Encyclopedia of Greater Philadelphia

James Higgins

Infectious Diseases and Epidemics

Despite Philadelphia’s prominence, throughout its history, as a center for medical education and care, the region has experienced numerous epidemics of infectious disease. British America’s largest city in the eighteenth century, Philadelphia suffered dreadful outbreaks of smallpox and yellow fever, while the nineteenth century brought an exotic new disease—cholera—that killed hundreds. By the early twentieth century, though rates of death from infectious disease remained high by modern standards, scientific advances began to limit their power. Nevertheless, epidemics of influenza, polio, and HIV/AIDS killed thousands through the turn of the twenty-first century even as diabetes, cancer, and cardiovascular disease accounted for an increased share of deaths in the region.

[caption id="attachment_22056" align="alignright" width="183"]A black and white illustration of Benjamin Rush seated at a desk with papers Dr. Benjamin Rush rose to prominence during the yellow fever epidemic of 1793. He became one of the first American physicians to gain international renown. (Historical Society of Pennsylvania)[/caption]

Eighteenth-century Philadelphia was a crossroads of the Atlantic world. Decades before Philadelphia’s founding, the Lenni Lenape suffered near extinction from diseases brought by Swedish and Dutch colonials who built posts along the Delaware River. Philadelphia enjoyed a lower mortality rate than major European cities because of its relative isolation and generally better standard of living, but infectious disease claimed lives daily, and epidemics occurred every year. The region faced threats from three major sources of infection: contamination of food and water with typhoid and other intestinal pathogens; airborne pathogens such as smallpox and measles; and insect vectors carrying diseases, especially malaria and yellow fever, though dengue also circulated in the city.

Smallpox was among the most feared of the infectious diseases. Outbreaks occurred in Philadelphia every year and Philadelphia was probably the only place in the thirteen colonies where smallpox was endemic. The city’s relatively large size enabled the virus to find a continual supply of susceptible individuals. Survivors often bore large, pitted scars and became blind. During the Revolution, smallpox exploded into a general North American epidemic. Philadelphia, occupied by the British, was host to thousands of American prisoners of war, hundreds of whom died of smallpox in indescribably miserable conditions.

While smallpox captured the imagination with its high death rate and gross manifestations on victims’ bodies, less obvious infections claimed even more lives. Eighteenth-century Philadelphians drank water contaminated with fecal matter, which resulted in endemic typhoid, dysentery, and other intestinal diseases. Infants and young children, who were especially susceptible to dehydration, died in large numbers. The young, in particular, also faced threats from scarlet fever, whooping cough, measles, and diphtheria, which was especially dreaded for its ghastly symptoms. In the most virulent cases, a leathery membrane covered large portions of the tonsils and pharynx and killed through slow asphyxiation.

Mosquito-Borne Illnesses

[caption id="attachment_21673" align="alignright" width="300"]A colored political cartoon of an ill man in bed surrounded by a crowd of doctors and an African American woman Yellow fever loomed in the consciousness of Philadelphians long after the 1793 epidemic. (Library Company of Philadelphia)[/caption]

Mosquitos found the region, with its many wetlands, an attractive breeding ground. Though its cold winters discouraged most tropical species from breeding, malaria sickened residents every summer, though most cases were milder than in the southern colonies where the Anopheles mosquito thrived. Dengue, referred to as “break bone” fever because of the excruciating pains that shot through the limbs and backs of sufferers, was also present in the city; the first major epidemic occurred in 1780. The most acute mosquito-borne illness, however, was yellow fever, which ravaged the city sporadically throughout the eighteenth century. The worst epidemic occurred in 1793, brought by ships arriving from the West Indies with infected tropical mosquitoes. By the onset of the first frosts in October, which killed off the mosquitoes, 10 to 15 percent of the city—between four and five thousand people—had died. The epidemic prompted a mass exodus of the city by those who could afford to leave, while those left behind often relied on African American citizens to render assistance and bury the dead.

[caption id="attachment_21675" align="alignright" width="300"]A black and white photograph of the Lazaretto as it appeared in the 1980s The Lazaretto is the nation's oldest surviving quarantine hospital. All passenger ships entering Philadelphia in the nineteenth century were required to dock here so that the passengers could be inspected for infectious diseases. (Library of Congress)[/caption]

Philadelphia’s high mortality rate from infectious disease during the colonial era revealed a lack of effective treatments. Physicians and surgeons understood a great deal about human anatomy by the middle of the eighteenth century and were able to suture wounds, set fractures, remove decayed teeth, and attend births. But doctors never suspected the causative agents of infectious disease were microscopic organisms. Standard responses to sickness included bleeding; application of caustic plasters to the skin to provoke blistering, which physicians believed would draw out poisons; and induction of vomiting with ipecac or diarrhea with calomel to purge the body. Such interventions often did more to hasten death than speed recovery. To ease pain, quiet a persistent cough, or stem diarrhea, doctors might use opium or laudanum, a tincture of opium and alcohol. For syphilis, which was common in Philadelphia, doctors prescribed doses of mercury high enough to cause symptoms, consistent with heavy-metal poisoning, such as uncontrollable salivation and loosened teeth. Physicians also prescribed less onerous therapies such as dietary and rest regimes.

The most impressive weapon against disease was smallpox inoculation, famously championed by Benjamin Franklin (1706–90) after the death of his beloved son in 1736 from the disease. Philadelphia boasted several hospitals, most importantly the Pennsylvania Hospital, the Almshouse (later Philadelphia General Hospital), and the Lazaretto, as well as a growing cadre of physicians, most famously Benjamin Rush (1746–1813), who taught at the nation’s first medical school, at the College of Philadelphia (later the University of Pennsylvania), founded in 1765. Two dozen of the city’s leading physicians founded the College of the Physicians of Philadelphia, dedicated to the advancement of medical practice, in 1787.

[caption id="attachment_21672" align="alignright" width="300"]A color political cartoon depicting cholera as a grim reaper figure on the bow of a ship flying British flags Cholera, depicted here as a grim reaper, escaped its endemic Ganges River region and swept across Europe in the early nineteenth century. It reached Philadelphia in 1832. (Historical Society of Pennsylvania)[/caption]

The population of Philadelphia exploded in the nineteenth century. As Philadelphia grew, it drained prodigious quantities of water from surrounding wetlands and diverted or obliterated numerous streams and ponds, decreasing mosquito breeding grounds. The press of people, however, further fouled water supplies. Cholera, a waterborne disease that originated in the Ganges Delta and caused a series of global pandemics, first entered the city in 1832 and killed hundreds. Repeated waves of cholera prompted greater attention to public health in Europe and America and ushered in new thinking about sewage and contagion. Typhus, a highly lethal disease spread by body lice, made its last appearance in Philadelphia in 1893, while smallpox, which state health authorities believed entered the city again with troops returning from the Spanish-American War, caused hundreds of deaths in Philadelphia during the first few years of the twentieth century before vaccination once again brought it under control. Of all infectious diseases, tuberculosis remained the “captain of death,” caused thousands of deaths in the region annually, and motivated the founding of hospitals, clinics, dispensaries, and research organizations.

Scientific Advances Ease Epidemics

Even as infectious disease killed thousands every year, scientific advances offered hope. The bacterial revolution between the 1850s and 1880s, which yielded growing evidence that microbes caused infectious disease, prompted Philadelphia to build the Philadelphia Municipal Hospital for Contagious Disease at Twenty-Second and Lehigh Streets in 1865 to isolate the sick and limit the spread of disease. By the mid-1890s, diphtheria antitoxin began to rescue victims, especially children, from the brink of death. The experiments of Benjamin Franklin Royer (1870-1961), head of the city’s contagious disease hospital, improved the effectiveness of the antitoxin regimen. Royer concluded that physicians should administer massive doses of antitoxin immediately when they suspected diphtheria, even before laboratory confirmation of the disease. Physicians across the country heeded Royer’s recommendations.

By World War I, Philadelphia filtered and chlorinated its water supply and watched as mortality from waterborne disease shrank to low background levels. Insect-vectored diseases, too, no longer posed a serious threat. Though most infectious diseases could not yet be cured, recognition of the importance of patient isolation, quarantine, cleanliness, and hygiene, along with increased access to hospitals and doctors all combined to reduce deaths from contagious disease.

[caption id="attachment_21678" align="alignright" width="300"]a black and white photograph of five polio stricken children holding March of Dimes posters with Philadelphia March of Dimes leader Poliomyelitis appeared in the early twentieth century. The paralytic infection's casualties peaked in 1952, three years before a vaccine became widely available. (Special Collections Research Center, Temple University Libraries)[/caption]

Still, in 1916, Philadelphia’s first major outbreak of polio sickened hundreds and paralyzed or weakened scores. Even more terrible than this specter of paralyzed and dying children was the influenza epidemic that raged across the world and emerged in Philadelphia in September 1918, the city’s first major epidemic since cholera, killing between thirteen thousand and nineteenth thousand people by March 1919. Philadelphia experienced the worst urban outbreak in the nation because the first appearance of the virus in the city coincided with a war bonds parade; the large crowds in attendance permitted the virus to infect thousands in one day, and tens of thousands within the next week. The large number of rapid deaths overwhelmed city services, with corpses languishing in apartments and mass burials the result.

Like the rest of the nation, however, Philadelphia entered the 1920s relatively free of infectious disease. Deaths from what are now vaccine-preventable diseases occurred at a much higher rate than they would a century later, but were a rarity compared to the rates experienced just a generation previous. The drop in mortality resulted mainly from public health measures that limited exposure to serious infectious disease, as well as from improved medical care. In the late 1930s, the first class of antibiotics—sulfa drugs—became available. A decade later, the introduction of penicillin, along with the rapid development of other antibiotics, led to the marked diminishment of bacterial infections, while the rapid introduction of vaccinations for diphtheria, mumps, whooping cough (pertussis), measles, polio, influenza, and tetanus further reduced sickness and mortality from infectious diseases. With the exception of polio and the influenza epidemics in 1957 and 1968, infectious disease ceased to be an important cause of death on the region’s component of mid-to-late-twentieth century mortality rolls.

Legionnaires' Disease, 1976

[caption id="attachment_21676" align="alignright" width="300"]A black and white photograph of a man at a Legionnaire's symposium pointing to a graph about the epidemic Legionnaires' disease baffled epidemiologists for almost six months after it appeared. The mysterious illness's first victims were members of the American Legion who attended the organization's 1976 convention at Philadelphia's Bellevue-Stratford Hotel. (Special Collections Research Center, Temple University Libraries)[/caption]

The hiatus from outbreaks ended, however, in 1976, when attendees of a convention of the American Legion in Philadelphia complained of weakness, fever, and shortness of breath. In little more than a week, more than two hundred convention-goers sickened and thirty-two died. The pathogen, a species of bacteria never linked to human illness, was named Legionnaires’ disease and forever linked to Philadelphia.

As the Legionnaires’ outbreak splashed across the headlines, another infectious killer stalked the city; by the mid- to late 1970s, the human immunodeficiency virus began its infiltration of Philadelphia, especially among the city’s intravenous drug users and gay men. By 1980, heterosexuals, too, especially hemophiliacs and those under age thirty, came into increasingly frequent contact with the virus. Deaths must have occurred, but because they were few and occurred in marginalized populations with limited access to medical care, they were missed. By September 1981, however, Philadelphia physicians diagnosed patients whose symptoms were consistent with those seen in the first reported cases in Los Angeles and New York a few months earlier. Throughout the 1980s and early 1990s, Philadelphia fought a rising tide of illness and deaths. Until the advent of retroviral treatment in 1996, Philadelphia relied on two classic principles of public health, isolation and prevention, to slow the virus’s destruction.

[caption id="attachment_21674" align="alignright" width="300"]A black and white photograph of HIV/AIDS activists from ACT-UP Philadelphia marching with signs AIDS activists believed that stigma surrounding the disease led politicians to avoid addressing it. Activist groups like ACT-UP Philadelphia, a local branch of a New York City-based organization, were formed to raise awareness. (John J. Wilcox LGBT Archives of Philadelphia)[/caption]

With the exception of HIV, infectious disease—though it always posed a threat—failed to produce a major, high-mortality outbreak, let alone a citywide epidemic. One national study of mortality from infectious disease, applicable to Philadelphia, found that between 1900 and 1996, mortality from infectious disease decreased from 797 deaths per 100,000 of the population in 1900 to only 36 per 100,000 in 1980. The AIDS epidemic and increased deaths from influenza and pneumonia among the elderly increased the rate to 59 per 100,000 by 1996, but this was still less than 10 percent of the rate a century earlier. As deaths from infectious disease declined, cancer, cardiovascular disease, diabetes, and Alzheimer’s claimed a greater percentage of lives and became the major killers in the region.

Founded during the early modern era of medicine, Philadelphia and the surrounding region partook in and contributed to the sweeping changes in our understanding of disease during the nineteenth century—and remained on the cutting edge of research and treatment into the twenty-first century. Few major episodes in American medicine failed to touch the region and its people, while the work of the area’s physicians, nurses, engineers, and researchers improved the lives of people across the globe.

James Higgins is a lecturer in American history at the University of Houston–Victoria. He specializes in the history of medicine, especially as it pertains to Pennsylvania. His manuscript, which analyzes four urban outbreaks in Pennsylvania during the 1918–19 influenza pandemic, is with the University of Rochester Press. He has offered a dozen conference papers and several articles, invited lectures, and book chapters.

Public Health

From the moment Native Americans, Europeans, and Africans came together in the Delaware Valley, they confronted a host of health threats. Philadelphia’s earliest public health efforts reflected the lack of scientific understanding of infectious diseases, and usually began only after an outbreak commenced. After the terrible 1793 yellow fever epidemic, Philadelphia’s leaders founded a permanent Board of Health that endured into the twenty-first century as the Department of Health. By the late twentieth century, public health efforts in the region, which included regulations intended to improve housing, food quality, and associated environmental standards, as well as private efforts to help the poor, had long since transitioned from a war against miasma and microbes to campaigns to stem the rising deaths associated with lifestyle choices.

[caption id="attachment_23588" align="alignright" width="300"]A black and white engraving of the main building of the Philadelphia Lazaretto Quarantine played a large part in disease control during the city's early years. The Lazaretto Quarantine station was the first stop for all passenger ships entering the city. (Library of Congress)[/caption]

Eighteenth-century Philadelphia experienced numerous threats to health and had almost no effective medicine. Lack of scientific knowledge limited public health efforts, too. Still, medical and civic authorities took action when particularly fearful diseases emerged. As early as 1700, the city instituted a regime of ship inspection on the Delaware River and by 1720 designated a doctor as port physician charged with regular inspection of vessels for signs of disease among crew and passengers. By 1743, the city built a lazaretto, or pest hospital, on Province Island, at the confluence of the Delaware and Schuylkill Rivers, for the purpose of quarantining the sick who arrived by ship. As the century wore on, officials recognized the need for a maritime quarantine station further down the Delaware, away from the growing city. It opened a new lazaretto in Tinicum in 1801, which operated until the end of the century.

[caption id="attachment_23591" align="alignright" width="300"]a black and white photograph of the Philadelphia Dispensary, a two story building Benjamin Rush established the Philadelphia Dispensary in 1786. It was the nation's first walk-in charity health clinic. (Library Company of Philadelphia)[/caption]

Private efforts to curtail disease included the Quakers’ Friends Almshouse, opened in 1713 for the exclusive use of destitute Friends. The City of Philadelphia later opened a charity hospital to care for the sick poor attached to the Philadelphia Almshouse, in 1732, which vied with Pennsylvania Hospital, opened on High Street in 1751, as the first hospital in the colonies. The almshouse and hospital moved to a new location, on Spruce and Eleventh Streets, in 1767. The hospital cared for many patients during epidemics and treated Continental Army soldiers who, in 1778, were hit with an outbreak of dysentery. In 1786, Benjamin Rush established the Philadelphia Dispensary on Fifth Street and charged it with caring for ill paupers, provided they did not suffer from venereal disease or delirium tremens. The Southern and Northern Dispensaries, founded in 1816 and 1817, respectively, joined the Philadelphia Dispensary in the effort to provide outpatient treatment to citizens of modest means.

Epidemics could prove catastrophic, killing hundreds, and sometimes thousands, in just a few months. In the city’s early years, it formed ad hoc boards of health during outbreaks, and these well-intentioned citizens turned to a mixture of responses, from the useless burning of smudge pots filled with sulfur and urine-soaked straw, to the incineration of the possessions of the dead; sometimes they razed the homes themselves. The boards also turned to the time-honored quarantine order, confining the sick to their homes or, especially in the case of the poor, to the almshouses and city-managed hospitals, where they died in huge numbers. Though mortality rates among the quarantined were high, isolation did provide a measure of protection for the community against contagious diseases.

Yellow Fever, 1793

In 1793, however, mosquito-borne yellow fever demonstrated the limits of quarantine. The disease settled over the city in the late summer and early autumn, infecting thousands. Along with the usual round of public health measures, the city commandeered Bush Hill, a vacant estate at the edge of the city, as a quarantine and treatment facility. Such public health efforts, however, did not avert the death of between five and six thousand residents, or more than 10 percent of Philadelphia’s population.

[caption id="attachment_23593" align="alignright" width="300"]A color illustration of Bush Hill, a red brick Georgian mansion with outbuildings seated on a large plot of land Andrew Hamilton's Bush Hill estate was pressed into service as an emergency hospital during the 1793 yellow fever epidemic, and again during cholera outbreaks in the nineteenth century. (Historical Society of Pennsylvania)[/caption]

This epidemic, and outbreaks in 1798 and 1806, catalyzed changes to Philadelphia’s public health apparatus. In 1794, the city formed a permanent Board of Health. In 1808, the board began to record the number of deaths from smallpox and a few other diseases. When cholera entered the city in 1832 and 1848, it sent out orders for useless cleaning of gutters and streets. More importantly, it again established an emergency hospital at Bush Hill, but, like at the almshouse and hospital, hundreds of patients endured indescribable conditions. Authorities later reported that “the nature of cholera,” which was marked by complete evacuation of the alimentary canal by uncontrollable, explosive diarrhea and vomiting, horrified attendants such that they fled in disgust and fright.

Yet, even as cholera stalked the city, a new era of public health began to dawn in Philadelphia. By 1835, the Philadelphia Almshouse moved to Cleveland Avenue and Thirty-Fourth Street, in West Philadelphia, and within a few decades was joined by the University of Pennsylvania’s School of Medicine. Just blocks from the new almshouse and charity hospital, it used the hospital as a training ground for its physicians and nurses. In 1837, the almshouse, nicknamed Blockley Hospital because of its location in the old township of that name, prevented the malnutrition of thousands of residents who suffered during the economic panic that year. The Board of Health began to register birth, deaths, and marriages in the city in 1860, gathering the basic data required to systematically tackle health threats. In 1865, Philadelphia opened the Municipal Hospital for Contagious Diseases at Twenty-Second and Lehigh Streets to replace the ad hoc Bush Hill estate hospital. This new hospital isolated patients suffering from the most severe and contagious diseases, especially the indigent poor who risked spreading disease in the crowded wards of Blockley.

The physical structure of cities underwent vast changes during the late nineteenth century, and many of those changes had an impact on health. In Philadelphia, streets of granite blocks and asphalt replaced those of cobblestone or packed earth, which made street cleaning immeasurably easier. Rubbish collection and street cleaning, when done well, reduced the population of rats, scavenging dogs that transmitted rabies, and flies, whose travels took them from trash, to feces, to food and thereby spread typhoid and other disease. The city began to better regulate cesspool cleaning, too, which, by the late 1870s, was supposed to be accomplished with airtight, leak-proof pumps and containers—though many carriers still employed leaky carts—and only during daylight hours, in order to facilitate inspection by city sanitary officers and concerned reformers alike. Real improvement in effluvia removal began when the city accelerated the construction of sanitary and storm sewers during the last few decades of the nineteenth century and ordered housing near sewers to connect to them, a development that ushered in the era of the modern toilet. By 1900 the city had eight hundred miles of sewage pipe. In the 1880s, Philadelphia, renowned for its lack of New York–style tenement buildings, increased housing regulations and inspections, paying particular attention to ventilation and drainage in the poorer sections of the city.

A Revolution in Public Health

[caption id="attachment_23586" align="alignright" width="300"]A print of a public service announcement showing a man sneezing into a handkerchief with two other men watching in the background. Text reads "Protect the Public from disease, use your handkerchief when you sneeze" As effective treatment for tuberculosis eluded doctors, public health campaigns instead focused on preventing the spread of the disease by urging people to practice good public hygiene. (Historical Society of Pennsylvania)[/caption]

The bacterial revolution of the mid-nineteenth century culminated in the determination by Louis Pasteur (1822–95), Sir Joseph Lister (1827–1912), and Robert Koch (1843–1910), among others, that microbes caused many diseases. After a rash of discoveries in the 1870s and 1880s uncovered the pathogens associated with anthrax, tuberculosis, and typhoid, effective remedies in the form of antitoxins, water filtration and chlorination, and isolation of the sick began to revolutionize public health. In 1887, half a dozen physicians and professional sanitarians replaced the two dozen members of the Philadelphia Board of Health, a move that, while reducing the number of managers, increased the expertise of the organization. The board moved to enforce vaccination of school children against smallpox in 1895, began to manufacture diphtheria antitoxin, and advocated the chlorination of the city’s water supply, which was completed in 1912. Cleansing of the city’s water reduced deaths from waterborne illnesses to near-modern levels and saved hundreds, perhaps thousands of lives every year. In 1894, the board mandated that all milk sold in the city be obtained only from cows it certified as healthy. In 1895, it built a bacteriology lab and also ordered the placarding of the homes of patients with serious contagious diseases.

In the early twentieth century, private organizations continued to provide ever more sophisticated public health services. Private groups offered visiting nurses services throughout the Philadelphia metropolitan area. Some, like Presbyterian Hospital’s School of Nursing, visited homes as an extension of their educational and clinical efforts, while others, for instance the Visiting Nurse Society of Philadelphia, were founded by nurses specifically for the purpose of home visitation, administering care to laboring families who could ill-afford medical care, especially for sick children. Visiting-nurses programs also aided mothers by providing proper nutrition and advice about hygiene and other childcare concerns. In Philadelphia, some private hospitals opened clinics that rendered both general and specialized care to the poor. St. Joseph’s Hospital, for instance, established free gynecological and obstetric care. The Board of Health also established health centers in conjunction with nurses and neighborhood physicians, an early attempt to synergize municipal public health efforts with private physicians; when a health center diagnosed a medical concern and determined a family could pay a physician, it made a referral, otherwise the city provided the service.

[caption id="attachment_23594" align="alignright" width="300"]A black and white photograph of a hospital dormitory showing long rows of tightly packed beds, some with patients on them. The Pennsylvania State Hospital, better known as Byberry, was opened to relieve overcrowding at the Blockley Almshouse. It became notorious for the crowded and filthy conditions patients endured. (Historical Society of Pennsylvania)[/caption]

Though many other diseases captured the imagination and provoked terror in the population because of their symptoms, it was tuberculosis that ranked as the greatest killer during the nineteenth and early twentieth centuries. The density of people in Philadelphia’s poorer areas allowed for efficient transmission of the bacteria that causes TB. The disease could also be contracted from milk from infected cows, which resulted in tuberculosis of the bowel. By 1892, the Anti-Tuberculosis League of Philadelphia organized to educate policy makers and the public about the dangers of the disease. The city also issued increasingly stringent pure milk requirements throughout these years. The most important measure against tuberculosis came with the founding, in 1905, of the state Department of Health, whose head for the first dozen years, Samuel G. Dixon (1851–1918), was a noted tuberculosis researcher. Dixon opened three large sanitaria and hundreds of dispensaries that, when allied with municipal TB clinics in the region, treated or removed to one of the state’s three large, rural tuberculosis sanitaria, thousands of cases from Philadelphia and surrounding Pennsylvania counties every year. New Jersey and Delaware, too, had anti-tuberculosis programs, but none were as extensive, or expensive, as Pennsylvania’s. City public health leaders also focused more attention on mental health, with the construction of Byberry Mental Hospital on Roosevelt Boulevard and Southampton Road in 1907, though standards of care there would shock later sensibilities.

Global Influenza

The greatest challenges to the public’s health in the early twentieth century emerged when the virus responsible for a global pandemic of influenza swept across the region between 1918 and 1919. Unfortunately, Philadelphia decided to go ahead with plans for a massive patriotic parade in the midst of this epidemic and the result was the most acute urban outbreak in the nation. The city responded with every weapon at its disposal, including quarantine, emergency hospitals, and calls for thousands of volunteers, literally the largest public health action in the city’s history. The effort was coordinated and powerful. Nonetheless, the highly infectious, airborne virus with no antidote proved beyond the capabilities of any health body to control, and at least thirteen thousand died in just six months. The Board of Health also confronted polio during the First World War, with isolation of patients and families the protocol.

[caption id="attachment_23590" align="alignright" width="300"]A black and white photo of a doctor administering a vaccine to a young girl being held by her mother. The vaccine is being administered on a city bus used as a mobile clinic. Philadelphia organized several polio vaccination campaigns in the mid-twentieth century. This photograph is from "Wipe Out Polio Week," a 1961 campaign where twenty buses brought vaccines door-to-door. (PhillyHistory.org)[/caption]

During the 1950s and 1960s, the advent of sulfa drugs and penicillin, as well as a host of inoculations, increasingly delivered not by public health workers but by private physicians, reduced the importance of government-provided public health efforts in the post–World War II era. For a time it appeared as though public health efforts would be permanently relegated to aiding the poor and addressing hygiene standards in public establishments. In the late twentieth century, however, the emergence of Legionnaires Disease and Swine Flu, both of which began in 1976 in Philadelphia and South Jersey, again prompted local public health entities to spring into action. Swine Flu provoked a regime of mass immunization in the region and across the nation. Worse followed in 1981 when gay men and, in very short order, intravenous drug users and hemophiliacs presented with symptoms of immune system collapse. By 1983, Philadelphia formed its first HIV/AIDS task force, while New Jersey instituted the nation’s first AIDS Awareness Month in February 1983.

Other public health initiatives advanced by both public and private organizations included a smoking cessation campaign, with bans on smoking in most public spaces passed by city council in 2006, bans that eventually included parks and all city-owned recreation centers, restaurants, bars, and all public buildings and their entrances. In the early twenty-first century, public health efforts expanded to include preparations in the case of a terrorist attack and initiatives to fight a rising tide of opiate addiction and drug overdose and to counter the increasing abuse of prescription painkillers. Diseases such as diabetes and heart disease led to new prevention and treatment campaigns aimed to inform citizens of the ways they could avoid or control disease through lifestyle changes. To aid the community, in the early twenty-first century the city proposed measures that would place an additional tax on certain sugary foods, most importantly soda and other high calorie beverages, and mandate listing of calories on the menus of chain restaurants.

Public health efforts in Philadelphia and the region mirrored those found throughout the nation, with Philadelphia, especially during the colonial era, leading the way by implementing some of the earliest public health efforts. Philadelphia’s public health measures reflected the growth of scientific knowledge over the course of more than three hundred years of discovery and practice. Public health leaders and organizations who once primarily responded to infectious disease outbreaks, later aided in changing the physical environment of the city and the region as a means of disease prevention, and then combated a mix of chronic diseases, addiction, and emerging pathogens, such as West Nile virus, Zika virus, and multiple influenza scares. Even in the face of an increased emphasis on private medicine, public health organizations continued to evolve to meet new challenges. The region’s public health efforts benefited, too, from an increased federal role in public health, including NIH/CDC responses to infectious disease outbreaks, Medicaid/and Medicare for the poor and elderly, and an array of federal health standards and agencies that enrich the quality of health in the region.

James Higgins is a lecturer in American history at the University of Houston–Victoria. He specializes in the history of medicine, especially as it pertains to Pennsylvania. His manuscript, which analyzes four urban outbreaks in Pennsylvania during the 1918–19 influenza pandemic, is with the University of Rochester Press. He has offered a dozen conference papers and several articles, invited lectures, and book chapters.

Board of Health (Philadelphia)

[caption id="attachment_19570" align="alignright" width="300"]A Health Center at 1633 Point Breeze Avenue from 1931 The Department of Health offered badly needed  resources during the Great Depression, when large numbers of Philadelphians could ill-afford medical fees. This 1931 photograph shows a health center in the city’s Point Breeze section. (PhillyHistory.org)[/caption]

Philadelphia suffered numerous outbreaks of epidemic disease throughout the seventeenth and eighteenth centuries, but it was not until 1794, in the wake of the disastrous 1793 yellow fever outbreak, that a group of concerned citizens founded the Board of Health, independent of the city’s control. In the nineteenth century, the city supported the board with an annual budget and continuously expanded its responsibilities to include sanitary and housing inspection, epidemic control, and management of several hospitals. By the turn of the twenty-first century, the renamed Department of Health participated in antiterrorism exercises, anti-heroin initiatives, and gun violence reduction programs.   

During its first decades, the Board of Health was most energetic during outbreaks of infectious disease, such as yellow fever, smallpox, and diphtheria, which it confronted with quarantines, removal of the indigent sick to hospitals, and burning smudge pots. In 1797, the city changed the board’s title to the Managers of the City and Marine Hospital and charged it with ship inspection and isolation/treatment of ill passengers. Again named the Board of Health in 1804, the board engaged in little preventative health work, as the city did not empower it to make sanitation laws.

Cholera offered the greatest challenge to the board when it arrived in 1832 and provoked a round of street cleansing and fumigation, which, though offering the appearance of a response, did nothing to beat back the disease. By the third cholera epidemic of 1866, however, science began to offer new explanations of disease causation and control. For instance, the theory of contagion—that diseases spread from person to person—came to dominate scientific circles, which also began to suspect the role bacterial pathogens played in infectious disease.

[caption id="attachment_19326" align="alignright" width="300"]Henry S. Tanner's world map depicts the spread of cholera prior to 1830 (green), in 1830 (yellow), in 1831 (blue), and in 1832 (red).  Courtesy of the New York Academy of Medicine. Henry S. Tanner's world map depicts the spread of cholera in 1832 in red. (Courtesy of the New York Academy of Medicine)[/caption]

The revolutions in medicine offered the first solid theoretical foundation for modern public health efforts in Philadelphia. For instance, the board, which had recorded deaths since 1838, began in 1865 to record marriages and births, too. It continuously refined the categories of causes of death as diseases, many of which produced similar symptoms, were recognized as distinct ailments. In 1866 the city opened the Philadelphia Municipal Hospital for Contagious Disease at Twenty-Second and Lehigh Streets under the management of the board’s growing cadre of physicians and nurses.

During the last two decades of the nineteenth century, however, as massive numbers of immigrants packed into tenements, the board struggled with diseases that threatened outbreaks. It had little power to effect real change in the city’s housing and sanitation and therefore dealt with diseases and other threats after they emerged, as smallpox and typhus did during the 1890s.

[caption id="attachment_19571" align="alignright" width="265"]A child receiving a Polio vaccination. A child receives a free Salk vaccination to protect against polio, administered by a doctor from the Department of Public Health. (PhillyHistory.org)[/caption]

In 1903, the state legislature centralized Philadelphia’s charity and health operations and placed such work under the aegis of the Department of Health and Charities. The department had expanded responsibilities, including operation of the city’s workhouse, increased responsibility for housing and food inspection, and the power to create and enforce health regulations. The department repeatedly called for water purification (accomplished by 1912), pressed for a new Municipal Hospital for Contagious Disease (opened in 1911 at Second and Luzerne Streets), and fought for general sanitary improvement of the city. The department’s greatest challenge was the 1918–19 influenza epidemic that killed roughly fifteen thousand residents. Although one other major city, Pittsburgh, suffered a slightly higher death rate, Philadelphia’s outbreak resulted in hundreds of corpses laying in cramped apartments and mass graves, phenomena not experienced in other American or European metropolises. 

In the wake of the pandemic the board was once again reorganized, this time as the Department of Health. The department offered badly needed health resources during the Great Depression, when large numbers of Philadelphians could ill afford medical fees. Throughout the mid-twentieth century, clean water, sanitary disposal of waste, inoculations, and antibiotics, as well as physicians’ resistance to tax-funded competition, relentlessly reduced the need and power of the department. Furthermore, the flight of working- and middle-class residents to the suburbs and the flood of drugs, especially heroin, into the city changed the nature of its health threats. 

While the advent of clean water, sanitary disposal of waste, inoculations, and antibiotics have greatly improved public health, outbreaks of Legionnaires’ disease and HIV/AIDS, to say nothing of the daily need to monitor restaurants, schools, buildings, and other possible sources of disease and injury, have demonstrated the continuing need for vigilance. In the wake of the September 11 attacks, the Philadelphia Department of Health partnered with law enforcement to refine responses to terrorist attacks. It also led a coordinated campaign to reduce gun violence, especially among the city’s poor children and young adults. These challenges highlighted the continuing need for a city board of health.

James Higgins is a lecturer in American history at the University of Houston–Victoria. He specializes in the history of medicine, especially as it pertains to Pennsylvania. His manuscript, which analyzes four urban outbreaks in Pennsylvania during the 1918–19 influenza pandemic, is with the University of Rochester Press. He has offered a dozen conference papers and several articles, invited lectures, and book chapters. 

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