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This historical inquiry illustrates the power of social networks by examining the Starr Centre and the Whittier Centre, two civic associations that operated in Philadelphia during the early 20th century, a time when Black Americans faced numerous public health threats. Efforts to address those threats included health initiatives forged through collaborative social networks involving civic associations, health professionals, and members of Black communities. Such networks provided access to important resources and served as cornerstones of health promotion activities in many large cities. I trace the origins of these two centers, the development of their programs, their establishment of ties with Black community residents, and the relationship between strong community ties and the development of community health initiatives. Clinicians, researchers, and community health activists can draw on these historical precedents to address contemporary public health concerns by identifying community strengths, leveraging social networks, mobilizing community members, training community leaders, and building partnerships with indigenous community organizations.
Black Americans have historically experienced worse health outcomes and much lower life expectancy than have their White American counterparts. These trends, although notable today, were equally prevalent nearly a century ago, when Blacks faced persistent health threats because of the cumulative impact of infectious diseases, poverty, and limited health resources.1 During the second decade of the 20th century, stark disparities in health between Blacks and Whites drew the increased attention of public health officials in northern cities as large numbers of rural southern Blacks left agricultural settings in search of jobs and increased social freedom in the north.2 Upon their arrival in northern metropolises many of their dreams were dashed as they encountered substandard housing, hazardous working conditions, and poor sanitation. A number of public health practitioners, aware of the relationship between poor health and social conditions, initiated campaigns to decrease urban blight and prevent communicable diseases. These programs, however, often failed to adequately address the needs of growing urban Black communities. Hence, left with a scarcity of resources from municipal agencies, Black community members turned inward toward their own private civic associations to meet their health and welfare needs.3
Civic associations during this period were characterized by progressive ideals and an agenda of social reform. As Smith and Hine demonstrate in their work on Black club women, these social welfare organizations laid the roots for the implementation of many large-scale public health reform initiatives.4 For Blacks in the early 20th century, membership in civic associations such as mission societies, charity organizations, churches, women’s clubs, mutual aid societies, and benevolent associations provided access to important public services and a network of social support. Because of their long-standing work in many Black communities, civic associations held positions of prominence in those communities, helping to form the fabric of social order by promoting messages of uplift, thrift, and personal responsibility. Most civic associations were financed by dues collected from their constituents or by contributions from wealthy donors and were located in poor immigrant and Black communities. Several offered health services through dispensaries or by nurses who were hired to provide care in the home.5
The popularity of civic associations grew steadily during the Progressive Era because they offered a wide variety of services. For the Blacks they served, civic associations brought relief from the often complex burden of illness, social isolation, and economic need. Blacks experienced high rates of tuberculosis (TB), so they were interested in civic programs pertaining to health and disease prevention. These programs were primarily focused on health promotion, but they also provided opportunities for middle-class and working-class Blacks to socialize with one another and with White philanthropists in the larger community. Over time, relationships between community members of diverse racial and class groups led to a growing sense of civic unity and laid the foundation for the subsequent development of a number of community health initiatives.
Civic associations have long occupied a prominent position in US society, and their role in the development and operation of community health programs warrants more attention. The accomplishments of many community health programs depended on a civic association’s ability to establish a sense of group cohesion and trust among community members. This was particularly true among members of Black communities, who for centuries relied heavily upon institutions such as churches and benevolent societies to meet their health, social, and welfare needs. Here I describe support networks developed with the aid of two civic associations—the Starr Centre and the Whittier Centre—to support Blacks in Philadelphia, Pennsylvania, during the early 20th century. I highlight the origins and programs of the associations, their establishment of ties with the Black community, and the relationship between building strong community ties and the development of health initiatives.
The events examined here occurred a full century ago, but they hold lessons applicable to 21st-century issues in public health. Many of the norms, values, and institutional infrastructures present in Black communities in the early decades of the 20th century remain in place today. Thus, a fuller appreciation of the dynamic and reciprocal nature of these relationships can serve as templates for public health activists who strive to create sustainable health coalitions among diverse communities today. Moreover, Black communities continue to experience health disparities in the form of disproportionate rates of HIV/AIDS and other chronic illnesses. If a central tenet of public health activism is the engagement of local residents in the development and implementation of health initiatives, then this case study is valuable because it highlights the benefits of these efforts.
In the early 20th century, Philadelphia experienced a cataclysm of immigration in the midst of rapid industrialization. Like other northern cities during this period, Philadelphia witnessed an upsurge of immigrants and rural Blacks migrating from the south. Between 1890 and 1910, the city’s Black population increased more than 100%, to 84 000, in a city with a total population of 1.5 million; by 1920, the Black population grew to 134 000 in a total population of 1.7 million.6 As Philadelphia’s newest residents packed into cramped dwellings, TB and other infectious diseases gripped the city, and housing conditions began to rapidly deteriorate.7 Progressive reformers battled the growing threat of infectious disease and urban decay by establishing a variety of charities, including settlement houses, in which middle-class volunteers lived as settlers in low-income areas and worked to serve the poor.8
During this turbulent time the Starr Centre, a settlement organized in 1897, became a clearinghouse for the numerous civic-improvement efforts launched by its benefactor, White social progressive Theodore Starr (1841–1884).9 During his lifetime, Starr was recognized as a keen businessman and philanthropist with a deep commitment to poor Black and immigrant families living in the fourth, fifth, and seventh wards of Philadelphia. His concern for the social welfare of local residents led to the development of a number of initiatives, including public playgrounds and gardening centers for neighborhood children. Starr’s desire to improve the quality of life for local Blacks led him to establish Philadelphia’s first Progressive Working Colored Men’s Club (1878) and the city’s first Penny Bank (1879), where Blacks could save small amounts of money to be used for planned purchases later. Starr also purchased plots of land that were used to build affordable homes for Blacks.10
By the time of his death in 1884, Starr’s social-welfare initiatives were well entrenched within Philadelphia’s Black community. Starr’s legacy continued through the efforts of several long-time acquaintances, including Susan Parrish Wharton, a well-known community member and civic activist. When the Starr Centre was founded in 1897, Wharton served as chairperson and president. Wharton and her colleagues stated that the Starr Centre Association’s aims were
[to] provide for and promote by practical methods, the educational and social improvement of those poor neighborhoods; primarily in the vicinity of the Starr Garden.11
The settlement operated with a modest budget and consisted of a board of directors, donors, various committees, and neighborhood residents. The Starr Centre’s programs included classes in domestic art and carpentry, the provision of inexpensive lunches and milk for schoolchildren, health lectures, visiting nursing services, and dispensaries for medical care.12 Local residents gained access to association membership by contributing one dollar annually. Over the course of the next decade, Starr Centre programs increased in popularity among local immigrant and Black families.13
Starr Centre leaders were particularly interested in health promotion and disease prevention. In 1905, the Starr Centre created a medical department and contracted with the Visiting Nurses Association of Philadelphia to provide nursing care to sick children and adults in clinics and homes.14 Despite the excessive illness present in the Black community, many families were forced to juggle their participation in health programs and visits to local clinics with more quotidian domestic concerns, such as finding coal to warm their homes or food to fill their children’s hungry stomachs. Even as infectious disease rates spiked among Blacks, poor families were frequently obliged to work long hours instead of seeking medical care. Starr Centre board members saw this dilemma and realized that any efforts to curtail excess sickness had to address the limited material resources of community members first.15
One of the Starr Centre’s early efforts to address the pressing economic needs of Black community residents began with the initiation of the Cooperative Coal Club. The Coal Club was created as a way to help Blacks by offering them protection from unscrupulous merchants who were known to sell coal at inflated prices.16 Many Black city residents relied on hard coal as a fuel source for cooking and heating their homes. Meager weekly wages, however, forced poor and working-class families to buy coal in small amounts. Buying coal in these small bucket portions often meant paying higher costs per pound. The Coal Club offered a way out of this trap by allowing members to form a cooperative for the purpose of buying coal in large quantities, thus bringing down the price.17
The Coal Club drew its membership from the area south of Lombard Street and reflected the diverse backgrounds of Blacks living there. Unlike some fraternal societies and social clubs, which offered membership to Blacks on an exclusionary basis, the Coal Club’s members represented a cross section of working-class and middle-class Blacks who were unlikely to meet in other settings because of different class or church affiliations.18 In the opinion of Susan Wharton, manager of the Coal Club, this convergence of individuals from different social strata and denominational affiliations was of significant value, for common concerns emerged in
[the] pulling together and . . . good fellowship growing up among people of varied occupations and interests and belonging to many different churches.19
The Coal Club’s open membership policy allowed it to serve as more than just a way to obtain necessary material resources; over time it helped foster a diverse set of social networks among its members.
From the early years of its inception throughout the first decade of the 1900s, the Coal Club’s membership steadily grew, as did the number of club-sponsored functions. Prompted by the club’s growth, the Starr Centre purchased a second property at 18th and Webster Streets in 1911 that was soon recognized as a central meeting space for Blacks living in the community.20 Coal Club members used the newly purchased house for monthly social and business purposes, and frequently stopped in for social calls and to seek advice from Starr Centre staff.21 The space was also used for monthly Coal Club meetings attended by women, men, and children from across the community. These meetings provided a venue for fellowship and discussion of important community topics. At larger monthly gatherings, often held at local churches, anywhere from 300 to 400 individuals would assemble to hear health lectures and to discuss club affairs. Like other mutual aid and benefit societies, the religious, secular, social, and political purposes of the Starr Centre and the Coal Club sometimes overlapped. Meetings called to discuss the cost of coal were often followed by singing hymns, enjoying refreshments, and socializing.22
During these gatherings, matters pertaining to illness and making provisions for poor health were commonly discussed. A recurring topic among club members was the lack of good medical and nursing services.23 Although the city’s Blacks could seek care from local health departments, neighborhood health centers, and the city hospital (Philadelphia General Hospital), treatment and services at these facilities were often of limited availability and poor quality. Philadelphia General Hospital, for instance, was frequently overcrowded and in disrepair. Philadelphia’s two Black-run hospitals, Frederick Douglass Memorial Hospital (established 1895) and Mercy Hospital (established 1907), extended services to Blacks, but neither hospital had beds for patients infected with TB, so they were unable to meet this critical need among Philadelphia’s growing Black community.24
Faced with the constant threat of illness, Coal Club members worked with Starr Centre organizers to form the Rainy Day Society in 1905. Similar to many other sick benefit societies in cities across the country, the Rainy Day Society served as a safety net for its members by providing financial protection against the devastation that unexpected illness caused. Individuals joined the Rainy Day Society by paying annual dues over the course of the year in small weekly payments. An all-White staff of paid Starr Centre visitors collected the payments by making personal calls to the home of each member. At each visit the typical payment was 10 to 15 cents. Monies received from Rainy Day Society members were deposited into the Starr Savings Bank and kept in a trust for members in the event that they had an emergency that required use of the funds.25 Society members could also withdraw their total savings at the beginning of each year for other purchases.
In time, the small amounts of savings contributed by club members steadily grew in value. In 1905, visitors made 6394 home-collection visits, through which Rainy Day Society members collectively saved $967. By 1909, those figures had doubled.26 One society member said, “I tell you this saving thing is a great thing; when sickness comes, you have the money, when death comes, you have the money, and when you want to . . . go down home [south] you’ve got the money for that.”27
Most of the members of the Rainy Day Society were also members of the Coal Club. This dual affiliation allowed members to access a range of services formed to address material and health needs. The Starr Centre coordinated its services with the Coal Club and the Rainy Day Society through frequent visits to the homes of club members. While in members’ homes, Starr Centre visitors were charged with collecting dues, learning about members’ living conditions, and offering assistance or referrals when needed. By building relationships and offering “constant sympathy and care,” trained visitors hoped “to help, to advise, to inspire.”28 In 1911, the Rainy Day Society and Coal Club together had more than 900 paid members, and visitors that year made more than 41 000 home visits.29 Members frequently asked visitors to “please call on my aunt, who wants to join” or “my cousin or friend.”30 The Starr Centre’s philosophy of “active touch” between the trained visitors and Coal Club and Rainy Day Society members helped to foster a “mutual understanding and confidence,” resulting in an inspiring partnership that would endure.31
What did it mean for White visitors to have such open access to the homes of Black club members? Certainly there was the risk that interracial and class tensions might emerge during these interactions. Indeed, other historical examples of interracial settlements and civic associations during the same period reveal significant discord between association leaders and Black members.32 Conversely, the Starr Centre appears unique because of the absence of overt class and racial bias in its annual reports. Its records instead display the conditions that allowed these weekly interactions to solidify the bonds of trust and mutual respect, setting the groundwork for the subsequent development of other health initiatives. As visitors became eyewitnesses to the conditions and home lives of club members, they took with them a deeper knowledge of the needs of Black residents that then translated into the programmatic efforts of the Starr Centre.
In 1912, the ever-present needs and continued growth of south Philadelphia’s Black community prompted Wharton to approach the Starr Centre board of directors with a plan for expansion. In a meeting on May 28, 1912, board members discussed the merit of Wharton’s “Plan for Readjustment,” which was designed to increase the services that the Starr Centre offered specifically to the Black community. After lengthy discussion, the board resolved that it would be unwise to undertake an expansion of its work for Blacks, though it hoped to continue providing such services at its present pace, with their “growth encouraged at a normal but steady manner.”33 The decision for limited expansion did not indicate an unwillingness to provide services to Blacks; rather, it reflected a reluctance to try to increase them. It must be recalled that the Starr Centre was never intended to address the needs of Black residents exclusively, and such an expansion might have threatened or undermined the center’s outreach to other poor or immigrant constituents of south Philadelphia.
On June 11, 1912, the matter of expansion of services in the Black community was again taken up at a Starr Centre board meeting in which it was unanimously carried that:
if an independent agency, as capable as ourselves of carrying on effectively the present objectives of the Coal Club and Rainy Day Society be formed, we should be willing to consider a transfer to that organization of our work in connection with individuals living out of the Starr Centre neighborhood.34
On October 8, 1912, Wharton tendered her resignation as founding member of the Starr Centre board. Within the month following her resignation, the board voted to allow Wharton and her newly formed association, the Whittier Centre, to assume responsibility for all operations of the Coal Club and the Rainy Day Society.35
As a newly formed civic association, the Whittier Centre was established with the primary aim of addressing the social and health needs of Philadelphia’s growing Black community. These efforts began in earnest in the fall of 1912 when Susan Wharton and several other prominent Philadelphians established the center at 712 South 18th and 510 South 7th Streets within the heart of the city’s historic Black district. Named after 19th-century poet and abolitionist Greenleaf Whittier, the new association’s mission was to create practical solutions to the social problems plaguing the Black community.36 Wharton served as the Whittier Centre’s first treasurer. Henry R.M. Landis, a prominent physician associated with the Henry Phipps Institute, served as the centre’s first president.37 The rest of the board of directors consisted of five physicians, one member of the clergy, and five female volunteers.
A group of 18 individuals made up the Whittier Centre’s advisory board. Henry Minton, a well-known Black physician, was added to the advisory board in 1915. Booker T. Washington Jr, son of the famous Black educator and author, joined the Whittier Centre as executive secretary in 1919 to assist the organization in addressing the housing concerns of Black community residents.38 The Whittier Centre’s racially integrated governance structure exemplified the organization’s commitment to placing Black activists and medical professionals in prominent positions. This strategy was essential to the sustainability of the Whittier Centre’s goals and objectives, which included “calling on the race to help itself.”39 Beyond this aim, the center’s Black leaders, as members of the targeted community, served as mediators and cultural brokers between the Whittier Centre and the communities it was intended to serve.
The Whittier Centre’s early programs were directed toward the active members belonging to the Coal Club and Rainy Day Society and to individuals living in the squalid alleyways around the city.40 During its first year, the Whittier Centre continued the tradition of home visits to club members, making 42 642 visits in 1912 and 1913.41 Whittier Centre visitors were viewed as neighbors who were trained
[to] get behind the scenes to determine not only the external facts but conditions that make for physical and moral deterioration.42
Visitors frequently provided services to entire families. They were able to see so many people because so many club members either lived together in the same houses or lived in close proximity to the center.
Whittier Centre leaders were especially concerned with excessive TB death rates in the Black community. In 1900, the TB mortality rate among Philadelphia’s Whites was 197.3 per 100 000; among Blacks, the rate was 447.0 per 100 000.43 In 1910, TB deaths among Blacks were 57% higher than among the city’s native-born Whites and 44% higher than among the city’s foreign-born Whites.44 Despite excessive illness rates, Blacks had limited treatment options. Local hospitals and private sanitariums often placed restrictions on admissions of Black patients.45 Adding to the problem of limited health care was low Black patient utilization of those services that were available. When TB beds were available, some Blacks refused to leave the comforts of home because they feared the treatment they would receive from strangers.46 One TB health official noted that
[Black residents] 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.47
Aware of the threat of TB, the Whittier Centre executive committee met on May 14, 1913, to discuss the merits of hiring a Black nurse to investigate possible cases of TB among its Coal Club and Rainy Day Society members.48 During the meeting, TB expert and Whittier Centre president Landis explained the advantage of hiring a Black nurse: “to really get behind the scenes requires a visitor within the race.”49 This nurse would “visit Black families in the home and subsequently gain their confidence” and would more easily dispel any fears or superstitions individuals held regarding illness.50 At this meeting, the Whittier Centre agreed to provide the salary to hire its first Black nurse.51
On February 1, 1914, Elizabeth Tyler, a graduate of Freedman’s Hospital Training School in Washington, DC, began providing TB nursing services to Black residents of south Philadelphia, working under the auspices of the Henry Phipps Institute; her salary was paid for by the Whittier Centre. The Phipps Institute was a world-renowned TB treatment and research facility founded in 1903 by Dr. Lawrence Flick. From its inception, the Phipps Institute offered comprehensive inpatient and outpatient treatment of TB.52 Despite its close proximity to the Black community, the Phipps Institute had not been able to establish a rapport with Black residents. This may have been partly caused by its policy requiring the nearest relative of patients admitted to the inpatient wards to give written permission for an autopsy in the event that the patient should die while on the ward.53 Although this policy undoubtedly was intended to ensure the advance of scientific inquiry, it did little to boost the confidence of Black community members, who were likely suspicious of such agreements.
Thus, despite the overall success of the Phipps Institute in its early years, the numbers of Black patients at the institute remained flat. In contrast with the Phipps Institute, the Whittier Centre had substantive, long-standing relationships with Black residents resulting from years of work in the community, and the board was betting that more Blacks would avail themselves of TB care if more Black nursing and medical staff were available. To that end, Tyler’s job involved going into the Black community, finding residents suspected of having TB, and referring them to the Phipps clinic for treatment. Tyler’s early months at her new post began with home visits to the nearly 1000 members of the Coal Club and Rainy Day Society. In a report summarizing the work of her first year, Tyler noted a tremendous voluntary response to her nursing visits and her advice to visit the TB health clinic. She noted,
it is gratifying to know that the number of colored people attending the Phipps Institute has been so greatly increased as a direct result of these house-to-house investigations.54
Her efforts were so effective that within six months of her hire, the Phipps Institute hired another Black nurse, Cora Johnson. Later that same year, Minton (the Black physician who was also a member of the Whittier Centre advisory board) joined the Phipps Institute staff to oversee the care of Black patients at the dispensary.55 In the Phipps Institute’s first year of working with the Whittier Centre, the number of Black patients visiting the clinic was twelve times higher than in the previous 11 years combined. By 1921, nearly 30% of all new Phipps patients came from the Black community.
Tyler, Johnson, and Minton were tireless in their efforts to improve health in the Black community. They organized health lectures in local churches, and the Whittier Centre established a prenatal clinic, well-baby clinics, and a home supervision service. By 1921, the center’s staff of Black clinicians, then known as the Negro Health Bureau, had grown from one nurse to 10 graduate nurses and from one physician to 12.56 However, the success of the Whittier Centre’s health initiatives did not hinge simply on the introduction of Black clinicians. The center’s accomplishments were the direct results of collective efforts undertaken by Black community members, social reformers, and health professionals that ultimately led to the development of a collaborative model of community health care many decades later.
Notwithstanding the successes of community mobilization and health initiatives launched by civic associations in the early 20th century, translating these historic achievements into the context of our 21st-century public health challenges presents its own set of difficulties. Today many urban communities are racially and economically less diverse than they used to be, and residents are generally less apt to have a mutual sense of shared responsibility toward one another, which limits the spirit of cooperative efforts so evident among Black club members a century ago. Still, despite the dissimilarities between time periods, we can learn from several key lessons embedded in the history of civic association community health initiatives.
First, civic associations of the early 20th century, such as the Starr Centre and the Whittier Centre, were in the vanguard of multiple movements, focused simultaneously on building a community health infrastructure while also addressing a housing shortage and income deprivation. Unlike the disease-focused models of community health, which grew in popularity over the remainder of the 20th century, the associations discussed here achieved success by identifying people’s material needs first. This focus on the comprehensive wants of the community was based on the recognition that the determinants of public health are structural and are largely related to poverty and the environment. Thus, any effort to address more abstract concerns, such as disease prevention, first had to address more immediate needs, such as food and coal. Once these areas of concerns were addressed, then interventions addressing infectious disease and other maladies followed with a greater degree of success.
What history demonstrates in this instance is the importance of beginning with an understanding of the base determinants of well-being. A more specific focus on health should wait until this preliminary step is accomplished. History also demonstrates how building community networks can serve as a valuable way to address the social determinants of health among targeted populations. This lesson can be generalized to many different communities throughout the country, not just racial or ethnic minorities.
Another key strength of the civic associations discussed here was their ability to forge social bonds between diverse racial and class groups. Indeed, the success of the health initiatives, particularly the Phipps campaign, hinged on the ability of civic association organizers to first build trust among neighborhood residents and form relationships with them. The introduction of Black clinicians aided in this endeavor, but assigning the success of the Whittier Centre’s anti-TB campaign merely to the inclusion of racially concordant health providers would be a disservice to White philanthropists such as Starr and Wharton who each spent decades working among Black community residents addressing community concerns and building rapport.57 It was this time commitment and active, persistent engagement with Black club members that served as the precursor to Tyler’s work among Black Philadelphians. This assemblage of equally invested partners—lay residents, health workers, and philanthropists—crossed racial and economic lines. Alhough divergent in origin, they remained unified in purpose.
A critical strength of the civic associations discussed here was their provision of a platform for community residents to help themselves through leadership opportunities and cooperative engagement. As members of civic associations, Blacks were more than mere silent partners in need of health and social reform; they were crucial to the development of public health initiatives, and their active participation was of paramount importance to the initiatives’ success. This focus on capacity building, increasing social capital, and investing in developing community leaders was most notable in the governance and organizational structure of the Whittier Centre, but such a focus can also be seen today in community-based participatory research, which aims to empower community members to own study questions, research methods, and data collected about themselves.58 Like its predecessors, community-based participatory research strives to enhance and increase health awareness and health activism among members of minority communities.
We now face altogether different public health concerns from those prevalent a century ago, but health inequities still persist. Clinicians, researchers, and community health activists can draw on historical precedents to address contemporary public health concerns by identifying community strengths, leveraging social networks, mobilizing community members, training community leaders, and building partnerships with indigenous community organizations. Many Black and minority communities continue to view civic associations, such as churches and social organizations, as valuable resources for health information and as places in which to address pressing social concerns. Thus, it is important for contemporary public health workers to integrate their health efforts within these institutions to advance mutually agreed-upon health goals. Civic engagement between community members and civic associations is still pivotal to the success of community health initiatives.
Margo Brooks Carthon is supported by the National Institute for Nursing Research (grant K01NR012006). This research was also supported by a Ruth L. Kirschstein NRSA Doctoral Fellowship from the Agency for Healthcare Research and Quality (grant F-31 HS01029-02).
Special thanks to Julie Fairman, PhD, Joan Lynaugh, PhD, Barbara Savage, PhD, Robin Stevens, PhD, Bridgette Brawner, PhD, Jillian Baker, PhD, Jasmine McDonald, PhD, and Melissa Gomes, PhD, for their support and feedback on earlier drafts of this article.