PROGRESSIVE PUBLIC HEALTH ADMINISTRATION IN THE JIM CROW SOUTH: A CASE STUDY OF RICHMOND, VIRGINIA, 1907-1920.

During the first decades of the twentieth century, various Southern cities began to employ new public health techniques in the administration of their public health departments. These techniques not only included introducing new scientific advances in epidemiology, diagnostics, and disease control, but also involved incorporating various social programs within the health department, most notably those associated with public health nursing. Although much has been written about the public health advances of this period from a northern, or national perspective, only a few studies have examined early twentieth century urban public health in its southern context. [1] Fewer still are the studies that specifically examine the interplay of race and public health. [2] By exploring the role of race in the development of three campaigns conducted by the Richmond Department of Public Health--the campaigns against typhoid fever, infantile diarrhea, and tuberculosis--this study will show that African Americans received few of the benefits derived from Richmond's move toward improved public health, and that the benefits they did receive were confined to those programs administered by the city's public health nurses. The pattern of racial differentials amid southern public health advance is an important story in its own right, if unsurprising given the racial attitudes of the time. The rare exceptions to this pattern also deserve exploration, yet the overall result formed a stark context for African-American life in Richmond.

In the early twentieth century, when Richmond, Virginia embarked on its campaign to modernize its public health department, national standards of public health practice were being developed in the North. [3] Confounding the easy importation of northern ideas of public health directly into southern practice, however, was the fact that the urban population of African Americans, a group that routinely experienced high rates of mortality and morbidity, was relatively high, and American racism existed in a very specific and institutionalized fashion. One of the consequences of southern racial attitudes was that, in Richmond and other southern cities, African Americans did not constitute a primary constituency for public health intervention. [4] This was based, in part, on strongly held beliefs that African Americans were largely responsible for creating their own particular health problems, either as the result of behavior or inheritance. [5] As a result, improvements in black health were largely incidental to eff orts to make southern cities healthier for their white citizens. With few exceptions, all of Richmond's public health initiatives tended to be undertaken with little regard for the particular health problems of the city's black population. Only in those programs administered by the city's public health nurses did African Americans receive health care services in proportion to their needs. The advent of city programs administered by public health nurses in Richmond held great Promise for improving the health of the city's African Americans, but in the end, they only achieved limited and short-term success. As this study shows, because of the racial discrimination inherent in the system of healthcare delivery, public health nursing's potential to dramatically improve the health of the city's blacks was never fully realized and Richmond's African-American community benefited only marginally from the city's overall advancement in public health.

In Richmond, as elsewhere, advances in public health were often closely tied to economic and political developments in the city. [6] At the turn of the century, Richmond was a growing and economically diverse city with a large African-American population. Between 1890 and 1920 Richmond's population more than doubled from 81,388 to 177,667. Although their percentage of the total population steadily declined during these years, African Americans remained an integral part of the city's workforce as the African-American population increased from 32,330 to 54,041 (see Table 1). [7] Richmond was an industrializing city, and between 1870 and 1910 it consistently ranked first or second in the South in the value of its manufactured product. Although tobacco, flour milling and iron working dominated the economy, the city's growing economic diversity offered workers employment in a variety of industries. [8] Even though the percentage of African Americans in Richmond's population fell from 45.3 to 39.7 between 1870 and 1890, blacks still comprised over forty-seven percent of the workforce in 1890 and provided the bulk of the city's unskilled workers. [9] The percentage of African Americans in Richmond's workforce remained about forty-five percent through 1910, dropping to 37.6 by 1920. [10] Concentrated primarily as laborers, teamsters, deliverymen, waiters, servants, maids and laundresses, Richmond's African Americans held many of the lowest paid and least skilled jobs in the city. [11]

The Reorganization of the Richmond Health Department

Beginning in the 1890s, Richmond's city leaders and public officials became increasingly concerned with the city's extraordinarily high death rates. Richmond had consistently ranked fourth or fifth among the nation's cities with the highest death rates. In 1893 only New Orleans, Charleston and Mobile recorded higher death rates than Richmond, and by 1905 Richmond's death rate had been ranked "higher than that of any city its size in the country." [12] According to the city's Chamber of Commerce, Richmond's poor showing in the national mortality statistics presented the city with a real economic problem. As Dr. Charles W. Shields, a member of the Chamber's special Committee on Health and Sanitation noted, Richmond's high death rate "was constantly operating to the disadvantage of the reputation of the city ... and the effect was that intelligent people were prevented from coming to and settling in a place having such a reputation."[13] Richmond's city officials were also aware that the high death rate of the c ity's African Americans, usually about twice that of whites, inflated the average for the city as a whole and negatively affected the health of all of Richmond's citizens. [14] (See Table 2)

Debate over the state of health of the city, and the appropriate steps to take to improve it had raged for years among the City Council, the Chamber of Commerce and the city Board of Health. [15] Following publication of the U.S. Public Health Service report listing Richmond's death rate higher than any city its size, the Richmond City Council ordered a formal hearing into the matter. Citing the high infant death rate, inconsistency in recording procedures and a high rate of tuberculosis deaths, the City Council concluded that either the ordinances in effect were inadequate to protect the health of the city or they were not being enforced. The City Council promptly appointed a committee to investigate the Health Department more fully. [16]

When the committee issued its report in May of 1906, it cited three major problems with the organization and operation of the old Board of Health. First, the division of authority between the Board of Health and the City Council's Committee on Health left both bodies with inadequate powers to ensure the health of the city. Secondly, the lack of a full time health officer as executive head of the department further hampered the work of public health. And, finally, the Board lacked sufficient funding from the City Council to carry out its duties. [17] The City Council responded to the report in June of 1906 by passing an ordinance creating a new Board of Health with an executive director, four additional full time health officers, additional funding, and expanded powers. [18]

After passing the basic ordinance, the City Council appointed the author of the report, Ernest C. Levy, as Chief Medical Officer of the newly reorganized Health Department. [19] At the time he wrote the report, Levy had been serving as Chief Bacteriologist for the City Board of Health. Levy was born in Richmond 11 August 1868 to a locally prominent Jewish family and graduated from Richmond's public schools. He attended Richmond College for three years before completing his professional training at the Medical College of Virginia in 1890. He performed post-graduate work in pathology and bacteriology at the College of Physicians and Surgeons of Columbia University in New York and spent two years as an intern at Mount Sinai Hospital before returning to Richmond to engage in private practice. After five years he joined the faculty of the Medical College of Virginia as Professor of Histology, Pathology and Bacteriology, a post he held for three years. In 1899 he resigned his position when Richmond city officials a sked Levy to perform some tests on the city's water supply, a task that launched his career in public health. In 1902, Levy went to Massachusetts Institute of Technology for further study as a special student in Biology and Public Health under William T. Sedgewick, a leading pioneer in the field of bacteriology. Levy returned to Richmond in 1904 as Director of the Laboratory of the Water Works, and assumed the newly created post of City Bacteriologist in December of 1905. [20] When the Committee to Investigate the Health Department gave Levy responsibility for writing the report, he called upon his former professor, Sedgewick, for advice and counsel. [21]

Following the City Council's acceptance of the report's recommendations in 1906, Levy became the first Chief Health Officer of the city, and held that position until 1917 when he resigned in protest over the lack of sufficient funding for the department. [22] At the time Levy took control of the reorganized health department in 1906, he was the only full-time, technically trained public health officer in the South. [23] In this regard, his appointment signaled a new era in the history of urban public health in the South.

Public Health Nursing in Richmond

In addition to the reorganization of the Health Department, the first decade of the twentieth century also saw the beginning of public health nursing in Richmond. In 1900, a small group of nurses led by Sadie Heath Cabanis, Superintendent of Nurses for the Old Dominion Hospital, formed the Nurses Settlement to provide nursing care to the city's poor. During their off hours from the hospital, these nurses visited the sick in their homes. The nurses themselves funded the operation. Continuously short of funds, the nurses sought support from the city's private charities. The Women's Club, under the leadership of B.B. Valentine, helped organize a Board of Managers and, in 1902 incorporated the Instructive Visiting Nurses Association (IVNA). [24] The IVNA was the first organization to bring the benefits of public health nursing to Richmond. When the Department of Health was reorganized in 1906, the Department paid the salary of one of the nurses to help with its programs. The Department of Health continued this af filiation until the Department developed its own corps of public health nurses in 1910. [25]

Public Health Nursing, or District Nursing as it was called, originated in England in 1859. It began as a means of uplifting the poor by helping them to improve the sanitary conditions of their homes and their own personal hygiene. Nineteenth century reformers viewed the unhealthy surroundings of the poor as a contributing factor in their poverty. Teaching the poor proper hygiene and nutrition would, they believed, rescue them from their wretched conditions. Caring for the sick among them was the means by which these health missionaries secured the confidence of the poor and gained access to their homes. [26] Brought to this country in 1877 by the Women's Board of the New York Mission, by 1900 over 200 visiting nurses were active in a number of American cities. [27]

Although both the reorganization of the health department and the advent of public health nursing in Richmond promised great improvement in the health of the city, the pervasive racism of the day and the priorities of the national leadership in the field of public health limited the benefits of these developments for the African-American segment of Richmond's population. For example, when Levy took office he consulted his mentors in Boston as to what actions he should take first, and his subsequent activities reflect the standards prevalent in public health circles of the day. [28] The control of typhoid fever and the prevention of infant mortality through the improvement of the urban milk supply were the two major national priorities in public health that gained most of his attention. [29] Unfortunately, the strategies and standards Levy adopted did little to address the real health concerns of the city's African Americans.

Discrimination in the Provision of Healthcare: The Campaign against Typhoid Fever

The first campaign of the newly reorganized Department of Health was directed toward lowering the city's typhoid fever rate. Fully in keeping with the national norms for public health officers, Levy stated unequivocally in his first report to the City Council that "the thorough investigation of typhoid fever in Richmond is one of the most important duties of the Health Department." [30]

But the Department of Health's campaign to reduce the typhoid fever rate in the city was not just good public health. It also fit a pattern of discrimination against the health needs of African Americans that had long operated in Richmond. In a city where African Americans died at almost twice the rate of whites, typhoid fever was one of the few diseases that afflicted whites more often than blacks (see Tables 2 and 3). [31] Between 1900 and 1910, only in one year, 1904, did more blacks die of the disease than whites. Of the approximately 150-500 cases contracted annually, fully seventy-eight percent of them were contracted by whites. In a city plagued by a significantly higher African-American death rate almost across the board, typhoid fever was a notable exception. [32]

The Richmond Health Department made great progress in lowering the city's death rate from typhoid fever between 1907 and 1920 (Table 4). Levy personally conducted a series of investigations that proved the city's water supply was not as much a factor in Richmond's typhoid fever rate as it had been reported to be in northern cities. With few exceptions, Levy suggested typhoid fever in Richmond resulted from "local foci," arising out of cases that occurred in the city rather than by being introduced from the outside through either the water or milk supply. As a result of his study, Levy concluded that the public health solution for Southern cities lay primarily in the control of unsanitary privies rather than investing in new, capital-intensive water supply systems. [33] Levy's study of typhoid fever was the first of several publications which helped propel him to a leadership role within the public health movement, culminating in his ascendancy to the Presidency of the American Public Health Association in 192 2. [34]

By getting the medical community to report each typhoid case promptly, educating the patient and family in proper care and prophylaxis, urging the extension of city sewers and water, working to diminish the number of wells and privies, enacting a program of rigid milk inspection and conducting a systematic campaign against flies, Levy significantly reduced the effects of the disease. [35] As indicated in Table 4, Richmond's death rate from typhoid fever fell from 41.4 per 100,000 in 1907 to only 6.4 in 1920. [36]

But the results of the campaign against typhoid also highlight the racial gap evident in the city's movement toward increased public health. Writing in 1916, Levy acknowledged that "the steady lowering of the death rate from typhoid fever in Richmond has apparently been brought about almost entirely by lowering the white death rate from this disease. [37] It was not until after 1916 that any progress was made in lowering the African-American death rate from typhoid, and by that time, the white death rate had been reduced to almost half that of the city's African Americans. It is unclear why, but beginning in 1917 the African-American death rate also began to fall along with the steady decrease in the white rate, yet it still remained higher than that of whites--a complete reversal of the situation in 1907 (see Table 4).

To some degree it might be unfair, given the context of the times, to be overly critical of the Richmond Health Department for focusing on one of the few diseases that killed more whites than blacks. Many people believed a high death rate from typhoid fever was especially harmful to a city's reputation, and prevention of typhoid fever was one of those issues on which a young public health official could gain national prominence. [38] But unfortunately for Richmond's African Americans, this was not the only area in which the Health Department adopted policies that seemed to favor whites. Discrimination can also be seen in the way in which the Health Department pursued the health problems of primary importance to the city's African Americans, particularly infantile diarrhea and tuberculosis.

Infantile Diarrhea

In the early years of the twentieth-century, the death rate in Richmond from infantile diarrhea was one and one-half to two times as high for African Americans as for whites. In keeping with developing national norms, the reorganized Health Department instituted a rigid program of milk inspection because impure milk was commonly thought to be the major cause of this disease. [39] This step was taken even though the President of the Board of Health and former Chief Health Officer of the city, William Oppenheimer, predicted that such a program would not do much to reduce the city's high infant mortality. Outlining the basic problem of the city's high infant death rate, Oppenheimer reported that in the past eleven years 5,852 children had died under five years of age, 2,308 were white and 3,534 were colored." Oppenheimer emphasized that there were twice as many whites in the city as African Americans, yet among children five and under deaths of African Americans accounted for more than sixty percent of the total deaths. "It is a fact," Oppenheimer said, "that the vast majority of these colored children do not drink milk except from their mother's breasts; that they live on fat meat and pot liquor, and any other food eaten by their parents, but certainly not on cow's milk." A large percentage of white babies who died under one year of age, however, were fed at least some cow's milk, and immediately following the 1906 reorganization, the Richmond Department of Health commenced the campaign to eliminate impure commercial milk. [40]

Successful at improving the quality of the city's milk supply with a rigid system of dairy and milk inspections, Levy's program further helped propel him into national prominence and earned him a seat on the prestigious National Commission on Milk Standards, but it did little to alter the numbers of Richmond babies dying from infantile diarrhea. [41] There was some improvement as Richmond's death rate from this cause fell from 142.0 per 100,000 in 1907 to 122.0 in 1908, but the rate rose again the following year and by 1911, it had climbed to 149.8 (Table 5). The rising statistics and a thorough investigation of alt reported deaths due to infantile diarrhea convinced Levy that none of the babies dying from this disease was acquiring it through the public milk supply. [42] Since Levy believed strongly that the milk inspection program was successful in improving the purity of the city's commercial milk supply, other factors had to be responsible for Richmond's high infant mortality rate. [43] Levy suggested tha t many of the cases were doubtlessly "caused by milk from some neighbor's cow, not under our supervision," or were misreported cases of deaths from other causes of which diarrhea was but a symptom, or resulted from the mishandling of milk in the home environment. [44]

In writing his report for 1910, Levy acknowledged that he had "felt for some time that no further lowering of the infant mortality could be brought about by further improvement in the general milk supply of the city." He went on to say, however, that he had "been long convinced that the next move should be to instruct the mothers in the care of their babies. Most of this is now accepted almost as axiomatic," he suggested, "not only by physicians, nurses and health authorities, but by the more intelligent people at large." [45] Levy was successful in securing funding for the Health Department to adopt a visiting nurse program in 1910 to help stem the rising tide of infant mortality. Unlike the earlier programs of the health department, this effort would target African Americans as well as whites. Three nurses were hired to instruct mothers on the proper care of infants, and in 1912, the number of nurses was increased to five. [46] Two districts with the highest infant mortality were chosen, one predominantly w hite, one predominantly black. The Department's nurses, all white, canvassed the areas for children under one year of age and began instructing mothers in proper nutrition and hygiene. The nurses promoted the continuance of breast feeding, and where this was not feasible, taught mothers the Department's formula for the proper preparation of milk, urging mothers to use whole milk rather than the more popular, but lower quality condensed milk. [47] Late in 1911, Levy's own investigations determined that infantile diarrhea was transmitted through the improperly handled feces of infants. [48] In 1912, the Department's nurses began instructing Richmond's mothers in the proper precautions to take when handling dirty diapers, and educated them in the terrible consequences of failing to do so. [49] The death rate from infantile diarrhea fell dramatically from 149.8 in 1911 to 98.8 the following year. The death rate continued to decline relatively steadily through the end of the decade, reaching 39.3 per 100,000 in 1920. [50]

In contrast to the Department's initial effort to reduce the death rate from infantile diarrhea, the visiting nurse program seemed to help more blacks than whites. Richmond, unlike Nashville and possibly other southern cities, put more effort into supervising the care of African American, than of white babies. [51] Between 1910 and 1916, about fifty-five percent of the 7,611 babies supervised were of African-American descent, even though they accounted for only about thirty-seven percent of the reported births during the same period. [52]

As a result of this relatively high level of care, the African-American death rate from infantile diarrhea declined almost as much as the white rate. Between 1907 and 1920 the white rate fell 71.7 percent from 101.2 per 100,000 to 28.6. During those same years, the African-American death rate fell 70.1 percent from 215.4 to 62.8 (Table 5). [53] Unfortunately, despite the progress made in reducing deaths from infantile diarrhea, the single largest cause of infant mortality in the city, Richmond's African-American babies were still dying at almost twice the rate of whites.

As Levy's successor as Chief Health Officer, Roy Flanagan, concluded in 1918, visiting nurses could help reduce the infant death rate significantly, but until the conditions of the African-American neighborhoods were improved, he said "the children of the poor will continue to die like flies when the heat of July and August comes." [54] Flanagan had come to Richmond after working as Virginia's Assistant State Health Commissioner, a position to which he returned after only two years. [55] While he was in Richmond, Flanagan was a strong proponent of an environmental approach to public health, even as it was tinged with the paternalistic racism that was common among southern white liberals at that time. As he wrote in his first annual report:

In part explanation of this high mortality, it must be noted that the negro sections of the city are abnormally crowded, and the housing conditions there are often unspeakably vile; so, with the colored man's aversion to fresh air and the external application of water, aided and abetted by his landlord, through the character of the dwellings furnished (in which the negro must live or be roofless), disease and death ride rampant over him.... A knowledge of what to do to prevent disease will be worthless to these poor people unless decent living quarters, at moderate rentals, be provided them, so that they may keep well. [56]

Although the sweeping changes needed to address the debilitating effects of extreme poverty in the African-American community and to improve the living conditions in the city's black neighborhoods were beyond the control of Richmond's public health nurses or the city's Chief Health Officer, the equal treatment of African Americans in the infant care program provides evidence of the willingness of Richmond's public health nurses to extend municipal benefits equally to blacks and whites, and the difference that could result when they did.

Tuberculosis

The fight against tuberculosis in Richmond also reflected the pattern in which health officials focused primarily on the needs of the city's white citizens, but with some notable exceptions in which the city's public health nurses ministered to more blacks than whites. When the Richmond City Council failed to allocate funds to build a special hospital for tuberculosis sufferers, several of the city's prominent citizens, including Levy and two members of the Board of Health, organized a private association to construct the facilities. [57] Opened in November 1910, Pine Camp was reserved exclusively for whites. Within one year of its construction, city officials were subsidizing the camp's operations. After slightly over six years, the city took over the facility completely. [58] Even though African Americans suffered from tuberculosis at a rate two to three times that of whites, as late as 1920 the City of Richmond had still not made any facilities outside a few beds in the city's Almshouse available for use b y African-American sufferers of the disease. Even arguments that indicated such a move would benefit whites as much as blacks, such as Levy's 1915 statement that a facility for blacks was "badly needed, not only for the sake of these cases themselves, but also for the protection of our white citizens," were not persuasive. [59] African Americans, however, did not passively wait for city officials to meet their needs. Richmond's African-American community organized an Anti-Tuberculosis League on 19 October 1909. The League sponsored a series of public meetings, encouraged ministers to preach sermons on tuberculosis, and canvassed the city, providing treatment, education and material support for African-American sufferers of the disease and their families. [60] In general, white taxpayers strongly resisted any expenditures that were seen to benefit African Americans, including money spent on the prevention and treatment of tuberculosis. [61] Richmond, of course, was not alone in focusing its health care dollars on the treatment of whites. Studies of Nashville, Atlanta, Birmingham and other cities suggest that Richmond's experience reflected larger trends evident throughout the South and across the country as a whole. [62]

Nonetheless, the egalitarian impulse on the part of Richmond's public health officer and his nurses was evident in the city's fight against tuberculosis. In 1906, tuberculosis deaths accounted for almost one-third of all deaths occurring between the ages of ten and forty in Richmond, and African Americans died from the disease at a rate more than twice that of whites. [63] As part of its charity healthcare work, the city had established two tuberculosis dispensaries in 1907--one for whites and one for African Americans. Run by white physicians hired by the Department and staffed by white nurses supplied by the privately funded IVNA, the dispensaries provided free diagnosis and treatment to the city poor. For the first four years of their existence, slightly more whites than African Americans availed themselves of the city's free tuberculosis services (656 whites versus 596 African Americans). This was the case even though the infection rate and mortality rates among blacks were widely known to be two to three times as high as for whites. [64] After 1912, though, when the city's public health nurses replaced the privately funded IVNA nurses, significantly more African Americans than whites participated in the dispensary program. Between 1912 and 1917, home visits to African Americans outnumbered those for whites 3,093 to 2,157. Patient visits to the dispensaries during this period also reflected the higher incidence of tuberculosis in the African-American population, with 3,953 visits by blacks and 3,128 visits by whites. Interestingly enough, when the health department stopped issuing free milk tickets to tuberculosis sufferers at the dispensaries, white attendance dropped significantly while African-American attendance reportedly remained steady. After 1917, the participation of African Americans declined when the city's public health nurses were given responsibility for investigating all claims for city charity and the nursing staff had less opportunity to engage in tuberculosis work. The percentage of white pa tients receiving treatment at the dispensaries between 1918 and 1920 was almost twice that of blacks--despite a continued overall African-American infection rate two to three times that of the white population. [65]

White Attitudes on Black Health

In many ways, institutional inattention to most of the health needs of Richmond's African Americans was deeply imbedded in the racial attitudes of the times. When confronted with the shocking disparity between the mortality rates of the two races in 1907, Richmond's Mayor, Carlton McCarthy, was struck by the fact that even though African Americans only comprised thirty-eight percent of the city's population, they supplied fifty-seven percent of the deaths from tuberculosis. "These simple facts," McCarthy stated, "show that the negroes furnish the culture beds for tuberculosis, and constitute a serious menace to the health of the white population of the city." Rather than investing any of the city's resources to determine the cause of the high incidence of tuberculosis among African Americans or to offer treatment, however, McCarthy simply issued "a warning against the indiscriminate employment of negroes in our households, and also a suggestion that we ought to be very careful where we send our clothing to be laundnied." [66] As late as 1918 Levy's successor, Flanagan, was still trying to motivate Richmonders to act by exploring white citizens' stake in black health. "When it is realized," he said, "that the serving class of the city, the nursemaids, cooks, butlers, washerwomen, and their children, brothers, sisters, cousins, aunts and affinities, are supplying the dead material for these statistics, and that for every death there are from five to ten unrecognized but actively contagious cases of lung disease, or worse, moving about the community, the need for action thrusts itself upon us." [67] But these arguments continued to have little or no effect.

In part, the failure to adequately address the health needs of Richmond's African-American community resulted from the expectation of many educated southerners, including health officials, that African Americans naturally died at a much higher rate than whites. Accepting a kind of scientific racism based on a theory of Social Darwinism popular at the turn of the century, many health authorities concluded that the city's African Americans were, in the words of one historian, "in the throes of a degenerative evolutionary process." [68] This position was extensively endorsed and encouraged by Frederick L. Hoffman, noted statistician for the Prudential Life Insurance Company. Hoffman, using the actuarial tables developed for Prudential, concluded that blacks were not holding their own in the struggle for race supremacy and would soon die out. [69] Richmond officials seemed to share this view. In 1908, Levy concluded that "unless they [African Americans] cease crowding into the cities, where they seem unable to su rvive, their ranks must steadily diminish." [70] Even for Levy, whose other writings suggest a fairly liberal perspective on issues of race and health, the underlying cause of high African-American mortality was an enigma. He asked: "Is the excessive negro death rate in our cities due entirely to average inferior living conditions, or, as seems quite likely, is modern city life, of necessity, detrimental to the well-being of a race so recently removed from savagery?" [71] Like many others, Levy wondered whether even under the best conditions African Americans would stilt have a higher death rate than the whites in cities. [72] Holding such beliefs made it easy for city officials to ignore the pressing health concerns of African Americans.

Conclusion

The willingness of Richmond's public health nurses to provide equal treatment across the color line despite the prominence of these health-related racial beliefs raises a number of questions. Why would white nurses, presumably sharing the racial sentiments of the day, minister to African Americans more filly in accordance with their needs? A possible answer lies in the social welfare origins of public health nursing itself.

Over the years, the social welfare function of public health nursing never entirely disappeared, even as the field expanded beyond its private charity beginnings and grew in nursing professionalism and technical training. Visiting nurses, in both public and private employ, were frequently the bringers of alms and other types of material support. [73] This was true in many cities, not only in the South, but throughout the country, and it was abundantly true in Richmond. In its infant mortality program, Richmond's public health nurses provided not only milk and ice to their patients, but also provided the layette when needed for newborns. [74] The public so readily identified visiting public health nurses with social welfare work that Richmond's privately funded visiting nurse association began to charge its customers in an effort to eliminate the stigma of almsgiving for its working-class patients. [75] In 1917, Richmond's city council went so far as to order the Health Department's nurses to administer the ci ty's aid to the poor program. As a result, Richmond's public health nurses spent over 1,800 hours making 1,577 visits investigating appeals to the city for coal, wood and shoes, on top of their other duties. [76] Richmond's public health nurses could not escape their social welfare functions, even if they wanted to. Ministering to the needs of the poor remained a major component of the ideology driving much early twentieth-century public health work. In Richmond, where many of the poor were black, the commitment of the city's public health nurses to meet the needs of the poor, rather than just the white poor, significantly increased the numbers of African Americans who were able to receive the benefits of the city's movement toward increased public health. [77]

It is unclear what additional factors, if any, also influenced the nature of the care given by Richmond's public health nurses. Little is known about the personalities of the individual nurses themselves, or the leadership provided by Levy. [78] Generally speaking, public health nurses tended to be socially conscious and take an environmental approach to health problems. In addition, as Darlene Clark Hine makes clear, the National Organization of Public Health Nurses, founded in 1912, was one of the few professional medical organizations that was not segregated, and early on evidenced a "concern for the status and development of black nurses." [79] Such a background could help explain the commitment of public health nurses to provide equal service to the black community.

Since Levy was ultimately the person responsible for setting the policies and finding the resources to support the programs that the public health nurses implemented, he, too, deserves some of the credit. There is evidence in the Health Department's Annual Reports that Levy cared deeply about what was known as the "Negro Question" in public health, even as he shared the paternalistic racism of the day and found there was little he could accomplish as a bureaucrat beholden to the whims of the City Council. [80] As Levy noted in his next to last report as Chief Health Officer of the City, "with monotonous regularity, year after year, I have called attention to the tremendously greater death rate among our colored people than among our white." [81] Levy resigned the following year in protest over the cost cutting moves of the city's Administrative Board, which he believed undermined the effectiveness of the Department. [82] In his last report he wrote that "in every one of my annual reports I have directed parti cular attention to the problem of negro mortality, and in many of these reports have spoken most earnestly of the necessity for intensive study in order to learn how this problem may best be solved. Before we can hope to reach a solution, there must be a most intelligent investigation along liberal lines. [83] It seems when left to his own discretion Levy used the city nurses to accomplish what little he could for the city's African Americans. It was no accident that after Levy's resignation, his public health nurses were charged with running the city's aid to the poor program and no longer had the time to devote to their tuberculosis work in the African-American community. As already discussed, black participation rates in the tuberculosis program declined precipitously as a result.

It is important to remember that only in those programs administered by the Health Department's nurses did Richmond's African Americans receive anything like an equitable share of the benefits of the city's conversion to modern public health policies and practices, and even there, the results were limited. Unfortunately, in the early years of the twentieth century in Richmond, even getting a fair deal in a few treatment programs left African Americans dying at a rate two to three times that of whites, a situation not unlike that which continues to plague us today. [84] Although the setting of public health policy was a complicated process colored by both racial attitudes and progressive beliefs in social justice, it seems clear from this study of the administration of Richmond's Health Department that race-consciousness on the part of the city's leaders influenced both the allocation of funds and distribution of services, which in turn had a profound effect on the overall health of the city's African American s. Although the exact nature of the interplay between race and health is unclear, the evidence presented in this study strongly suggests that racial discrimination in the allocation of health funds and distribution of health services directly affected the relative health status of whites and African Americans at least as much as non-medical factors such as housing and nutrition. Although we live in an age where these questions are still being debated, the determination of Richmond's public health nurses to deliver the appropriate care to the appropriate clientele is a useful reminder of the importance of ensuring African Americans and other minorities adequate access to healthcare services. For African Americans, the legacy of early twentieth century progressive health reform has largely been a broken promise. Almost a century has passed, yet African American babies still die at a rate more than twice that of whites. But the commitment of Richmond's public health nurses to serve where the need was greatest, w ithout regard to the race of the recipients, serves as a notable example of what can be done, even in the face of a system that promotes discrimination. [85]

ENDNOTES

(1.) John Duffy, The Sanitarians, A History of American Public Health (Urbana and Chicago, 1990); George Rosen, A History of Public Health (Baltimore, 1993); Karen Buhler-Wilkerson, False Dawn, The Rise and Decline of Public Health Nursing, 1900-1930 (New York, 1989). For a southern perspective, see Edward H. Beardsley, A History of Neglect: Health Care for Blacks and Mill Workers in the Twentieth-Century South (Knoxville, TN, 1987); 0. Erickson, "Southern Initiative in Public Health Nursing: The Founding of the Nurses' Settlement and Instructive Visiting Nurse Association of Richmond, Virginia, 1900-1910," Journal of Nursing History (Nov. 1987): 17-29; S.L. Smith, "White Nurses, Black Midwives, and Public Health in Mississippi, 1920-1950," Nursing History Review (1994): 29-49; Don H. Doyle, New Men, New Cities, New South; Atlanta, Nashville, Charleston, Mobile, 1860-1910 (Chapel Hill, 1990); C.E. Terry, "The Negro, A Public Health Problem," Southern Medical Journal 7(1914): 458-467.

(2.) Beardsley, A History of Neglect is the best and most comprehensive study that examines the role of race in the administration of public health in the early twentieth century South.

(3.) Duffy, The Sanitarians; and Rosen, A History of Public Health.

(4.) William A. Link, The Paradox of Southern Progressivism, 188-1930 (Chapel Hill, 1992), p. 79; and V.F. King, and K.F. Kiple, Another Dimension to the Black Diaspora (Cambridge, Eng., 1981); and Phoebe Ann Pollitt, "From National Negro Health Week to National Public Health Week," of Community Health (December 1996): 401- 407; F. 0. DuBose, "The Condition of the Negro in the South, Southern Medical Journal 7(1914): 864-866.

(5.) Beardsley, A History of Neglect, 142; Ellis, Yellow Fever and Public Health in the New South (Lexington, KY, 1992), 164-165; and S. B. Jones, "Fifty Years of Negro Public Health," Annals of the American Academy of Political and Social Science 49 (Sept. 1913): 138-146.

(6.) John H. Ellis, "Businessmen and Public Health in the Urban South During the Nineteenth Century: New Orleans, Memphis, and Atlanta" Bulletin of the History of Medicine vol. 44, no. 4 (July-August 1970): 346-71; and Duffy. The Sanitarians.

(7.) U.S. Department of Commerce, Bureau of the Census, Fourteenth Census of the United States Population: 1920, Occupational Statistics, Tables 46 and 47.

(8.) U.S. Department of Commerce, Bureau of the Census, Statistics of the United States ... in 1860, book 4 (Washington, D.C., 1866), xvii-xix; U.S. Department of Commerce, Ninth Census of the United States, Volume III, The Statistics of Wealth, and Industry of the United States, 1870, Table ix(A); U.S. Department of Commerce, Bureau of the Census, Report on the Manufactures of the United States ... 1880, Table VI; U.S. Department of Commerce, Bureau of the Census, Report on Manufactures for the 12th Census, 1900, Part I, Table XXIV; U.S. Department of Commerce, Bureau of the Census, Census of Manufactures, 1920, Volume VIII, Table l2and Table 50; see also, Steven J. Hoffman, "Behind the Facade: The Constraining Influence of Race, Class and Power on Elites in the City-Building Process, Richmond, Virginia, 1870-1920 (Ph.D. Dissertation, Carnegie Mellon University, 1993), 32-48, 96-108, 158-172.

(9.) U.S. Department of Commerce, Bureau of the Census, Statistics of Population of the United States, 10th Census, Table VI; U.S. Department of Commerce, Bureau of the Census, 13th Census, Population, Table 46; and U.S. Department of Commerce, Bureau of the Census, Statistics of Population, 1890, Table 118.

(10.) U.S. Department of Commerce, Bureau of the Census, Statistics of Occupation, 1900, Table 43; U.S. Department of Commerce, Bureau of the Census, Statistics of Occupation, 1910, Table VIII; and U.S. Department of Commerce, Bureau of the Census, Statistics of Occupation, 1920, Table 2.

(11.) Hoffman, "Behind the Facade," 156-72.

(12.) Richmond's 1893 death rate of 24.27 placed it fourth on the list behind New Orleans (28.17), Charleston (27.91) and Mobile (26.99). Richmond Chamber of Commerce, Minutes, vol. 5: 99 (8 June 1894); Annual Report of the Health Department of the City of Richmond for the Year 1893 (Richmond, Virginia), 8 (hereafter Annual Report of the Health Department); and Richmond City Council, "Resolution Regarding Investigation of Health Department," adopted 12 January 1906, Papers of Both Branches (6/05-5/06), Richmond City Papers, Virginia State Library and Archives, Richmond, Virginia (hereafter Papers of Both Branches).

(13.) Richmond Chamber of Commerce, Minutes, vol. 4:183 (27 November 1891).

(14.) Hoffman, "Behind the Facade," 172-201.

(15.) Hoffman, "Behind the Facade," 194-204.

(16.) Papers of Both Branches (6/05-5/06), "Resolution Regarding Investigation of the Health Department," 12 January 1906.

(17.) Annual Report of the Health Department, 1906, 8.

(18.) Ibid.

(19.) Hoffman, "Behind the Facade," 172-201; Annual Report of the Health Department, 1907, 33-34; American Journal of Public Health, vol. 7, no. 12 (Dec. 1922): 1042-1044; and vol. 12, no. 11 (Nov. 1924): 982.

(20.) Annual Report of the Health Department, 1906, 10.

(21.) Ibid., 1915, 50.

(22.) Ibid, 1916, 5-7 and 47-50. Richmond city government had been reorganized in 1916, and the new Administrative Board acted quickly to cut expenditures across the board. After a year of fighting for more funding for the Department, Levy put his job on the line and declared he would resign unless the Health Department received a minimum level of funding need to maintain its standards. When the budget numbers were released they did not include any additional funding for the Health Department and Levy made good on his promise and resigned. (Ibid, 1916, 6-7) He spent a year in public health consulting in New York City before joining the U.S. Army Medical Corps in August of 1918. Upon his discharge from the army in January of 1919, Levy returned to Richmond to assume the post of Director of Social Welfare. With a change of administrations in 1924, however, Levy lost his position and returned to teaching at the Medical College of Virginia before moving to Tampa, Florida as that city's Chief Health Officer from 1 925 to 1928. Upon retiring from the Tampa position, Levy returned to Richmond and continued consultation work in public health and sanitation until he died on 29 September 1938 after a long illness. (Richmond News-Leader, 30 September 1938; "E.C. Levy," vertical files, Special Collections and Archives Department, Tompkins-McCaw Library, Virginia Commonwealth University).

(23.) American Journal of Public Health, vol. 7, no. 12 (Dec. 1922): 1042-1044.

(24.) The Instructive Visiting Nurse Association of the Nurse's Settlement, Richmond, Virginia (Richmond, Everett Waddey Company, 1903). p.1, and Samuel Nadler, "A History of the Instructive Visiting Nurse Association of Richmond, Virginia, 1900-1950," Master's Thesis, Richmond Professional Institute, College of William and Mary, 1951), 4-8; Erickson, "Southern Initiative in Public Health Nursing".

(25.) Nadler, "A History of the Instructive Visiting Nurse Association of Richmond," 20-21; and Annual Report of the Health Department, 1910, "Report of the Nurse in Charge of Work for the Prevention of Infant Mortality," 130-132.

(26.) Buhler-Wilkerson, False Dawn; Catherine W. Tinkham and Eleanor E Voorhies, Community Health Nursing, Evolution and Process (New York, 1972), 18-25; and Susan M. Reverby, Ordered to Care, The Dilemma of American Nursing, 1850-1945 (New York, 1987), 109-110; and Diane Hamilton, "The Cost of Caring: The Metropolitan Life Insurance Company's Visiting Nurse Service, 1909-1953," Bulletin of the History of Medicine, vol. 63, no. 3 (Fall 1989): 414-434.

(27.) Duffy, The Sanitarians, 208; Buhler-Wilkerson, False Dawn; and Reverby, Ordered to Care.

(28.) E.C. Levy, "Reciprocity Between the Health Officials and the Medical Profession" (Presidential Address to American Public Health Association, Boston, 8 October 1923) American Journal of Public Health vol. 13, no. 12 (December 1923): 989.

(29.) Duffy, The Sanitarians, Rosen, A History of Public Health; and Richard A. Meckel, Save the Babies: American Public Health Reform and the Prevention of Infant Mortality, 1850-1929 (Baltimore, 1990).

(30.) Duffy, The Sanitarians, Rosen, A History of Public Health; and Annual Report of the Health Department, 1906, 17.

(31.) The other communicable diseases with a higher mortality rate among whites than among blacks were Diphtheria, and occasionally Measles and Scarlet Fever. Whites consistently outnumbered African Americans for deaths due to Diabetes, Cancer, Suicide, Appendicitis, and Senile Debility, but none of these was a communicable disease and none of them was susceptible to the kinds of public health interventions available at the time. Annual Report of the Health Department, 1900-1920. See also, D.C. Ewbank, "History of Black Mortality and Health Before 1940," Milbank Quarterly 1987 (65 Suppl 1): 100-28.

(32.) Annual Report of the Health Department, 1900,Table 13:29; 1901, Table 13:34; 1902, Table 13: 29; 1903, Table 13:30; 1904, Table 13: 30; 1905, Table 13: 30; 1906, Table 23: 59; 1907, 33 and 67; 1908, 41 and 81; 1909, 35 and 73; and 1910, 48 and 104.

(33.) Ibid., 1911, 15; Ernest C. Levy and Allen W. Freeman, "Certain Conclusions Concerning Typhoid Fever in the South," Reprinted from the Old Dominion Journal of Medicine and Surgery, Vol. viz, No. 5 (November 1908)(Richmond, 1908); and E.C. Levy, "Reductions of Deaths from Infantile Diarrhea by Care of the Bowel Discharges of Infants" American Journal of Public Health vol. 10(1920): 400.

(34.) American Journal of Public Health, vol. 7, no. 12 (Dec. 1922): 1042-1044.

(35.) Annual Report of the Health Department, 1908, 28-31; and 1915, 16.

(36.) Ibid., 1920, 9.

(37.) Ibid., 1916, 18.

(38.) Ibid., 1910, 10.

(39.) Meckel, Save the Babies; Duffy, The Sanitarians; Stuart Galishoff, Safeguarding the Public Health, Newark, 1895-1918 (Westport, CT, 1975), 81-119; Jesse D. Burks, "Clean Milk and Public Health," 192-206, in Emory R. Johnson, editor, The Public Health Movement, The Annals of the American Academy of Political and Social Science. Vol. XXXVII, No. 2 (March 1911); and S.W. Newmayer, "The Warfare Against Infant Mortality," 288-298, in Emory R. Johnson, editor, The Public Health Movement, The Annals of the American Academy of Political and Social Science. Vol. XXXVII, No. 2 (March 1911).

(40.) "Response of Dr. Oppenheimer," 28 May 1906, 6-7 (Papers of Both Branches, 5/06-1/07); and Annual Report of the Health Department, 1906, 12.

(41.) American Journal of Public Health, vol. 7, no. 12 (Dec. 1922), 1044.

(42.) Annual Report of the Health Department, 1914, 29; and 1920, 33.

(43.) Ibid., 1914, 30.

(44.) Ibid., 29.

(45.) Ibid., 1910, 65.

(46.) Annual Report of the Health Department, 1914, 29.

(47.) Ibid., 1910, "Report of the Nurse in Charge of Work for the Prevention of Infant Mortality," 130-132.

(48.) Annual Report of the Health Department, 1914, 29-31.

(49.) Ibid.

(50.) Ibid., 1920, 32.

(51.) Doyle, New Men, New Cities, New South, 286; Annual Report of the Health Department, 1910, 68; and 1912, 44.

(52.) Annual Report of the Health Department, "Report of the Nurse in Charge of Work for the Prevention of Infant Mortality," 1910-1914; "Report of the Chief Nurse," 1915-1916; and Annual Report of the Health Department, Table 2 and Table 2A, 1910-1916.

(53.) Annual Report of the Health Department, 1920, 33.

(54.) Ibid., 1918, 28-29.

(55.) Ibid., 1916, 49, and 1918, 5.

(56.) Ibid., 1917, 33.

(57.) Ibid., 1909, 33. This was not unusual. In Birmingham, Alabama, even though tuberculosis was the largest cause of deaths of African Americans in 1915, no medical institutions in the city would admit African American tuberculosis patients. Carl V. Harris, Political Power in Birmingham, 1871-1921 (Knoxville, 1977), 160. This was often the case in northern cities as well. See Barbara Bates, Bargaining for Life: A Social History of Tuberculosis, 1876-1938 (Philadelphia, 1992); and Marion M. Torchia, "Tuberculosis among American Negroes: Medical Research on a Racial Disease, 1830-1950." Journal of die History of Medicine and Allied Sciences (July 1977): 260-261.

(58.) Annual Report of die Health Department, 1910, 46-47; 1911, 39-40; and 1916, 30.

(59.) Ibid., 1914, 29.

(60.) Ibid., 1909, 33-34; and John A. Kenney, "Health Problems of the Negroes," in Emory R. Johnson, editor, The Public Health Movement, The Annals of the American Academy of Political and Social Science. Vol. XXXVII, No. 2 (March 1911).

(61.) Beardsley, A History of Neglect, 137.

(62.) Doyle, New Men, New Cities, New South, 278-289; Stuart Gallishoff, "Germs Know No Color Line: Black Health and Public Policy in Atlanta, 1900-19 18," Journal of the History of Medicine and Allied Sciences (Vol. 40, Jan. 1985): 22-41; Harris, Political Power in Birmingham, 160; Duffy, The Sanitarians; Torchia, "Tuberculosis among American Negroes;" Bates, Bargaining for Life; and John W. Trask, "The Significance of the Mortality Rates of the Colored Population of the United States," American Journal of Public Health 6 (1916): 254-260.

(63.) Annual Report of die Health Department, 1907, 25.

(64.) Ibid., 1907-1912.

(65.) Annual Report of die Health Department, 1908-1920, "Reports of the White Tuberculosis Dispensary," 1908-1920; "Reports of the Colored Tuberculosis Dispensary," 1908-1920; "Reports of the Nurse in Charge of Work for the Prevention of Infant Mortality," 1910-1914; and "Reports of the Chief Nurse, 1915-1920."

(66.) Annual Message of the Mayor, 30 March 1907 (Richmond, Virginia), 21.

(67.) Annual Report of die Health Department, 1917, 33

(68.) Allan M. Brandt, "Racism and Research: The Case of the Tuskegee Syphilis Study," in Judith Walzer Leavitt and Ronald L. Numbers, eds., Sickness and Health In America; Readings in die History of Medicine and Public Health, second edition, revised (Madison, 1985), 331. See also, John Haller, Outcasts from Evolution; Scientific Attitudes of Racial Inferiority, 1859-1900 (Urbana, IL, 1971); Beardsley, A History of Neglect; David McBride, From TB to AIDS: Epidemics Among Urban Blacks Since 1900 (Albany, New York, 1991); James Reed, "Racism, Scientific," in Charles Reagan Wilson and William Ferris, eds., Encyclopedia of Southern Culture, vol. 4 (New York, 1991), 158-161; and Torchia, "Tuberculosis among American Negroes," 260-261.

(69.) Frederick L Hoffman, Race Traits and Tendencies of the American Negro (New York, 1896); Beardsley, A History of Neglect, 130; W.D. Weatherford, Negro Life in the South, Present Conditions and Needs (New York, 1915), 71-83.

(70.) Annual Report of die Health Department, 1908, 40.

(71.) Ibid., 1917, 10.

(72.) Ibid., 1913, 36. See also Frederick L. Hoffman, Race Traits and Tendencies of the American Negro (New York, 1896, part of volume 11 of the Publications of the American Economic Association); Beardsley, A History of Neglect; and McBride, From TB to AIDS.

(73.) Buhler--Wilkerson, False Dawn; and Reverby, Ordered to Care.

(74.) Annual Report of the Health Department, 1910-1920, "Reports of the Nurse in Charge of Work for the Prevention of Infant Mortality," 1910-1914; and "Reports of the Chief Nurse, 1915-1920."

(75.) The Ninth Annual Report of the Instructive Visiting Nurse Association of Richmond Virginia, 31 January 1911 (Richmond, 1911), 11. This was not uncommon, see Buhler-Wilkerson, False Dawn for other examples.

(76.) Annual Report of the Health Department, 1917, "Report of the Chief Nurse," 90.

(77.) An additional factor influencing Richmond's public health nurses' uncharacteristic attention to the needs of African Americans was their relationship to the city's private physicians and the policies of the city's private visiting nurse association. The IVNA, dependent on charitable donations and fees for its livelihood, attended only those patients retaining a doctor. Families employing midwives were routinely dropped from care. The Ninth Annual Report of the Instructive Visiting Nurse Association of Richmond Virginia, 31 January 1911 (Richmond, 1911); The Seventeenth Annual Report of the instructive Visiting Nurse Association of the Nurses' Settlement, Richmond, Virginia, 31 December 1918; and The Nineteenth Annual Report of the Instructive Visiting Nurse Association of the Nurses' Settlement, Richmond, Virginia, 31 December 1920.) The Health Department nurses, on the other hand, specialized in caring for patients without doctors and, in particular, those mothers employing midwives. Given the prominen t role of midwives in the African-American community and the widespread inability to afford regular physicians' fees, the caseload of the Health Department nurses naturally accommodated a larger percentage of African Americans (Annual Report of the Health Department, 1910-1920, "Reports of the Nurse in Charge of Work for the Prevention of Infant Mortality," 1910-1914; and "Reports of the Chief Nurse, 1915-1920.")

(78.) An important influence on Levy, no doubt, was his courtship and marriage to the city's Chief Public Health Nurse in 1912. Annual Report of the Health Department, 1912.

(79.) Darlene Clark Hine, Black Women in White, Racial Conflict and Cooperation in the Nursing Profession, 1890-1950 (Bloomington, 1989), 92.

(80.) Annual Report of the Health Department, 1906-1916.

(81.) Ibid., 1915, 34.

(82.) Ibid., 1916, 6-7.

(83.) Ibid., 10.

(84.) Based on 1995 statistics, infant mortality among African Americans is 2 1/2 times as high as among whites. U.S. Department of Health and Human Services, Health Resources and Services Administration, Health Care Rx: Access for All, The President's Initiative on Race, "Barriers to Health Care for Racial and Ethnic Minorities: Access: Workforce Diversity, and Cultural Competence," 2. See, also, the web site established on the issue by the Office of Minority Health, http://www.raceandhealth.omhrc.gov/ accessed June 24, 2000.

(85.) Edward A. McKinney, "The Crisis of Medical Care in the United States: Implications of a Canadian Type Health Plan for African Americans," Urban League Review, vol. 16, no. 1 (1993): 57.

Table 1
African-American Population of Richmond 1890-1920
                        African-American  African-American
Year  Total Population     Population      % of total pop.
1890       81,388            32,330             39.7
1900       85,050            32,230             37.9
1910      127,628            46,733             36.6
1920      171,667            54,041             31.5
Source: 13th Census, Population, Table 46, p. 212; 14th Census,
Population, Table 11, p. 45; Abstract of Occupation Statistics of the
14the Census of the United States, Population, 1920, Table 46, pp. 78-79
and Table 47, pp. 80-81; and Census of Negro Population, 1790-1915,
Table II, p. 793.
Table 2
Reported Death Rates Richmond, Virginia 1890-1905
      Number of          death rate
       deaths           per 1000 [*]
Year    white    black     total      white  black
1890    1,094    1,224     23.18      19.53  27.81
1891    1,050    1,121     25.54      23.34  29.50
1892    1,006    1,104     24.82      21.40  29.05
1893      979    1,084     24.27      20.83  28.52
1894      846      874     18.35      16.41  20.74
1895      689      867     16.10      12.89  20.06
1896      745      913     16.58      13.67  20.07
1897      700      813     14.61      12.40  17.25
1898      813      934     19.41      13.81  29.98
1899      741      838     15.55      11.72  21.85
1900      955    1,059     20.14      15.34  28.05
1901      871    1,036     19.07      13.99  27.44
1902      875    1,043     19.18      14.05  27.63
1903      884    1,051     19.35      14.20  27.84
1904      858    1,018     18.76      13.76  27.49
1905      820      897     17.17      13.17  23.76
        Board of Health/
      population estimates
Year         total          white   black
1890        100,000         56,000  44,000
1891         85,000         47,000  38,000
1892         85,000         47,000  38,000
1893         85,000         47,000  38,000
1894         93,734         54,554  42,180
1895         96,660         53,440  43,220
1896        100,000         54,500  45,500
1897        103,560         56,440  47,120
1898         90,000         58,850  31,150
1899        101,560         63,220  38,340
1900        100,000         62,250  37,750
1901        100,000         62,250  37,750
1902        100,000         62,250  37,750
1903        100,000         62,250  37,750
1904        100,000         62,250  37,750
1905        100,000         62,250  37,750
(*)The reported death rates for both black and whites were lower than
the actual rates because of the consistent overestimation of the size
of the population. Actual death rates for 1890 were 22.76 for whites
and 37.86 for blacks based on Census Bureau population figures of 49,058
whites and 32,330 African Americans. The actual death rates for 1900
were 18.08 for whites and 32.85 for blacks based on population figures
of 52,820 and 32,230.
Source: Annual Report of the Board of Health, 1890, p. 6; 1891, pp.
15-16; 1892, p. 10; 1893, p. 10; 1894, p. 7; 1895, p. 6; 1896, p. 5;
1897, p. 5; 1898, p. 6; 1899, p. 5; 1900, p. 6; 1901, p. 7; 1902, p. 7;
1903, p. 7; 1904, p. 7; 1905, p. 7.
Table 3
Typhoid Fever and Tuberculosis Deaths Richmond, Virginia 1890--1906
      Typhoid Fever         Tuberculosis [*]
Year      white      black       white        black
1890       58         14          136          153
1891       35          6          121          141
1892       36         22          119          133
1893       31         17          101          134
1894       22          6          127          120
1895       15         11           94          134
1896        7          5          102          144
1897       15          5          126          153
1898       17         12          116          171
1899       27         10          118          165
1900       57         18          142          196
1901       22         10          122          146
1902       24         18          116          178
1903       29         22          119          121
1904        9         25          130          153
1905       20          8          106          107
1906       27         14          102          133
(*)The Richmond Board of Health changed the way it reported tuberculosis
deaths in 1901 making it more difficult to get an accurate count between
1901 and 1906.
Source: Annual Report of the Board of Health, 1890, pp. 28, 34; pp. 31,
37; 1892, pp. 26, 43; 1893, pp. 26. 32; 1894, pp. 24, 30; 1895, pp. 23,
28; 1896, pp. 17, 21; 1897, pp. 19, 23; 1898, pp. 18, 22; 1899, pp. 18,
27; 1900, pp. 18, 22; 1901, pp. 21, 23; 1902, pp. 19, 20; 1903, pp. 19,
20; 1904, pp. 20, 21; 1905, pp. 21, 22; 1907, pp. 18, 47.
Table 4
Death Rates from Typhoid Fever Richmond, Virginia 1907-1920
      Death Rate
      Per 100,000
                   African-
Year     White     American  Total
1907     52.5        23.3    41.4
1908     54.6        41.5    49.7
1909     24.9        22.8    24.1
1910     18.4        27.8    21.8
1911     19.0        14.9    17.6
1912     18.5        12.8    16.5
1913     20.2        19.1    19.8
1914      8.7        23.4    13.7
1915      5.8        24.2    11.9
1916     15.7        37.2    22.8
1917      4.5        11.1     6.7
1918      5.3        11.1     7.2
1918      4.3         1.8     3.5
1920      5.9         7.4     6.4
Source: Annual Report of the Health Department, 1920, "Report of the
Medical Inspector," Table 6, p. 80.
Table 5
Annual Death Rate from Infantile Diarrhea (under 2 years) Richmond,
Virginia 1907-1920
      Number of                   Death Rate
       Deaths                     per 100,000
                 African-                      African-
        White    American  Total     White     American  Total
1907     72         89      161      101.2      215.4    142.0
1908     73         67      140      101.1      159.9    122.0
1909     69         78      147      101.5      187.9    126.5
1910     62        107      169       76.9      226.1    131.8
1911     87        109      196      106.7      228.3    149.5
1912     63         69      132       76.3      143.3     98.8
1913     58         54      112       69.4      111.3     82.2
1914     51         46       97       59.6       93.1     69.8
1915     53         48      101       54.1       84.7     63.3
1916     47         55      102       47.3       95.8     62.9
1917     45         68      113       44.8      116.9     68.5
1918     41         41       82       40.3       69.6     48.9
1919     36         23       59       34.9       38.6     34.6
1920     34         34       68       28.6       62.8     39.3
      Ration A-A
      Death Rate
       To White
1907     2.13
1908     1.58
1909     1.85
1910     2.94
1911     2.14
1912     1.88
1913     1.60
1914     1.56
1915     1.57
1916     2.02
1917     2.61
1918     1.73
1919     1.10
1920     2.20
Source: Annual Report of the Health Department, 1907, p. 33; 1908,
p. 41; 1909, p. 35; 1910, p. 48; 1911, p. 41; 1912, p. 35; 1913, p. 43;
1914, p. 32; 1915, p. 36; 1916, p. 40; 1917, p. 34, 1918, p. 26; 1919,
p. 22, 1920, pp. 33 and 36.