiar with the role of visitors and were apt to see Tyler as a “friend offering advice,” making them less likely to reject her recommendations.

This examination does not deny that the presence of black clinicians contributed tremendously to the increase in black patient attendance at the HPI. The fact that the three early clinicians were members of the black community is critical. During this period, black medical professionals were few in number; thus, the increasing presence of black clinicians probably invoked a sense of racial pride among community residents, increased trust, and provided a sense of belonging.

The success of the Whittier Centre–HPI collaboration hinged, however, on the ability of health workers to extend their efforts beyond immediate TB prevention to include improvement of living conditions and provision of material relief to community residents. Working to meet both the material and health needs of black residents, the institute acknowledged the likely causes of excessive illness, such as poverty and joblessness, and appropriately addressed these factors as contributors to poor health in the black community.

These findings suggest that community health efforts rest on partnerships between like-minded organizations for the purposes of coalition building. The Whittier Centre partnership with the HPI is instructive in that it features the trajectory of two separate organizations that were able to collaborate to form a new shared vision. While the Whittier Centre explicitly began as an agency purposely organized to meet the social/welfare needs of black city residents, HPI had been unsuccessful for most of its early years in attracting blacks to its clinics. Together they were able to leverage their individual strengths and expertise to a positive end.

Acknowledgments

The author acknowledges that this research was supported by the Agency for Health Research Quality (Grant F-31 HS01029 – 02) and the National Institutes of Health, National Institute of Nursing Research T-32 NR0714. Special thanks to Drs. Julie Fairman, Joan Lynaugh, and Barbara Savage for their support and feedback on earlier drafts of this manuscript.

Notes

1. By the late nineteenth century, the infectious nature of TB had generated debate for years in the United States and Europe. Despite the discovery of the pathogen responsible for consumption, deeply rooted beliefs regarding “hereditary consumption” (transmittal of the disease from parent to child) prevailed. This belief gained traction as whole families succumbed to the disease. Lawrence Flick effectively argued, however, that consumption was indeed contagious and fully discussed the differences between heredity and predisposition in his journal article, Contagiousness of Phthisis (Tubercular Pulmonitis) Transactions of the Medical Society of the State of Pennsylvania. 1888 June;20:164–82.Anticontagionists denied that consumption was spread between individuals — rather, they claimed that the disease was acquired when persons of a certain genetic predisposition came into contact with “miasmas” emanating from decaying garbage. For more on anticontagionists see Lerner Barron H. New York City’s Tuberculosis Control Efforts: The Historical Limitations of the ‘War on Consumption,’ American Journal of Public Health. 1993 May;83(5):758–66. [PubMed]
2. Lawrence F. Flick, Henry Phipps Institute Fifth Annual Report (Philadelphia, 1909) (hereafter HPI Annual Report). In his annual Clinical and Sociological Report, Flick explains the natural course of TB: “An individual inhales the dust carrying tubercle bacilli which is then implanted in the bronchial lymphatic glands or in the glands of the upper respiratory tract. The disease lies dormant in these glands or else slowly progresses during a period of years, until finally in the grown-up individual, under the stress and the vicissitudes of life and under the demands of labor and deprivation, the bacilli having gotten into the lungs or some other tissue by way of the lymphatic’s or the circulation, it breaks out full force” (21).
3. Brandt Lilian. Social Aspects of Tuberculosis. Annals of the American Academy of Political and Social Science. 1903 May;21:65.Brandt concluded that social conditions such as physical environment, poor ventilation, and lack of sanitation contributed the prevalence of TB.
4. Newman Bernard J. Preventing Tuberculosis in Pennsylvania. Philadelphia: The Society; 1914. “The Relationship of Housing to Tuberculosis,” in Pennsylvania Society for the Prevention of Tuberculosis; p. 39.
5. Brandt, “Social Aspects of Tuberculosis,” 65. According to Brandt, physical predisposition to TB was not merely a function of heredity, but was also attributed to the “attendant evils of poverty, such as ignorance and carelessness, … all of which produce a physical condition predisposed to disease” (67).
6. City of Philadelphia Bureau of Health. Annual Report of the Director of the Department of Public Safety and Bureau of Health. Philadelphia: 1901. In 1901, consumption caused 2,845 deaths. Due to the high death rates, “consumption of the lung” was placed on the list of reportable diseases on 12 March 1901. Physicians were then required to contact the Bureau of Health to report all cases of consumption.
7. Landis Henry RM. A Report of the Tuberculosis Problem and the Negro. Philadelphia: Henry Phipps Institute; 1923. p. 10a., Table 7. Landis used the U.S. Mortality Statistics for 1920, which demonstrate that Philadelphia’s TB was higher than that in any other region of Pennsylvania. It was also noted that not all cities shared Philadelphia’s high mortality. Detroit, St. Louis, and Newark all reported death rates under 100 per 100,000 compared to Philadelphia’s 137.3 per 100,000. Rates increased in the city in general and blacks specifically between 1916 and 1919 due to the combined effects of influenza, World War I, and increased occupational hazards.
8. Bureau of Health Annual Report. 1901. p. 80.
9. Mossell Sadie T. A Study of the Negro Tuberculosis Problem in Philadelphia. Philadelphia: Henry Phipps Institute; 1923. McBride David. The Henry Phipps Institute, 1903–1937: Pioneering Tuberculosis Work with an Urban Minority. Bulletin of the History of Medicine. 1987;61:78–97. [PubMed]McBride David. From TB to AIDS: Epidemics Among Urban Blacks Since 1900. New York: New York University Press; 1989. Bates Barbara. Bargaining for Life: A Social History of Tuberculosis, 1876–1938. Philadelphia: University of Pennsylvania Press; 1992. P.S. I Am … Colored; pp. 288–310.
10. It is worth noting that there is an ongoing debate regarding what factors contributed to the decrease in TB rates. While some historians argue that improved housing conditions, water filtration, and other environmental changes decreased disease rates, others attribute the decline to the success of the antituberculosis campaign. In the 1916 Bureau of Health Annual Report, diminishing rates of TB were attributed to several factors, including increased health education of the lay public with an emphasis on how the disease was spread (by means of sputum) and how the disease can be destroyed; early diagnosis and immediate reporting of cases; and isolation and segregation of advanced consumptives. Last, decreased rates were attributed to the gradual establishing of “immunity against the disease” (279).
11. Bureau of Health Annual Report. 1918.
12. First Annual Message of Mayor John E. Reyburn. Philadelphia: 1908. p. 96.
13. U.S. Department of Commerce, Bureau of the Census. Negro Population in the United States, 1790–1915. Vol. 68. Washington, DC: GPO; 1918. pp. 350–51.. It is also worth noting that while TB death rates were elevated in blacks, they were also elevated in some, though not all, European immigrants. Irish-born immigrants’ TB rates were among those elevated in the early twentieth century, but trended downward rapidly as the decades progressed. While experiencing some elevation in TB mortality rates, European immigrant death rates were never as high as for blacks and dropped more quickly. When considering mortality rates it was then and is now common practice to compare disease rates between racial and ethnic groups. While I make no specific attempt to make such comparisons, it is worth noting that a review of vital statistical records compiled by the Bureau of Health for 1900–1920 included comparative breakdowns of TB death rates by race and ethnicity. Categories such as “people of color” and “nativity” were used as broad taxonomic categories. The breakdown by race and ethnicity is helpful for stratifying disease, but it has limitations due to inconsistencies in the use of categories. For instance, a review of death rates due to TB in 1900–1918 shows that the term “people of color” generally referred to blacks except for in 1915, when “Chinese” were also grouped under this heading. It remains unclear why this change occurred in this singular year, given that every year before and after 1915 put Chinese under the subheading “nativity.” Furthermore, when considering mortality rates that compared “colored” and “whites,” it is not clear from the tables whether foreign-born whites were considered in the “white” mortality values.
14. Though death rates fell for both groups between 1908 and 1913, the rate for blacks reveals a remarkable 51 percent decline. Several plausible reasons may explain this drop. Blacks newly arrived in the city may have had low resistance. Some scholars have argued that, unlike native whites, some of whom had lived in the city for nearly a century, blacks may have been more susceptible to the disease once exposed to white society. As large numbers of black migrants arrived in Philadelphia after the Civil War, the high TB mortality at the opening of the twentieth century may reflect more recently infected blacks, whose rates were higher initially after arriving to the city, then fell off due to the natural progression (and the progressive development of resistance) of the disease. For further explanations for fluctuations in TB mortality in Philadelphia across racial and ethnic groups, see Landis . A Report of the Tuberculosis Problem and the Negro.
15. Bates, “P.S. I Am … Colored.”
16. Fuller William D. The Negro Migrant in Philadelphia” (1924), Negro Migrant Study, 1923, Housing Association of the Delaware Valley, Records, 1923–1924, 5 folders and oversize worksheets, URB 31; Sadie T. Mossell, “The Standard of Living Among One Hundred Negro Migrant Families in Philadelphia. Annals of the American Academy of Political and Social Science. 1921 November;98:173–218.
17. National Tuberculosis Association. Report of the Committee on Tuberculosis Among Negroes: A Five-Year Study and What It Has Accomplished. New York: The Association; 1937. p. 24.. See also Du Bois WEB. The Philadelphia Negro: A Social Study. Philadelphia: University of Pennsylvania Press; 1899. pp. 147–63.
18. Landis . A Report of the Tuberculosis Problem and the Negro.
19. Bureau of Health Annual Report (1918), 343. While the mortality figures surrounding TB are helpful for capturing trends, the contextual background is equally important, and useful for those interested in “unpacking” the numbers. First, when considering the accuracy of available TB mortality rates during the early twentieth century, the reliability of TB reporting should be considered. A law adding TB to the list of reportable diseases was passed in 1901, but not formally put into practice until 1906. Thus mortality rates for TB before 1906 may have been influenced by underreporting in all groups (actual rates may have been higher).
20. Landis . A Report of the Tuberculosis Problem and the Negro. p. 12.Flick . HPI Annual Report. 1906. Work of the Year; p. 19.Differences in TB mortality between socioeconomic class and occupational groups are discussed in Flick . HPI Annual Report. 1909. Clinical and Sociological Report; p. 31.
21. Flick . HPI Annual Report. 1906. Work of the Year; p. 19.Though few discussions in the primary sources discuss class differences in TB mortality rates, it is made clear that class distinctions existed and that it may be assumed that members of less affluent classes likely succumbed to the disease at higher rates.
22. National Tuberculosis Association. Report of the Committee on Tuberculosis. p. 6.
23. For further readings on early twentieth-century intellectual thoughts on heredity and race, see Ross Edward A. The Causes of Race Superiority. Annals of the American Academy of Political and Social Science. 1901 July;18:67–89.Thomas William I. The Mind of Woman and the Lower Races. American Journal of Sociology. 1907 January;12(4):435–69.
24. See also Grandy CR. Inherited Immunity in Tuberculosis. American Review of Tuberculosis. 1926 April;13(373):78.Carter HG. Pulmonary Tuberculosis Among Negroes. American Review of Tuberculosis. 1923 January;6:1002–7.Grandy CR. The Control of Tuberculosis in the Negro. Virginia Medical Monthly. 1927 December;54:566–71.Note that a similar debate was occurring regarding the high rate of TB in the Irish as compared to the English. Early twentieth-century writers continued to regard the Irish as a separate and inferior racial group, and as such, more inclined to develop TB.
25. Bushnell George EA. A Study in the Epidemiology of Tuberculosis, with Special Reference to Tuberculosis of the Tropics and of the Negro Race. New York: William Wood; 1920. p. 221.
26. National Tuberculosis Association. Report of the Committee on Tuberculosis. p. 21.
27. McCain PP. Tuberculosis Among Negroes in the United States. American Review of Tuberculosis. 1937 January;35:25–35.
28. McBride David. Integrating the City of Medicine: Blacks in Philadelphia Healthcare, 1910–1965. Philadelphia: Temple University Press; 1989.
29. Mossell . A Study of The Negro Tuberculosis Problem. p. 18.Mossell found that blacks could receive care for TB at Philadelphia General Hospital at Thirty-Fourth and Pine Streets, Rush Hospital and Clinic at Thirty-Third Street and Lancaster Avenue, Jefferson Chest at 238 Pine Street, State Clinic no. 21 at 1724 Cherry Street, State Clinic no. 107 at Frankford Avenue and Palmer Streets, and the Henry Phipps Institute at Seventh and Lombard Streets.
30. Ibid. Philadelphia General Hospital’s large number of black patients was likely due to its open admission policy, which did not bar them. It was also large and had 300 beds devoted to TB patients. Despite its size it was frequently overcrowded and accommodations were lacking. Several of the other facilities mentioned had limited bed availability on their inpatient wards.
31. Landis . A Report of the Tuberculosis Problem and the Negro. p. 3.Landis noted a lack of hospital beds at the two black hospitals, Douglass Memorial Hospital and Mercy Hospital, and attributed this to lack of funds. See also Bates Barbara. Bargaining for Life: A Social History of Tuberculosis, 1876–1938. Philadelphia: University of Pennsylvania Press; 1992. p. 220.
32. Mossell . A Study of The Negro Tuberculosis Problem.
33. Historian Barbara Bates attributes the prohibition of admitting blacks to private sanatoriums to open prejudice and the desire of white patients to limit social interaction with blacks. This was the case at White Haven Sanatorium, which enacted a policy prohibiting blacks in December 1914. In the early twentieth century, White Haven was among the institutions that accepted black patients, but white patients were angered when forced to share the same space as blacks and sent letters of protest and threats. The board of directors capitulated to the demands of white patients who threatened to leave. The fear of reprisal from private patients was of particular concern to proprietors who relied on these patients as their primary means for reimbursement for services. For more see Bates Bargaining for Life. :294–95. 323.
34. Hunter John E. Tuberculosis in the Negro: Causes and Treatment. In: Gamble Vanessa N., editor. Germs Have No Color Lines. Blacks and American Medicine 1900–1940. New York: Garland Publishing; 1989. pp. 12–19. quote on p. 18.
35. Landis . A Report of the Tuberculosis Problem and the Negro. p. 1.See also HPI Annual Report (1909), 10, 19. In his Clinical and Sociologic Report, Flick notes the low percentage of blacks treated at the institute from its beginning. During its first five years the percentage of black patients was low: in 1904, blacks represented 6.63 percent of HPI patients; in 1905, 5.65 percent; in 1906, 5.96 percent, in 1907, 9.83 percent; and in 1908, 7.68 percent. Blacks held nearly the highest rates of single visits with no return follow-up compared to other racial/ethnic groups.
36. Who’s Who in America. 1903. p. 1856.; news clipping, “$5,000 Is Phipps Gift to University of Pennsylvania for Tuberculosis Fight,” December 1909. Born in Philadelphia on 27 September 1839, son of an immigrant English shoemaker, Phipps moved to Allegheny City, close to Pittsburgh, in 1845. As a young boy, Phipps made the acquaintance of the Carnegie family, forming in particular a friendship with Carnegie sons Andrew and Tom. The boyhood friendship between Henry and Andrew turned into a profitable business partnership in the iron forge and manufacturing industry. In 1901, after four decades, Phipps sold his business interests to the United States Steel Corporation, netting $100 million. In his early sixties, Phipps increasingly focused his attention on humanitarian efforts.
37. Bates . Bargaining for Life. pp. 99–100.Pennsylvania Society for the Prevention of Tuberculosis. Preventing Tuberculosis in Pennsylvania. Philadelphia: The Society; 1914. p. 55.. The Pennsylvania Society for the Prevention of Tuberculosis was one of the first organizations in the United States to mount an organized campaign against TB. One of Flick’s early endeavors began with the founding of Rush Hospital for Consumption and Allied Diseases. The hospital opened in 1891 and accepted its first patients in 1892.
38. Gazette. 5 March, 1926. The Phipps Gift., University of Pennsylvania Archives Information Files Collection ( UPF 8.51), Folder Henry Phipps Institute; news clipping, “Dedication of the Phipps Institute,” December 1909. The HPI takeover was completed with the continued annual support of $50,000 per year from Phipps.
39. News clipping, “Dedication of the Phipps Institute.”
40. News clipping, “$5,000 Is Phipps Gift.”
41. Bates . Bargaining for Life. p. 101.
42. HPI Annual Report. 1904:4–5.
43. Ibid., 6. The early annual reports of the institute do not explicitly provide the racial makeup of its nursing staff. It may be surmised with a great deal of certainty that these nurses were white, since as indicated in subsequent Phipps records, the first black nurse, Elizabeth Tyler, is hired in 1914.
44. Ibid., 8.
45. Ibid., 12.
46. Ibid., 12.
47. Landis, A Report of the Tuberculosis Problem and the Negro, Table 1, “Analysis of Negro Patients Within Present District, in Attendance at Phipps Institute Tuberculosis Clinic in 1903, 1906, 1913, 1922, by Diagnosis, Prognosis, and Result.”
48. Ibid., Table 3, “Analysis of White Patients Living Within Present District, in Attendence at Phipps Institute Tuberculosis Clinic in 1903, 1908, 1913, 1922, by Diagnosis, Prognosis, and Result.”
49. Ibid., Table 9, “Attendance at Five Tuberculosis Clinics in Philadelphia in 1921, Showing the Number and Percent of White and Negro Patients Examined and the Number of Negro Patients Diagnosed.”
50. Ibid., Table 3.
51. Ibid.
52. Whittier Centre Annual Report. Philadelphia: 1914. p. 4.
53. Starr Centre Association. Untitled Pamphlet. Philadelphia: 1907. , Barbara Bates Center for the Study of the History of Nursing, Starr Centre Collection, Box 9, Folder 105.
54. Whittier Centre Executive Board Meeting Minutes, 1913.
55. Whittier Centre Annual Report. 1914. p. 5.
56. “Who’s Who, 1924–25 American Men of Science,” University of Pennsylvania Archives, Information Files Collection (UPF 8.51) Folder Henry Phipps Institute; Bates, “P.S. I Am … Colored,” 296.
57. Whittier Centre Annual Report. 1914. pp. 3–4.
58. Whittier Centre Annual Report. 1915.
59. Ibid.
60. Whittier Centre Executive Board Meeting Minutes, 1913.
61. Pitts Mosely Marie O. Satisfied to Carry the Bag: Three Black Community Health Nurses; Contributions to Health Care Reform, 1900–1937. Nursing-History Review. 1996;4:65–82. [PubMed]Elizabeth Tyler’s career as a public health nurse did not end in Philadelphia. In 1921 she left the HPI to take a position in Delaware for the State Health and Welfare Commission. Later she held positions in Newark and Essex County, New Jersey, for the New Jersey Tuberculosis and Essex County Tuberculosis leagues, respectively. In each position Tyler maintained her community outreach efforts for education and disease prevention. In the current examination of Tyler’s public health activities, I attempt to layer her nursing work alongside those of civically active community residents and thereby recontextualize her health promotion success within the larger scope of community-building initiatives already perculating in local black communities.
62. Whittier Centre Annual Report. 1914. p. 4.
63. Ibid.
64. Ibid., 6. The total number of visits for each family is not provided.
65. Ibid., 4.
66. Ibid.
67. Ibid., 7.
68. Whittier Centre Annual Report. 1916. p. 6.
69. Whittier Center Annual Report (1915), 5. In my examination, I saw no evidence of forcible removal of patients from their homes. Tyler could only encourage patients to go to hospitals or sanatoriums for treatment; ultimately black patients had the right to refuse.
70. Ibid., 6.
71. Whittier Centre Annual Report. 1916. p. 6.
72. Whittier Centre Annual Report. 1915. p. 6.
73. Whittier Centre Annual Report. 1916. p. 2.
74. Whittier Centre Annual Report. 1915. p. 6.
75. Philadelphia Colored Business Dictionary. Philadelphia: 1913. p. 81.
76. Minton Russel F. The History of Mercy-Douglas Hospital. Journal of the National Medical Association. 1957;43(3):153–59. [PMC free article] [PubMed]
77. Ibid., 154.
78. Whittier Centre Annual Report. 1924. p. 13.
79. This new clinic was established based on the Whittier Centre–sponsored research conducted by Sadie Mossell under the supervision of Landis. Mossell’s study indicated the need for increased treatment facilities due to persistently high rates of Mossell TB. A Study of The Negro Tuberculosis Problem
80. Whittier Centre Annual Report. 1924. pp. 13–14.
81. Whittier Centre Annual Report. 1915. p. 6.. The names of the churches are not provided.
82. Whittier Centre Annual Report. 1919. p. 11.