Infectious Respiratory Disease

Content Objectives

History & Epidemiology of the Disease

Tuberculosis, or at least a description of its symptoms, can be traced back almost as far as medical history exists, and the causative bacterium Mycobacterium tuberculosis has been identified in human skeletons at least 9,000 years old.² Whether called phthisis by Greeks, chaky oncay by Incans, huaifu or “destroyed palace” by the Chinese, or consumption by English-speakers, this “wasting” disease that slowly but fatally damages its victims’ lungs has been endemic around the world.³ Tuberculosis is most often an infection of the lungs that begins when bacteria enter through a respiratory pathway; over time, as the bacteria multiply in the lungs, lung tissue is affected and victims find it increasingly difficult to breathe.⁴ Lack of appetite, abdominal pain, and iron and oxygen deficiency in the blood lead to the pale, skeletal appearance of the long-term sufferer. What begins as a dry cough can becomes bloody as the internal cavities formed by the bacterium begin to encroach upon blood vessels. This leads to the stereotypical “spot of blood on the handkerchief” common in period dramas and heartrending novels, but tuberculosis is very far from a historical curiosity.

Tuberculosis remains endemic, especially in sub-Saharan Africa and southeast Asia, and despite the existence of a vaccine that is effective when administered to children. Except for brief periods when it was eclipsed by HIV or COVID-19, tuberculosis has been and remains the leading infectious cause of death from a single infectious agent worldwide. Both now and in the past, the disease is also noticeable for often affecting people in their prime; almost three quarters of tuberculosis patients in the United States in 2024 were between the ages of 15 and 65, following a worrying spike in especially ages 25-44.⁵ Tuberculosis can be treated effectively with antibiotics, although MDR-TB (multi-drug resistant tuberculosis) that resists the most common antibiotics is an ongoing issue. Popular author John Green’s recent publication, Everything is Tuberculosis, begins by declaring that many tuberculosis patients die each year because “the cure is where the disease is not, and the disease is where the cure is not.”⁶ Green also emphasizes how even if a cure is technically available, it is a long-running and difficult course of antibiotics that any given patient may struggle to complete. The background below will show how this intersection of physical health and social barriers has been part of tuberculosis for many years.

Early 19th-Century Views of Tuberculosis

In the nineteenth century, “consumption” was often a romanticized illness, at least in western Europe. Writer Charlotte Bronte wryly remarked of the illness that would kill most of her siblings that it was considered “a flattering malady.”⁷ Partly through its association with impoverished writers and artists, consumption gained a reputation as a disease that shrunk the body to give the spirit greater weight. Books like the 1909 Tuberculosis and the Creative Mind even claimed that the “spes phthisca,” or tubercular spirit, led to a “quickening of genius.”⁸ John Green contrasts the gentle, spiritual consumptive death of a fictional white child in the 1852 novel Uncle Tom’s Cabin with the actual descriptions of conscious suffocation and constant pain described by sufferers and caretakers.⁹

Western medicine blamed tuberculosis on either miasma (“bad air”) or on heredity. When the 19th-century literary family of the Brontes died of tuberculosis in their late twenties, their deaths were blamed on inherited weakness or the cemetery adjacent to their home, not on the way that each family member had diligently nursed the one to die before them. In Bargaining for Life: A Social History of Tuberculosis, Barbara Bates argues that this reluctance to recognize contagion was partly because tuberculosis can present in a number of ways, can be dormant in the body for many years, and in most cases would never become active disease.¹⁰ Unlike a typhoid or smallpox epidemic where the chain of infection was quite obvious, tuberculosis could manifest weeks, months, or decades after their first exposure; at a Philadelphia institute devoted to the treatment of tuberculosis, barely half the patients diagnosed in 1903 could even guess at their source of exposure.¹¹ Even today, approximately a third of the global population is infected with tuberculosis, with that population concentrated in but by no means limited to the developing world, but only about five percent of those people will ever see their infection move beyond a latent, asymptomatic disease which they cannot spread. Under these circumstances, tuberculosis required a more rigorous scientific experimentation process to prove causality.

Proving Tuberculosis Was Contagious

That rigorous process occurred in Germany, in 1882, in the laboratory of a scientist named Robert Koch. Koch’s postulates lay out the requirements for proving a disease is contagious:  first, find a microorganism that is only present in ill people, isolate and grow that microorganism independently, make someone, or at least some thing, sick when the germ is transferred to them, and finally, re-isolate the same germ from the now-ill organism. By transferring anthrax from the organs of dead cows and sheep to healthy mice using nothing more complex than splinters, Koch proved that anthrax could be spread by blood. In 1882, he was able to isolate a microorganism that appeared in the sputum of tuberculosis sufferers and, when grown and injected into rabbits, damaged their lungs in the same way. This organism, christened Mycobacterium tuberculosis, can infect humans in a variety of tissues and organs, but when inhaled, settles in the lungs and becomes tuberculosis. In the year before Koch’s isolation of the bacteria, some records estimated that one out of every four adult deaths in the world were caused by this invisible killer.¹²

A student-friendly TED-Ed animation highlights the way this bacterium settles in the lungs and multiplies.¹³ The immune system responds swiftly to M. tuberculosis, swarming the invader with macrophages—white blood cells that attack dangerous microorganisms and signal other immune system cells to engage. These macrophages surround the tuberculosis bacteria but sometimes cannot penetrate its particularly dense cell wall. As a next-best option, the white blood cells often wall off the bacteria inside a tiny, calcified lesion that is the eponymous “tubercule.” When someone’s immune system succeeds in this step, they have “latent tuberculosis,” which is not contagious but can become active at any point should the immune system falter due to stress, pregnancy, or other illness. If the immune system is not strong enough to counter the initial infection, the bacteria reproduces inside the macrophages, quickly spreads, and begins to degrade the lung tissue around it. Even such a “successful” infection, however, manifests slowly and insidiously. An Escheria coli bacterium, for example, doubles in number three times an hour; the slow-growing M. tuberculosis doubles its numbers only once per day. Someone with active tuberculosis may infect ten to fifteen other people each year before becoming ill enough to seek treatment.¹⁴

A young doctor in Philadelphia highlighted this issue soon after Koch’s discovery. Dr. Lawrence Flick argued for a stronger governmental response to tuberculosis in a short, insistent pamphlet called “The Contagiousness of Phthisis.”¹⁵ He dismisses the arguments for hereditary disease, pointing out that a family decimated by tuberculosis could be equally decimated by scarlet fever, and “if those same families had died, in the same order of succession, of a disease which runs a shorter course, no one would have doubted its contagiousness.”¹⁶ Flick backs up his argument with a series of maps of a Philadelphia neighborhood showing how, over a long enough timeline, “phthisis” clusters in the same patterns as known contagious illnesses such as typhoid and smallpox (see Fig. 1). Dr. Flick would later draft a lengthy book for the “layman,” explaining how tuberculosis and related bacteria “grow in us the same way as wheat, timothy, and clover grow in the field”¹⁷ and counseling ventilation and rigid cleanliness to avoid spreading the disease. Flick is consistently, brightly optimistic about the “consoling corollary of the contagiousness,”¹⁸ that “if consumption is contagious, it can be exterminated.”¹⁹

Figure 1. Dr. Lawrence Flick’s 1888 map of one neighborhood of Philadelphia. Each square represents a collection of blocks, with the population indicated in the top left.  The dark dots show clusters of deaths from short-term, obvious infections such as typhoid in 1865 (top row, fourth from left) or small-pox (bottom center), but also from the slower epidemic of tuberculosis spreading gradually over ten years. Lawrence F. Flick, The Contagiousness of Phthisis (Tubercular Pumonitis) (Philadelphia: WM. J. Dornan, Printer, 1888), 13.

Doctors did not yet fully understand the means of this contagion, either. Koch and Flick believed it was mainly spread by “dust” composed of dried, tubercular sputum, and that even moving into an apartment once occupied by a consumptive patient could be a death sentence.²⁰ Reflecting some fifty years later, a prominent Philadelphia physician would recall how Koch’s discovery “that danger often lurks in the sputum made promiscuous spitting more than a breach of propriety; it now became a greater offense than a disgrace.”²¹ Laws outlawing public spitting and requiring the provision of spittoons proliferated. In 1897, another German scientist, Carl Flügge, blew dust from the dried handkerchiefs of tuberculosis patients into the air breathed by guinea pigs to little effect. When he asked infected tuberculosis patients to talk, laugh, sing, and cough in a room scattered with Petri dishes, however, M. tuberculosis duly appeared, and did so even if those Petri dishes were placed in the room an hour or two after the infected patients left. Tuberculosis, it seemed, was not the fault of one’s race, one’s family, or one’s feather-duster—it spread in the all-but-invisible droplets sprinkled throughout the room in conversation.²²

Responses & Results

Tuberculosis & the Phipps Institute

As another Philadelphia doctor, Henry Landis, obtained his medical degree in 1897, the Board of Health in Philadelphia was arguing that “as tuberculosis is an infectious disease...isolation and treatment in [free, state-run] hospitals must be depended upon.”²³ In 1903, Landis was hired by the Henry Phipps Institute for the Treatment, Study, and Prevention of Tuberculosis, newly founded by Lawrence Flick in partnership with a local steel magnate.²⁴

The need was undeniable. Between 1870 and 1914, tuberculosis was sometimes responsible for as much as 25% of all yearly deaths in Philadelphia, and rarely less than 10%. At the same time, in 1904, only four hundred hospital beds (public, private, and charitable combined) were available to treat the 3,117 Philadelphians who would die of the disease that year.²⁵ Tuberculosis affected many groups in Philadelphia and elsewhere, but lower-income people were both the most exposed and the least equipped to recover. Case numbers were particularly high in the low-income areas occupied by newcomers to the city, which included European immigrants (mostly Italian and Irish at the turn of the century) and many newly-arrived African-Americans, mostly from southern states.²⁶

If you were one of those Black men or women feeling short of breath in 1910’s Philadelphia, you might have considered yourself more fortunate than a similar sufferer elsewhere. Philadelphia was home to the Pennsylvania Society for the Prevention of Tuberculosis, founded by Flick in 1892. Your children might have been educated on how to avoid illness by this society’s school visits (Fig 2.) or been checked for signs of tuberculosis by a school nurse paid for by the society²⁷ or by one of the other charitable and nascent public health organizations around the city. Many of those organizations, such as the Starr Centre, the Whittier Centre, and clinics in south, east, and northwest Philadelphia, had grown out of the Settlement House movement.²⁸ As a new arrival to Philadelphia—perhaps from Alabama, Georgia, or Kentucky—you would be one of the tens of thousands who more than doubled the city’s Black population between 1870 and 1910. You might have settled in the “Black belt,” the cluster of about forty blocks just south of City Hall where W.E.B. DuBois conducted the exhaustive sociological research for The Philadelphia Negro in 1897. You might have found work as one of the 20% of Black men employed in brick or road construction, or as one of the many Black women employed in domestic service. You might even be putting aside ten or fifteen cents a week with the Whittier Centre’s “Rainy Day Society,” a sort of savings bank to support members in illness.²⁹ If you did find yourself with a painful cough, night sweats, or other alarming symptoms, you could comfort yourself that you lived in a city with not one but two Black-run hospitals: Frederick Douglass since 1895 and Mercy Hospital since 1907. There was also the Phipps Institute on 3rd and Pine Streets, barely outside the neighborhood.³⁰

Fig 2 - A few excerpts from a 1914 “portable exhibit” taken to Philadelphia schools by the Pennsylvania Society for the Prevention of Tuberculosis. The images urge children and families to buy “clean milk,” highlight signs of unsafe milk conditions, counsel against patent medicine cures and emphasize that “No baby is too poor to enjoy fresh air.” Pennsylvania Society for the Prevention of Tuberculosis, “Preventing Tuberculosis in Pennsylvania” (Philadelphia: Pennsylvania Society for the Prevention of Tuberculosis, 1914), 7-8.

The Phipps institute was unique in several ways. In the first report, Flick and Landis detailed the work done to transform two adjoining houses into a medication dispensatory, laboratory, library, and small hospital ward to show “how inexpensively and easily an old building can be transformed into a fairly good modern hospital in a short time.”³¹ The Institute, as its name implied, focused not only on treating or even preventing tuberculosis but also on gaining new knowledge about the disease, giving regular lectures, and publishing annual reports that were closer to medical journals. The Phipps Institute was also, for both practical and philosophical reasons, committed to making “absolutely no distinction”³² between its Black and white patients.

In the decades following Koch’s discovery, tuberculosis had increasingly become a disease associated with race and class issues. No longer the domain of tragic geniuses and saintly virgins, tuberculosis was now the scourge of the slums, evidence of the filthy lifestyles of the new European and African-American city-dwellers. African-Americans were believed to be particularly susceptible to the disease, even by doctors like Flick and Landis who championed contagion as the cause. Almost forty years after the identification of the tuberculosis bacterium, Landis still needed to regularly counter the argument that Black people were so uniquely vulnerable to tuberculosis that they would eventually vanish entirely from America.³³ Flick, a passionate advocate for nonsegregation, nonetheless theorized that high rates in the Black community were because they were “newer…to order and civilization.”³⁴ Fighting this idea, one young Black doctor, Charles A. Lewis, gathered $125 from Penn and Lincoln Universities in 1911 and conducted a door-to-door study of tuberculosis in a few Philadelphia blocks. Lewis’ survey situated the causes of tuberculosis primarily in “the deplorable conditions under which Negroes were forced to live,” including “improper nourishment”.³⁵ The Phipps Institute would soon partner with the Whittier Centre, a social service organization, to attempt an approach to tuberculosis that did not forget the needs of the infected.

That partnership, however, was slow to take off. Imagine again that you are a young or middle-aged Black patient in early 20th-century Philadelphia, facing the possibility of a tuberculosis diagnosis. True, the Phipps Institute is quite convenient, offering diagnosis, outpatient treatment, and even hospitalization free of charge. However, a diagnosis of consumption might affect your ability to work more than the symptoms would; tuberculosis to some is as much a moral as a physical contagion. Perhaps you have skimmed the pamphlet put out by a local life insurance company, “A Friendly Word to the Philadelphians,” that coupled a seeming compassion for tuberculosis patients with the insistence that these “careless or ignorant victims” be “placed under the rigid supervision of the public health authorities.”³⁶ Perhaps you have heard of the tuberculosis sanitariums where Black patients are discriminated against, if they are allowed at all, and where even the wife of “a very prominent member of the negro race” willing to pay full price could only obtain treatment on the understanding that she would “of course not dine with the other patients” lest “she be Hurt.”³⁷ In the same Phipps Institute report in which Landis agonized that Black patients were avoiding the Institute despite “no distinction” in treatment, he also described them as “careless in their habits, not overly cleanly [and] therefore a menace to community unless they can be brought under control and supervision.”³⁸ You may not have read the words that Mabel Jacques, a white visiting nurse, wrote for a national magazine, that the Black people of Philadelphia were “insolent and overbearing with a smattering of education,” “the most difficult people with whom we have to deal,” and in urgent need of being “taught or compelled.”³⁹ However, you have probably encountered enough nurses like her to confirm your concerns. After all, the white doctors and nurses who claim to want to help you out of mere fellow-feeling are also writing to their peers with a different concern: that Black people are a “servant class”⁴⁰, the “people who wash our clothes, clean our homes and cook our meals,” and therefore any illness in Philadelphia’s predominantly Black Seventh Ward could travel into many well-off houses.⁴¹ Lawrence Flick may have opined that “the colored people are more loath to become a public charge and…will not go into a public institution if they can manage to crawl around,”⁴² but it is equally possible that what Black Philadelphians were loath to do was enter a public institution where they would undergo questionably effective treatments from unquestionably racist staff.

The treatments for tuberculosis at this time were limited and often amounted to nothing more than a “rest cure.” A common approach called for the consumptive patient to consume three to six quarts of milk and six to twelve eggs per day⁴³—an expensive diet that, one scholar points out, would be particularly unpleasant for the approximately 70% of African-Americans who experience symptoms of lactose intolerance.⁴⁴ Rest at home required extensive care by someone who would then be exposed to disease themselves; rest in the hospital was an unpleasant, institutional experience. The most extreme treatment options included an artificial pneumothorax, an invasive and painful procedure where surgeons deliberately collapsed a tubercular lung in the hopes of stopping infection.⁴⁵ Small wonder that some patients preferred to stay at home, hope for the best, and partake of patent medicines such as “Radam’s Microbe Killer,” whose logo featured a medical man with a spiked club bludgeoning a skeletal Death.⁴⁶ However, without patients, the Phipps Institute could neither make new discoveries about tuberculosis nor slow its spread through Philadelphia’s Black residents (and the white-owned homes, factories, and offices that employed them). When Elizabeth Tyler arrived in Philadelphia in 1914, reaching these patients would be her principal goal.

The Work of Visiting Nurses

Nine years after Tyler’s arrival, Dr. Landis would somewhat disingenuously describe Philadelphia’s first Black public health nurse as having been “taught the methods employed by the white field nurses and instructed to go among the colored people and induce any with whom she might come in contact” to seek treatment.⁴⁷ When she reached Philadelphia in February of 1914, however, Elizabeth Tyler was already at least as much of an expert in such matters as Mabel Jacques and other white nurses in the emerging field of “medical social work.”

Tyler enters the historical record in 1894 as part of the inaugural class of 37 Black nurses at the Freedmen’s Hospital in Washington D.C. It’s possible she was born in Delaware, where she died in 1959,⁴⁸ but Tyler spent her career in a relentless and geographically diverse quest for impactful, demanding work. Students may benefit from understanding how rare and difficult such a quest was for a Black woman in 1896, the year Tyler graduated from her nursing program. Black nurses were broadly prohibited from tending to white patients, limiting their options to private nursing or the few, and under-resourced, Black hospitals. An 1898 alumni report places her as a private nurse in Northampton, Massachusetts⁴⁹, but Tyler’s sphere quickly expanded. By 1899 she was many miles south, working at A&M University in Alabama as a campus nurse and teaching courses in hygiene and physiology. In 1902, she was in the same role in Virginia, now at the St. Paul Normal and Industrial School. Tyler enjoyed the combined responsibility of educator and healthcare professional, but a post-graduate course created by the first Black supervisor of Lincoln School for Nursing enticed her to New York City in 1906. It was here Tyler perfected the combination of medical, educational, and social expertise that would alter Philadelphia’s consumptive landscape.⁵⁰

The Henry Street Settlement House in New York City served new migrants, whether they fled stagnating opportunities in Dublin, Florence, or Atlanta. In 1900, reluctantly and uncertainly, the staff at Henry Street had been convinced to hire the first Black public nurse in the nation, a young woman named Jessie Sleet. A year later, Sleet would declare this experiment “successful,” writing for the American Journal of Nursing. In only two months, Sleet wrote, she had made 156 calls to 41 families, many suffering from tuberculosis, and formed collaborative partnerships with several societies, churches, and hospitals. Sleet did not write merely of medical issues. Her short writing is worth giving students to read in full: first, she describes her care of a paralyzed single mother whose thirteen-year-old daughter, Sleet implies, is being groomed for prostitution by a neighbor. Secondly, she gives the sad tale of providing what we would now call hospice care for a twenty-seven-year-old mother dying of tuberculosis, but this care expands to include changes to the house windows to improve ventilation, employment opportunities for the patient’s mother, and preventive care for the patient’s three-year-old daughter. Sleet describes her patients with warmth and humanity, and highlights that she is greeted with the feeling that “We don’t know you, but we belong to the same race.”⁵¹ Jessie Sleet and Elizabeth Tyler were fellow alumni of Freedmen’s Hospital, and Sleet quickly persuaded the Henry Street Settlement to add Tyler to the payroll. Then, Tyler began to wear out her shoe leather in endless door-to-door visits up and down the tenement stairs of San Juan Hill. Tyler befriended janitors to learn who was ill, visited churches to see who was not attending, and by December, had acquired enough patients to persuade the Henry Street Settlement to hire another visiting nurse, then to open a new location closer to her Black patients. For the next nine years, Tyler would give what the American Journal of Nursing called her “rare ability and devotion”to the Stillman Settlement House, making it a center of not only medical but social, psychological, pharmaceutical, and educational care.⁵² 

A few hours south in Philadelphia, the Phipps Institute had also tried to become more geographically convenient. By 1913, the Institute had outgrown its converted rowhome origins and moved to a purpose-built structure at 7th and Lombard Streets. One of the world’s premier facilities for the study and treatment of tuberculosis was now located in the heart of Philadelphia’s Black Belt, but it had made no difference in the numbers. Dr. Henry Minton, Philadelphia’s first Black pharmacist and later an expert in tuberculosis, wrote in 1915 of his bleak math based on population numbers and death rates: “Among every nineteen patients in tuberculosis clinics of this city, four should be colored. I don’t think this is true anywhere.”⁵³ In a city where almost 450 of every 100,000 Black residents were dying of tuberculosis, only fifty-seven patients had knocked on the Institute’s doors in 1913. Landis believed that “to really get behind the scenes requires a visitor in sympathy with the race” and in a meeting on May 13th, persuaded the board to hire a Black visiting nurse at the respectable salary of $65 a month.

Elizabeth Tyler arrived on February 1st, a veteran of many meetings, deathbeds, and unrecognized emergencies. Philadelphia began to feel her impact almost at once in two ways: the treatment of tuberculosis, and the analysis of the environments in which it flourished.

Communication, Control & Treatment

Tyler’s full narrative of her work from February 1st to October 1st, 1914, is included in Fig. 3, as it is not otherwise digitized. In those eight months, Tyler visited 327 families, or 1,084 individuals, offering medical and social service referrals, treating symptoms, and connecting families to the Phipps Institute. Her description of her work gives a clear example for students of the interaction of scientific knowledge and empathy.

Fig. 3. Elizabeth W. Tyler, “Summary of Work: February 1st to October 1st, 1914” (Wharton Centre Records, Box 30. Urban Archives, Temple University Libraries, Philadelphia.: Whittier Centre Annual Report, 1914., 1914).

Tyler knew that many of the Black families in the Seventh Ward were suffering from tuberculosis and spreading it as they went without treatment. When visiting churches, she writes, “one could hear the telltale cough, note the symptoms in physique and carriage, but this was not the time nor the place to win the confidence of those who needed advice.”⁵⁴ Tyler is dismissive of nurses who think their duty begins and ends with the “perfunctory question, ‘Is there any illness in the family?’” and gives a detailed account of her interaction with one mother in particular. Despite obvious signs of illness in her children and a husband making today’s equivalent of barely $1,000 a month, the mother insisted that all was well. Writing in the third person, Tyler describes her conversation:

The worker was puzzled to know how the children were cared for the four days the mother was away from home [working in a laundry]; but to all questions designed to clear up this point she replied, ‘They do the best they can.’ The worker understood. This woman was unwilling to go more into details of her family life with a stranger, so the visit ended. The worker said she was glad to know Mrs. W and would like to call again. She received a very courteous invitation to do so.⁵⁵

In those three words, “the worker understood,” lies the heart of Tyler’s success. On a second visit to the same family, she learned the father, suffering from tuberculosis, had actually cut back his duties at work and was earning barely half his former wage. The mother, seeking additional work, was often keeping her seven-year-old child home from school to care for the two toddlers. Tyler helped the mother find additional work, connected the father to hospital treatment, and facilitated the arrival of an elderly family member to provide more reliable childcare. Summing up the experience, she explains, “In the case in question we have a very serious health problem, we have a school problem, and we have also the problem of support for the entire family…this demonstrates the point the worker wishes to make,” namely, that physical health could not be disentangled from social issues. The doctors at the Phipps Institute knew what the beleaguered laundress’ husband required to arrest the damage to his lungs, but not the complex and interlocking responsibilities that made hospitalization untenable for his family. It required nurses like Tyler to take “the great deal of time to gain such intimate knowledge as is necessary for the intelligent handling of a given case.”⁵⁶

Tyler served as the connective tissue between the neighborhood and what services existed. She gave health lectures at churches, gathered data on housing instability, and taught classes of “Little Mothers’ Clubs” to the many children caring for their infant siblings, lessons “designed to reduce the rate of infant mortality in the city of Philadelphia.”⁵⁷ (See Fig. 4.). It is perhaps not surprising that by August, six months after arriving, she was so enmeshed in the landscape of Philadelphia that her absence for a two weeks’ vacation was considered worthy of publishing in the local paper.⁵⁸ But a year later, she still bemoaned that “the surface has barely been scratched. There are gaps and leaks in the system which cause failure”⁵⁹ such as the patient who resisted hospitalization until three weeks before his death. The delicately-described “woman with whom he lodged” was now showing signs of illness, and one hears Tyler’s frustration in her terse conclusion that “had the man been discovered earlier, the woman might be in good health today.” Nevertheless, Tyler now had the aid of a second nurse paid for by the Pennsylvania Society for the Prevention of Tuberculosis, and “intimate knowledge” of some 750 families whose illnesses and issues were now being addressed before they could metastasize into contagion and disaster.

There is only one example I have been able to find of Elizabeth Tyler’s handwriting: her signature is on an invitation to Bernard Neumann, the Executive Secretary of the Philadelphia Housing Commission, who sat with her on the committee directing the Whittier Centre (Fig 4.) In the same year Tyler arrived, Neumann had controversially dismissed the Pennsylvania Society for the Prevention of Tuberculosis’ “campaign of education” as narrow and short-sighted. He argued that “bad housing” was to blame for many tuberculosis cases for three reasons: the crowded and unventilated nature of housing that made germs present, the dark and damp conditions that allowed them to spread easily, and the general poor health that such housing engendered in its inhabitants. In other words, slum housing in Philadelphia helped “to weaken the patient and make him on the one hand more susceptible to the disease, and on the other hand…weaken him so he cannot successfully resist it.”⁶⁰  Tyler agreed with the leadership at the Whittier Centre and Phipps Institute that, as Landis had also written to Neumann, “tuberculosis [was] essentially a house disease.”⁶¹ Tyler’s notes on her “medical social work” visits in 1914 include the number of instances where housing law was violated to the family’s detriment.⁶² Her 1915 records highlight the 72% of Black dwelling places that lacked indoor toilets, and the 32% without sewer connections at all. An unsigned letter in the Whittier Centre archives, dated March 1914, might very well be Tyler’s own suggestions for new initiatives, as it refers to work “we carried on in Brooklyn” with children’s and mother’s activities. It also emphasizes the importance of housing as a matter of public health and for combatting tuberculosis. The letter-writer suggests that children engaged with the Whittier Centre be deputized to “note insanitary [sic] conditions in and about their own and about their neighbors’ properties, and on the streets, and forward the complaints to our office.”⁶³ The writer also suggests that the Centre look to identify “a number of respectable colored families living in houses below par, then find sanitary homes for them and persuade or help them to move into such.” This letter can be only circumstantially ascribed to Tyler, but it demonstrates the Whittier Centre’s preoccupation with housing for Black people in Philadelphia.

Tyler makes explicit the connection between housing and health, particularly in her 1915 report: “In such poor homes they have not the means at hand for adequate care of the tuberculous patient nor the protection of the non-tuberculous members of the household.”⁶⁴ During her tenure, the Whittier Centre conducted a close survey of the housing within its area of service. In 1916, at a public meeting, a housing commissioner from Washington, D.C. warned Centre staff that “where the sun did not enter, the doctor would”⁶⁵ and the Whittier Centre officially shifted much of its efforts to improving Black housing in Philadelphia. In the same year, the Whittier Centre Housing Committee had already purchased and begun improving thirty-two properties for Black families in Philadelphia; other organizations such as the Octavia Hill Association did likewise.

Fig 4. Left: A note from E.W. Tyler to Bernard Neumann, inviting him to a monthly meeting of the Whittier Centre executive committee.⁶⁶ Right: Tyler, left, is pictured with the “Little Mothers’ Club” and their illustrative doll.⁶⁷

In 1914, Tyler had modestly acknowledged that “It is gratifying to know the number of colored people attending has greatly increased as a direct result of these house-to-house visits…the number treated since February 1st, 1914, is twelve times greater than the number treated in the same length in the history of the institution”⁶⁸ This growth continued. By 1921, Tyler’s protegee Cora Johnston was interviewed about the extensive case management work needed at the Phipps Institute to “restore each family to a standard of normal, healthful living,” visiting a hundred or more families every month. ⁶⁹ By 1923, so many Black patients were seeking support that a secondary health center was opened in north Philadelphia, less than half a mile from the school where I teach today. The same year, a young Black sociology student conducted a detailed study of “The Negro Tuberculosis Problem in Philadelphia.”  She observed that the Phipps Institute alone served more than half of the Black patients seeking treatment in Philadelphia, and that patients at Phipps and other clinics with Black clinicians were more compliant and more successful in treatment.⁷⁰ The success of these clinics, one Black doctor proclaimed, was “largely dependent upon the efficiency and faithfulness of the nurse.”⁷¹ By the numbers of individuals receiving and benefiting from treatment, Tyler’s efforts were clearly bearing fruit, even if in official Phipps Institute reports she was referred to anonymously and dismissively as “the colored nurse.”⁷²

Tyler’s work on Black housing in Philadelphia, unfortunately, did not progress as smoothly as that of tuberculosis. A 1927 report from the Whittier Centre bemoans that one company had built 20,885 homes but only 50 for Black people, while demolishing 2,788 homes of which 1/4th were occupied by Black people.⁷³ The same unsafe properties not only continued to be rented to Black owners but were often rented or sold at higher rates than the same property to a white customer.⁷⁴ The Whittier Centre’s appeals for funds and support (see Fig. 5) may have helped the few dozen families in their managed Opal Street properties, but no more. Although partners such as the Octavia Hill Association and the Armstrong Association (now the Urban League) continue to support housing in Philadelphia today, the issue remained a significant problem when Tyler left Philadelphia in the early 1920s to take a position in public health in Delaware.  This is useful for students to study as a counter-example to Tyler’s success in other areas of public health. While individual decisions about infection control and hospitalization could be affected by her thoughtful and empathetic engagement, no amount of “the worker understood” could manifest safe, sanitary, and affordable homes for every patient and their family.

Fig 5. Two images from the Whittier Centre highlight the intersection of housing and health. On the left, a child sits near a pile of laundry, with the caption “All I want is a fair chance and a good home to live in.” On the right, a chaotic underground scene is labeled as “A Cellar In Which Three Women Had Been Living.” Whittier Centre, “Whittier Centre Annual Report, 1919” (Philadelphia: Wharton Centre Records, Box 30. Urban Archives, Temple University Libraries, 1919).

After understanding the development of tuberculosis knowledge, its intersection with social issues in the early 1900s, and the ways Elizabeth Tyler and her fellow nurses leveraged human connection to improve patients’ medical and personal outcomes, students will be equipped to analyze Tyler’s actions and their effectiveness. After such analysis, students can then conduct their own research on a similar instance where science and society met, and argue for the effectiveness or ineffectiveness of communication in each situation. A list of some suggested topics and a few starter sources for each is included in the resources.