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.

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)

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.

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)

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.

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)

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

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)

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.

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)

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.

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. (

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.

Copyright 2016, Rutgers University


Friends Almshouse

Historical Society of Pennsylvania

Colonial Philadelphia housed some of America's first almshouses, institutions that offered medical care, shelter, and food to society's poorest members. The earliest was the Friends Almshouse, established in 1713 for members of the Society of Friends (Quakers). Initially, the Almshouse operated out of a small house on Walnut Street near Fourth Street, until a larger facility was constructed on the site in 1729. Families were housed in separate quarters and those able to work were encouraged to do so. It remained in operation until 1841, when it was closed and subsequently demolished.

Bush Hill

Historical Society of Pennsylvania

Philadelphia was gripped by a devastating yellow fever epidemic in 1793 while it served as the capital of the new nation. The wealthy fled as the disease spread through the city, and those who could not leave died in the thousands. In response to the epidemic the city commandeered the Bush Hill Estate, a vacant mansion built in the 1730s by colonial lawyer Andrew Hamilton. There, an emergency hospital and quarantine station was established. It was managed by merchant and philanthropist Stephen Girard, one of the wealthiest men in America. Girard volunteered to manage the hospital at Bush Hill and personally cared for sick patients, even using his personal carriage to transport the sick to the facility. Five thousand died in the epidemic, an estimated 10 percent of the city's total population. Bush Hill would again be used as an emergency hospital during the 1840s when cholera reached the city.

Philadelphia Dispensary from Independence Square

Library Company of Philadelphia

Philadelphia's destitute could seek medical care at the Philadelphia Dispensary. Established by Benjamin Rush in 1786, the Dispensary was the nation's first walk-in charity health clinic. It was located on Fifth Street near Sansom Street. This photograph is of its second building, completed in 1801. The Philadelphia Dispensary provided both inpatient and outpatient services, but refused to treat patients with venereal disease or delirium tremens, a side effect of alcohol withdrawal. The building was demolished in 1922 and the site is now part of Independence National Historical Park.

The Lazaretto

Library of Congress

Quarantine was one of the city's earliest methods of controlling the spread of disease. The Lazaretto quarantine station was opened in 1799 in response to the city's recurring yellow fever outbreaks. It was built on Tinicum Island, near the present site of Philadelphia International Airport, and replaced an existing quarantine station on Province Island. All passenger ships entering Philadelphia had to first dock at the Lazaretto for inspection. At its peak in the 1870s, the Lazaretto inspected thirty thousand new arrivals to the city every year. It was closed in 1895 when a new quarantine station was constructed several miles south of the city in Marcus Hook.

Lower Roxborough Filter Plant, 1901

A major outbreak of typhoid fever at the end of the nineteenth century drove the city to filter its water supply. Typhoid is caused by a strain of Salmonella bacterium spread primarily through water tainted with fecal matter, but also through contaminated milk and contact with asymptomatic carriers. In the 1890s, the disease killed some 5,400 Philadelphia residents while lay and medical groups, including the College of Physicians and the Women's Health Protective Association, clamored for the city to take action. Little action was taken until 1898-99, when a particularly virulent outbreak killed nearly a thousand people. This 1901 photograph shows the lower Roxborough filter plant under construction. By the start of the next decade, the city's drinking water was both filtered and chlorinated and, augmented by a vaccination campaign in the 1910s and 1920s, cases of typhoid decreased dramatically.

Dormitory at Byberry Hospital

Historical Society of Pennsylvania

Mental health services became a public health concern after reformers urged cities to move poor mentally ill patients out of the jails and prisons in which they were held. In 1911 the Pennsylvania State Hospital, better known as Byberry, was opened to relieve overcrowding at the Blockley Almshouse. Two years after it opened, Blockley stopped admitting mental health patients. Though opened to improve conditions for the mentally ill, the public attitude towards Byberry changed dramatically in its years of operation. Investigations of the hospital found it overcrowded, understaffed, and underfunded, leading to neglect and filthy conditions for the patients. This undated photograph shows one of the hospital's overcrowded dormitories. Even after the state took control of Byberry in 1938 and new dormitories were constructed, conditions did not improve. After years of negative publicity, the hospital was shuttered in 1990. It remained standing and vacant until its demolition in 2006.

"Wipe Out Polio Week"

The Philadelphia Department of Health, formerly the Board of Health, administered free Salk vaccines to the children of Philadelphia during the height of the polio epidemic. Improvements in sanitation in the early twentieth century may have triggered a dramatic increase in occurrence of the disease by delaying the age at which children were exposed to the polio virus. A vaccine became publicly available in 1955, three years after the diseased reached its epidemic peak. This 1961 photograph shows a child receiving the vaccine on one of the twenty buses deployed for “Wipe Out Polio Week,” a four-day door-to-door vaccination campaign in the city. An aggressive national vaccination program nearly eradicated the disease. No naturally occurring cases of polio have been diagnosed in the United States since 1979.


Centers for Disease Control

In July 1976, an atypical form of pneumonia was diagnosed in members of the American Legion who had recently attended a convention in Philadelphia's Bellevue-Stratford Hotel. Over two hundred people were stricken with the disease, which caused chest pains, high fever, and chest congestion. Twenty-nine people died in six months while no cause for the infection could be identified. The Bellevue-Stratford was forced to close due to declining business. In January 1977, a previously unknown bacteria, dubbed Legionella, was found in the Bellevue-Stratford's air conditioning units. The bacteria enters the lungs when infected water is aerosolized and reproduces rapidly in the macrophages, a type of white blood cell. Today, it can be treated with antibiotics.

"Use Your Handkerchief When You Sneeze"

Historical Society of Pennsylvania

Philadelphia's densely populated neighborhoods allowed airborne diseases like tuberculosis to spread rapidly. The cause of the disease was unknown until 1882, and an effective cure remained elusive for many decades after. Public health advocacy groups like the Anti-Tuberculosis League of Philadelphia educated policymakers on the disease. An extensive network of clinics and sanitariums opened in the state to treat the ill, while posters like this one from 1917 urged the public to practice prevention techniques. In 1944 the newly discovered antibiotic streptomycin was found to cure tuberculosis. There are occasional resurgences of the disease, especially in the city's poor and immune-compromised populations.

Related Topics


Time Periods



Related Reading

Alewitz, Sam. “Filthy Dirty:” A Social History of Unsanitary Philadelphia in the Late-Nineteenth Century. New York: Garland Publishing Inc., 1989.

McCarthy, Michael P. Typhoid and the Politics of Public Health in Nineteenth-Century Philadelphia. Philadelphia: American Philosophical Society, 1987.

Cheney, Rose A. “Seasonal Aspects of Infant and Childhood Mortality: Philadelphia, 1865–1920.” Journal of Interdisciplinary History 14, no. 1 (Winter 1984): 561–85.

Condran, Gretchen A., Henry Williams, and Rose A. Cheney, “The Decline in Mortality in Philadelphia from 1870 to 1930: The Role of Municipal Services.” Pennsylvania Magazine of History and Biography 108, no. 2 (April 1984): 153–77.

Estes, J. Worth and Billy G. Smith, eds. A Melancholy Scene of Devastation: The Public Response to the 1793 Philadelphia Yellow Fever Epidemic. Sagamore Beach, Mass.: Science History Publications, 2013.

Finger, Simon. The Contagious City: The Politics of Public Health in Early Philadelphia. Ithaca, N.Y.: Cornell University Press, 2012.

Henry, Frederick P., ed., Standard History of the Medical Profession of Philadelphia. Chicago: Goodspeed Brothers, Publishers, 1897.

Lawrence, Charles. History of the Philadelphia Almshouses and Hospitals. Philadelphia: Self-Published, 1895.

Related Collections

Records of the Visiting Nurse Society of Philadelphia, MC 5B, Barbara Bates Center for the Study of the History of Nursing, Suite 2U, Claire M Fagin Hall, 418 Curie Boulevard, Philadelphia.

Records of the Board of Health – 76.1 through 76.44, Philadelphia City Archives, Suite 150, 3101 Market Street, Philadelphia.

Related Places

Remains of the Lazaretto, 99 Wanamaker Ave, Essington, Pa.

Remains of Blockley Hospital (original brick wall and iron gate), University of Pennsylvania Campus, Thirty-Fourth Street and Civic Center Boulevard, Philadelphia.

Site of first Municipal Hospital for Contagious Disease, Twenty-Second and Lehigh Streets, Philadelphia.

Site of second Municipal Hospital for Contagious Disease, Second and Luzerne Streets, Philadelphia.

College of the Physicians of Philadelphia/Mütter Museum, 19 S. Twenty-Second Street, Philadelphia.


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