making ends meet

� PUBLIC HEALTH THEN AND NOW �

American Journal of Public Health | August 2011, Vol 101, No. 81392 | Public Health Then and Now | Peer Reviewed | Carthon

| Margo Brooks Carthon, PhD

public health practitioners, aware of the relationship between poor health and social conditions, initi-ated campaigns to decrease urban blight and prevent communicable diseases. These programs, how-ever, often failed to adequately address the needs of growing urban Black communities. Hence, left with a scarcity of resources from municipal agencies, Black community members turned inward toward their own private civic associations to meet their health and welfare needs.3

Civic associations during this period were characterized by progressive ideals and an agenda of social reform. As Smith and Hine demonstrate in their work on Black club women, these social welfare organizations laid the roots for the implementation of many large-scale public health reform initiatives.4 For Blacks in the early 20th century, member-ship in civic associations such as

BLACK AMERICANS HAVE historically experienced worse health outcomes and much lower life expectancy than have their White American counterparts. These trends, although notable today, were equally prevalent nearly a century ago, when Blacks faced persistent health threats because of the cumulative impact of infectious diseases, poverty, and limited health resources.1 During the second decade of the 20th century, stark disparities in health between Blacks and Whites drew the increased attention of public health officials in northern cities as large numbers of rural southern Blacks left agricultural settings in search of jobs and increased social freedom in the north.2 Upon their arrival in northern metropolises many of their dreams were dashed as they encountered substandard housing, hazardous working conditions, and poor sanitation. A number of

This historical inquiry illustrates the power of social networks by examining the Starr Centre and the Whittier Centre, two civic as-sociations that operated in Philadelphia during the early 20th century, a time when Black Americans faced numerous public health threats. Efforts to address those threats included health initiatives forged through collaborative social networks involving civic associations, health professionals, and members of Black communities. Such networks provided access to important resources and served as cornerstones of health promotion ac-tivities in many large cities. I trace the origins of these two cen-ters, the development of their programs, their establishment of ties with Black community residents, and the relationship be-tween strong community ties and the development of community health initiatives. Clinicians, researchers, and community health activists can draw on these historical precedents to address con-temporary public health concerns by identifying community strengths, leveraging social networks, mobilizing community mem-bers, training community leaders, and building partnerships with indigenous community organizations. (Am J Public Health. 2011;101:1392–1401. doi:10.2105/AJPH.2011.300125.)

Community Networks and Health Promotion Among Blacks in the City of Brotherly Love

ENDSMaking

Meet


Carthon | Peer Reviewed | Public Health Then and Now | 1393August 2011, Vol 101, No. 8 | American Journal of Public Health

mission societies, charity organi-zations, churches, women’s clubs, mutual aid societies, and benevo-lent associations provided access to important public services and a network of social support. Because of their long-standing work in many Black communi-ties, civic associations held posi-tions of prominence in those communities, helping to form the fabric of social order by promot-ing messages of uplift, thrift, and personal responsibility. Most civic associations were financed by dues collected from their constit-uents or by contributions from wealthy donors and were located in poor immigrant and Black communities. Several offered health services through dispensa-ries or by nurses who were hired to provide care in the home.5

The popularity of civic associa-tions grew steadily during the Progressive Era because they offered a wide variety of services. For the Blacks they served, civic associations brought relief from the often complex burden of ill-ness, social isolation, and eco-nomic need. Blacks experienced high rates of tuberculosis (TB), so they were interested in civic programs pertaining to health and disease prevention. These programs were primarily focused on health promotion, but they also provided opportunities for middle-class and working-class Blacks to socialize with one another and with White philan-thropists in the larger community. Over time, relationships between community members of diverse racial and class groups led to a growing sense of civic unity and laid the foundation for the subse-quent development of a number of community health initiatives.

Civic associations have long occupied a prominent position in US society, and their role in the

development and operation of community health programs war-rants more attention. The accom-plishments of many community health programs depended on a civic association’s ability to estab-lish a sense of group cohesion and trust among community members. This was particularly true among members of Black communities, who for centuries relied heavily upon institutions such as churches and benevolent

societies to meet their health, social, and welfare needs. Here I describe support networks devel-oped with the aid of two civic associations—the Starr Centre and the Whittier Centre—to sup-port Blacks in Philadelphia, Penn-sylvania, during the early 20th century. I highlight the origins and programs of the associations, their establishment of ties with the Black community, and the relationship between building strong community ties and the development of health initiatives.

The events examined here occurred a full century ago, but they hold lessons applicable to 21st-century issues in public

health. Many of the norms, values, and institutional infrastructures present in Black communities in the early decades of the 20th century remain in place today. Thus, a fuller appreciation of the dynamic and reciprocal nature of these relationships can serve as templates for public health activists who strive to create sustainable health coalitions among diverse communities today. Moreover, Black communi-

ties continue to experience health disparities in the form of dispro-portionate rates of HIV/AIDS and other chronic illnesses. If a central tenet of public health activism is the engagement of local residents in the development and implementation of health ini-tiatives, then this case study is valuable because it highlights the benefits of these efforts.

THE STARR CENTRE CREATES EARLY TIES

In the early 20th century, Phil-adelphia experienced a cataclysm of immigration in the midst of rapid industrialization. Like other

Cooperative Coal Club

Source. Starr Centre, "Annual Report," 1911. Reprinted with the permission of the Barbara Bates Center for the Study of the History of Nursing, University of Pennsylvania.



By the time of his death in 1884, Starr’s social-welfare initia-tives were well entrenched within Philadelphia’s Black community. Starr’s legacy continued through the efforts of several long-time acquaintances, including Susan Parrish Wharton, a well-known community member and civic activist. When the Starr Centre was founded in 1897, Wharton served as chairperson and presi-dent. Wharton and her colleagues stated that the Starr Centre Asso-ciation’s aims were

[to] provide for and promote by practical methods, the educa-tional and social improvement of those poor neighborhoods; primarily in the vicinity of the Starr Garden.11

The settlement operated with a modest budget and consisted of a board of directors, donors, various committees, and neigh-borhood residents. The Starr Centre’s programs included classes in domestic art and carpentry, the provision of inex-pensive lunches and milk for schoolchildren, health lectures, visiting nursing services, and dispensaries for medical care.12 Local residents gained access to association membership by con-tributing one dollar annually. Over the course of the next decade, Starr Centre programs increased in popularity among local immigrant and Black families.13

Starr Centre leaders were par-ticularly interested in health pro-motion and disease prevention. In 1905, the Starr Centre created a medical department and con-tracted with the Visiting Nurses Association of Philadelphia to provide nursing care to sick children and adults in clinics and homes.14 Despite the excessive ill-ness present in the Black commu-nity, many families were forced

northern cities during this period, Philadelphia witnessed an upsurge of immigrants and rural Blacks migrating from the south. Between 1890 and 1910, the city’s Black population increased more than 100%, to 84 000, in a city with a total population of 1.5 million; by 1920, the Black population grew to 134 000 in a total population of 1.7 million.6 As Philadelphia’s newest residents packed into cramped dwellings, TB and other infectious diseases gripped the city, and housing conditions began to rapidly deteri-orate.7 Progressive reformers battled the growing threat of infectious disease and urban decay by establishing a variety of chari-ties, including settlement houses, in which middle-class volunteers lived as settlers in low-income areas and worked to serve the poor.8

During this turbulent time the Starr Centre, a settlement organized in 1897, became a clearinghouse for the numerous

civic-improvement efforts launched by its benefactor, White social progressive Theo-dore Starr (1841–1884).9 During his lifetime, Starr was recognized as a keen business-man and philanthropist with a deep commitment to poor Black and immigrant families living in the fourth, fifth, and seventh wards of Philadelphia. His con-cern for the social welfare of local residents led to the develop-ment of a number of initiatives, including public playgrounds and gardening centers for neighbor-hood children. Starr’s desire to improve the quality of life for local Blacks led him to establish Philadelphia’s first Progressive Working Colored Men’s Club (1878) and the city’s first Penny Bank (1879), where Blacks could save small amounts of money to be used for planned purchases later. Starr also purchased plots of land that were used to build affordable homes for Blacks.10

Coal Club, "Ready for the Lecture to Begin"

Source. Starr Centre, "Annual Report," 1906. Reprinted with the permission of the Barbara Bates Center for the Study of the History of Nursing, University of Pennsylvania.


August 2011, Vol 101, No. 8 | American Journal of Public Health Carthon | Peer Reviewed | Public Health Then and Now | 1395

from 300 to 400 individuals would assemble to hear health lectures and to discuss club affairs. Like other mutual aid and benefit societies, the religious, secular, social, and political pur-poses of the Starr Centre and the Coal Club sometimes overlapped. Meetings called to discuss the cost of coal were often followed by singing hymns, enjoying refreshments, and socializing.22

During these gatherings, mat-ters pertaining to illness and mak-ing provisions for poor health were commonly discussed. A recurring topic among club mem-bers was the lack of good medical and nursing services.23 Although the city’s Blacks could seek care from local health departments, neighborhood health centers, and the city hospital (Philadelphia General Hospital), treatment and services at these facilities were often of limited availability and poor quality. Philadelphia Gen-eral Hospital, for instance, was frequently overcrowded and in disrepair. Philadelphia’s two Black-run hospitals, Frederick Douglass Memorial Hospital (established 1895) and Mercy Hospital (established 1907), extended services to Blacks, but neither hospital had beds for patients infected with TB, so they were unable to meet this critical need among Philadelphia’s grow-ing Black community.24

Faced with the constant threat of illness, Coal Club members worked with Starr Centre organiz-ers to form the Rainy Day Society in 1905. Similar to many other sick benefit societies in cities across the country, the Rainy Day Society served as a safety net for its members by providing financial protection against the devastation that unexpected illness caused. Individuals joined the Rainy Day Society by paying annual dues

the Coal Club’s members repre-sented a cross section of working-class and middle-class Blacks who were unlikely to meet in other settings because of different class or church affiliations.18 In the opinion of Susan Wharton, manager of the Coal Club, this convergence of individuals from different social strata and denom-inational affiliations was of signifi-cant value, for common concerns emerged in

[the] pulling together and . . . good fellowship growing up among people of varied occupa-tions and interests and belonging to many different churches.19

The Coal Club’s open mem-bership policy allowed it to serve as more than just a way to obtain necessary material resources; over time it helped foster a diverse set of social networks among its members.

From the early years of its inception throughout the first decade of the 1900s, the Coal Club’s membership steadily grew, as did the number of club-spon-sored functions. Prompted by the club’s growth, the Starr Centre purchased a second property at 18th and Webster Streets in 1911 that was soon recognized as a central meeting space for Blacks living in the community.20 Coal Club members used the newly purchased house for monthly social and business pur-poses, and frequently stopped in for social calls and to seek advice from Starr Centre staff.21 The space was also used for monthly Coal Club meetings attended by women, men, and children from across the community. These meetings provided a venue for fellowship and discussion of important community topics. At larger monthly gatherings, often held at local churches, anywhere

to juggle their participation in health programs and visits to local clinics with more quotidian domestic concerns, such as find-ing coal to warm their homes or food to fill their children’s hungry stomachs. Even as infectious dis-ease rates spiked among Blacks, poor families were frequently obliged to work long hours instead of seeking medical care. Starr Centre board members saw this dilemma and realized that any efforts to curtail excess sick-ness had to address the limited material resources of community members first.15

Building Community Resources

One of the Starr Centre’s early efforts to address the pressing economic needs of Black commu-nity residents began with the ini-tiation of the Cooperative Coal Club. The Coal Club was created as a way to help Blacks by offer-ing them protection from unscru-pulous merchants who were known to sell coal at inflated prices.16 Many Black city resi-dents relied on hard coal as a fuel source for cooking and heating their homes. Meager weekly wages, however, forced poor and working-class families to buy coal in small amounts. Buying coal in these small bucket portions often meant paying higher costs per pound. The Coal Club offered a way out of this trap by allowing members to form a cooperative for the purpose of buying coal in large quantities, thus bringing down the price.17

The Coal Club drew its mem-bership from the area south of Lombard Street and reflected the diverse backgrounds of Blacks living there. Unlike some frater-nal societies and social clubs, which offered membership to Blacks on an exclusionary basis,



approach the Starr Centre board of directors with a plan for expansion. In a meeting on May 28, 1912, board members dis-cussed the merit of Wharton’s “Plan for Readjustment,” which was designed to increase the ser-vices that the Starr Centre offered specifically to the Black community. After lengthy discus-sion, the board resolved that it would be unwise to undertake an expansion of its work for Blacks, though it hoped to continue pro-viding such services at its present pace, with their “growth encour-aged at a normal but steady man-ner.”33 The decision for limited expansion did not indicate an unwillingness to provide services to Blacks; rather, it reflected a reluctance to try to increase them. It must be recalled that the Starr Centre was never intended to address the needs of Black res-idents exclusively, and such an expansion might have threatened or undermined the center’s out-reach to other poor or immi-grant constituents of south Philadelphia.

On June 11, 1912, the matter of expansion of services in the Black community was again taken up at a Starr Centre board meeting in which it was unani-mously carried that:

if an independent agency, as capable as ourselves of carrying on effectively the present objec-tives of the Coal Club and Rainy Day Society be formed, we should be willing to consider a transfer to that organization of our work in connection with in-dividuals living out of the Starr Centre neighborhood.34

On October 8, 1912, Wharton tendered her resignation as founding member of the Starr Centre board. Within the month following her resignation, the board voted to allow Wharton and her newly formed association, the

over the course of the year in small weekly payments. An all-White staff of paid Starr Centre visitors collected the payments by making personal calls to the home of each member. At each visit the typical payment was 10 to 15 cents. Monies received from Rainy Day Society members were deposited into the Starr Savings Bank and kept in a trust for mem-bers in the event that they had an emergency that required use of the funds.25 Society members could also withdraw their total savings at the beginning of each year for other purchases.

In time, the small amounts of savings contributed by club members steadily grew in value. In 1905, visitors made 6394 home-collection visits, through which Rainy Day Society mem-bers collectively saved $967. By 1909, those figures had dou-bled.26 One society member said, “I tell you this saving thing is a great thing; when sickness comes, you have the money, when death comes, you have the money, and when you want to . . . go down home [south] you’ve got the money for that.”27

Most of the members of the Rainy Day Society were also members of the Coal Club. This dual affiliation allowed members to access a range of services formed to address material and health needs. The Starr Centre coordinated its services with the Coal Club and the Rainy Day Society through frequent visits to the homes of club members. While in members’ homes, Starr Centre visitors were charged with collecting dues, learning about members’ living conditions, and offering assistance or referrals when needed. By building rela-tionships and offering “constant sympathy and care,” trained visi-tors hoped “to help, to advise, to

inspire.”28 In 1911, the Rainy Day Society and Coal Club together had more than 900 paid members, and visitors that year made more than 41 000 home visits.29 Members fre-quently asked visitors to “please call on my aunt, who wants to join” or “my cousin or friend.”30 The Starr Centre’s philosophy of “active touch” between the trained visitors and Coal Club and Rainy Day Society members helped to foster a “mutual under-standing and confidence,” result-ing in an inspiring partnership that would endure.31

What did it mean for White visitors to have such open access to the homes of Black club mem-bers? Certainly there was the risk that interracial and class tensions might emerge during these inter-actions. Indeed, other historical examples of interracial settle-ments and civic associations dur-ing the same period reveal significant discord between asso-ciation leaders and Black mem-bers.32 Conversely, the Starr Centre appears unique because of the absence of overt class and racial bias in its annual reports. Its records instead display the condi-tions that allowed these weekly interactions to solidify the bonds of trust and mutual respect, set-ting the groundwork for the sub-sequent development of other health initiatives. As visitors became eyewitnesses to the con-ditions and home lives of club members, they took with them a deeper knowledge of the needs of Black residents that then translated into the programmatic efforts of the Starr Centre.

Growth and DivisionIn 1912, the ever-present

needs and continued growth of south Philadelphia’s Black com-munity prompted Wharton to



were able to see so many people because so many club members either lived together in the same houses or lived in close proximity to the center.

Whittier Centre leaders were especially concerned with exces-sive TB death rates in the Black community. In 1900, the TB mortality rate among Philadel-phia’s Whites was 197.3 per 100 000; among Blacks, the rate was 447.0 per 100 000.43 In 1910, TB deaths among Blacks were 57% higher than among the city’s native-born Whites and 44% higher than among the city’s foreign-born Whites.44 Despite excessive illness rates, Blacks had limited treatment options. Local hospitals and private sanitariums often placed restrictions on admis-sions of Black patients.45 Adding to the problem of limited health care was low Black patient utiliza-tion of those services that were available. When TB beds were available, some Blacks refused to leave the comforts of home because they feared the treatment they would receive from strang-ers.46 One TB health official noted that

activists and medical professionals in prominent positions. This strat-egy was essential to the sustain-ability of the Whittier Centre’s goals and objectives, which included “calling on the race to help itself.”39 Beyond this aim, the center’s Black leaders, as mem-bers of the targeted community, served as mediators and cultural brokers between the Whittier Centre and the communities it was intended to serve.

The Whittier Centre’s early programs were directed toward the active members belonging to the Coal Club and Rainy Day Society and to individuals living in the squalid alleyways around the city.40 During its first year, the Whittier Centre continued the tradition of home visits to club members, making 42 642 visits in 1912 and 1913.41 Whit-tier Centre visitors were viewed as neighbors who were trained

[to] get behind the scenes to de-termine not only the external facts but conditions that make for physical and moral deterio-ration.42

Visitors frequently provided services to entire families. They

Whittier Centre, to assume respon-sibility for all operations of the Coal Club and the Rainy Day Society.35

THE WHITTIER CENTRE EXPANDS SOCIAL NETWORKS

As a newly formed civic asso-ciation, the Whittier Centre was established with the primary aim of addressing the social and health needs of Philadelphia’s growing Black community. These efforts began in earnest in the fall of 1912 when Susan Wharton and several other prominent Phil-adelphians established the center at 712 South 18th and 510 South 7th Streets within the heart of the city’s historic Black district. Named after 19th-century poet and abolitionist Greenleaf Whit-tier, the new association’s mission was to create practical solutions to the social problems plaguing the Black community.36 Wharton served as the Whittier Centre’s first treasurer. Henry R.M. Landis, a prominent physician associated with the Henry Phipps Institute, served as the centre’s first presi-dent.37 The rest of the board of directors consisted of five physi-cians, one member of the clergy, and five female volunteers.

A group of 18 individuals made up the Whittier Centre’s advisory board. Henry Minton, a well-known Black physician, was added to the advisory board in 1915. Booker T. Washington Jr, son of the famous Black educator and author, joined the Whittier Centre as executive secretary in 1919 to assist the organization in addressing the housing concerns of Black community residents.38 The Whittier Centre’s racially integrated governance structure exemplified the organization’s commitment to placing Black

Elizabeth Tyler, RN, with members of the Little Mother's Club.

Source. Whittier Centre, "Annual Report," 1915. Reprinted with the permission of the Urban Archives, Temple University Libraries.



the care of Black patients at the dispensary.55 In the Phipps Insti-tute’s first year of working with the Whittier Centre, the number of Black patients visiting the clinic was twelve times higher than in the previous 11 years combined. By 1921, nearly 30% of all new Phipps patients came from the Black community.

Tyler, Johnson, and Minton were tireless in their efforts to improve health in the Black com-munity. They organized health lectures in local churches, and the Whittier Centre established a prenatal clinic, well-baby clinics, and a home supervision service. By 1921, the center’s staff of Black clinicians, then known as the Negro Health Bureau, had grown from one nurse to 10 graduate nurses and from one physician to 12.56 However, the success of the Whittier Centre’s health initiatives did not hinge simply on the introduction of Black clinicians. The center’s accomplishments were the direct results of collective efforts under-taken by Black community members, social reformers, and health professionals that ulti-mately led to the development of a collaborative model of com-munity health care many decades later.

HEALTH PROMOTION IN BLACK COMMUNITIES TODAY

Notwithstanding the successes of community mobilization and health initiatives launched by civic associations in the early 20th cen-tury, translating these historic achievements into the context of our 21st-century public health challenges presents its own set of difficulties. Today many urban communities are racially and eco-nomically less diverse than they

[Black residents] did not avail themselves of the benefits of dispensaries, or if they did, made but a few visits, often but one, and then ceased coming.47

Aware of the threat of TB, the Whittier Centre executive com-mittee met on May 14, 1913, to discuss the merits of hiring a Black nurse to investigate possi-ble cases of TB among its Coal Club and Rainy Day Society members.48 During the meeting, TB expert and Whittier Centre president Landis explained the advantage of hiring a Black nurse: “to really get behind the scenes requires a visitor within the race.”49 This nurse would “visit Black families in the home and subsequently gain their con-fidence” and would more easily dispel any fears or superstitions individuals held regarding ill-ness.50 At this meeting, the Whit-tier Centre agreed to provide the salary to hire its first Black nurse.51

On February 1, 1914, Elizabeth Tyler, a graduate of Freedman’s Hospital Training School in Wash-ington, DC, began providing TB nursing services to Black residents of south Philadelphia, working under the auspices of the Henry Phipps Institute; her salary was paid for by the Whittier Centre. The Phipps Institute was a world-renowned TB treatment and research facility founded in 1903 by Dr. Lawrence Flick. From its inception, the Phipps Institute offered comprehensive inpatient and outpatient treatment of TB.52 Despite its close proximity to the Black community, the Phipps Institute had not been able to establish a rapport with Black residents. This may have been partly caused by its policy requir-ing the nearest relative of patients admitted to the inpatient wards to give written permission for an

autopsy in the event that the patient should die while on the ward.53 Although this policy undoubtedly was intended to ensure the advance of scientific inquiry, it did little to boost the confidence of Black community members, who were likely suspi-cious of such agreements.

Thus, despite the overall suc-cess of the Phipps Institute in its early years, the numbers of Black patients at the institute remained flat. In contrast with the Phipps Institute, the Whittier Centre had substantive, long-standing rela-tionships with Black residents resulting from years of work in the community, and the board was betting that more Blacks would avail themselves of TB care if more Black nursing and medical staff were available. To that end, Tyler’s job involved going into the Black community, finding residents suspected of having TB, and referring them to the Phipps clinic for treatment. Tyler’s early months at her new post began with home visits to the nearly 1000 members of the Coal Club and Rainy Day Society. In a report summarizing the work of her first year, Tyler noted a tremendous voluntary response to her nursing visits and her advice to visit the TB health clinic. She noted,

it is gratifying to know that the number of colored people at-tending the Phipps Institute has been so greatly increased as a direct result of these house-to-house investigations.54

Her efforts were so effective that within six months of her hire, the Phipps Institute hired another Black nurse, Cora John-son. Later that same year, Minton (the Black physician who was also a member of the Whittier Centre advisory board) joined the Phipps Institute staff to oversee



of public health initiatives, and their active participation was of paramount importance to the initiatives’ success. This focus on capacity building, increasing social capital, and investing in developing community leaders was most notable in the gover-nance and organizational struc-ture of the Whittier Centre, but such a focus can also be seen today in community-based partic-ipatory research, which aims to empower community members to own study questions, research methods, and data collected about themselves.58 Like its predeces-sors, community-based participa-tory research strives to enhance and increase health awareness and health activism among mem-bers of minority communities.

We now face altogether differ-ent public health concerns from those prevalent a century ago, but health inequities still persist. Clinicians, researchers, and com-munity health activists can draw on historical precedents to address contemporary public health con-cerns by identifying community strengths, leveraging social net-works, mobilizing community members, training community leaders, and building partnerships with indigenous community organizations. Many Black and minority communities continue to view civic associations, such as churches and social organizations, as valuable resources for health

serve as a valuable way to address the social determinants of health among targeted populations. This lesson can be generalized to many different communities throughout the country, not just racial or eth-nic minorities.

Another key strength of the civic associations discussed here was their ability to forge social bonds between diverse racial and class groups. Indeed, the success of the health initiatives, particu-larly the Phipps campaign, hinged on the ability of civic association organizers to first build trust among neighborhood residents and form relationships with them. The introduction of Black clini-cians aided in this endeavor, but assigning the success of the Whit-tier Centre’s anti-TB campaign merely to the inclusion of racially concordant health providers would be a disservice to White philanthropists such as Starr and Wharton who each spent decades working among Black community residents addressing community concerns and building rapport.57 It was this time com-mitment and active, persistent engagement with Black club members that served as the pre-cursor to Tyler’s work among Black Philadelphians. This assem-blage of equally invested part-ners—lay residents, health workers, and philanthropists—crossed racial and economic lines. Alhough divergent in origin, they remained unified in purpose.

A critical strength of the civic associations discussed here was their provision of a platform for community residents to help themselves through leadership opportunities and cooperative engagement. As members of civic associations, Blacks were more than mere silent partners in need of health and social reform; they were crucial to the development

used to be, and residents are gen-erally less apt to have a mutual sense of shared responsibility toward one another, which limits the spirit of cooperative efforts so evident among Black club mem-bers a century ago. Still, despite the dissimilarities between time periods, we can learn from several key lessons embedded in the his-tory of civic association commu-nity health initiatives.

First, civic associations of the early 20th century, such as the Starr Centre and the Whittier Centre, were in the vanguard of multiple movements, focused simultaneously on building a community health infrastructure while also addressing a housing shortage and income deprivation. Unlike the disease-focused mod-els of community health, which grew in popularity over the remainder of the 20th century, the associations discussed here achieved success by identifying people’s material needs first. This focus on the comprehensive wants of the community was based on the recognition that the determinants of public health are structural and are largely related to poverty and the environment. Thus, any effort to address more abstract concerns, such as disease prevention, first had to address more immediate needs, such as food and coal. Once these areas of concerns were addressed, then interventions addressing infectious disease and other maladies fol-lowed with a greater degree of success.

What history demonstrates in this instance is the importance of beginning with an understanding of the base determinants of well-being. A more specific focus on health should wait until this pre-liminary step is accomplished. His-tory also demonstrates how building community networks can

”“As members of civic associations, Blacks

were more than mere silent partners in need of health and social reform; they were crucial to the development of public health

initiatives, and their active participation was of paramount importance to the

initiatives’ success.



of Pennsylvania Press, 1979), 7–32. See also: DuBois, The Philadelphia Negro, 357; Michael B. Katz, In the Shadow of the Poorhouse: A Social His-tory of Welfare in America (New York, NY: Basic Books, 1986).

9. “Starr Centre Historical Information Sheet,” p. 2, Starr Centre Collection, Barbara Bates Center for the Study of the History of Nursing, University of Pennsylvania. See also: V.P. Franklin, “Operation Street Corner: The Wharton Centre and the Juvenile Gang Problem in Philadelphia, 1945–1958,” in W.E.B. DuBois, Race and the City: The Philadel-phia Negro and Its Legacy, ed. Michael Katz and Thomas J. Sugrue (Philadel-phia: University of Pennsylvania Press, 2000), 97; E.J.G. Beardsley, “The Value of the Intelligent Direction of the Sick Poor - A Story of The Starr Centre As-sociation of Philadelphia,” Therapeutic Gazette June (1911): 2.

10. Beardsley, “The Value of the Intelli-gent Direction of the Sick Poor,” 2; “Starr Centre Historical Information Sheet,” Starr Centre Collection, p. 2.

11. Starr Centre Association, “Charter and Bylaws of the Starr Centre Associa-tion,” June 2, 1905, p. 4, Starr Centre Collection, box 9, folder 105.

12. Beardsley, “The Value of the Intelli-gent Direction of the Sick Poor, ” 1–11.

13. Starr Centre, “A Few Facts About the Starr Centre,” 1905, Starr Centre Collection, MC 9, series IV, folder 105; Starr Centre Association, “Milk and Medical Department,” 1911, Starr Cen-tre Collection, MC 9, series IV, folder 104.

14. Starr Centre Association, untitled pamphlet, 1907, Starr Centre Collec-tion, box 9, folder 105.

15. Susan P. Wharton, “Starr Centre First Annual Report,” 1903, Starr Cen-tre Collection.

16. Starr Centre Association, untitled pamphlet, 1907, Starr Centre Collec-tion, box 9, folder 105.

17. Starr Centre Association, board of directors meeting minutes, July 13, 1911, Starr Centre Collection.

18. It is important to note that intrara-cial tensions were not uncommon among Black civic association members because of differences in class standing and religious affiliation. In her historical account of health promotion in the rural south, historian Susan Smith uncovers evidence of such tensions in her exami-nation of the Tuskegee Woman’s Club. The club women were all Black, edu-cated, and well off, and they believed it their “calling” to improve the physical, spiritual, moral, and educational lives of rural Blacks. Middle-class Black women asserted that their class, as well as their

information and as places in which to address pressing social concerns. Thus, it is important for contemporary public health work-ers to integrate their health efforts within these institutions to advance mutually agreed-upon health goals. Civic engagement between community members and civic associations is still piv-otal to the success of community health initiatives.

About the AuthorMargo Brooks Carthon is with the School of Nursing, University of Pennsylvania, Philadelphia.

Correspondence should be sent to Margo Brooks Carthon, 418 Curie Blvd, Philadelphia, PA 19104-6096 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints/Eprints” link.

This article was accepted January 10, 2011.

AcknowledgmentsMargo Brooks Carthon is supported by the National Institute for Nursing Re-search (grant K01NR012006). This re-search was also supported by a Ruth L. Kirschstein NRSA Doctoral Fellowship from the Agency for Healthcare Re-search and Quality (grant F-31 HS01029-02).

Special thanks to Julie Fairman, PhD, Joan Lynaugh, PhD, Barbara Savage, PhD, Robin Stevens, PhD, Bridgette Brawner, PhD, Jillian Baker, PhD, Jasmine McDonald, PhD, and Melissa Gomes, PhD, for their support and feedback on ear-lier drafts of this article.

Endnotes1. The enduring pattern of health ineq-uities among Black communities has been captured in the work of a number of historians from the 19th and early 20th centuries. For more on the history of illness among Blacks, see: David McBride, From TB to AIDS: Epidemics among Urban Blacks Since 1900 (New York: University of New York Press, 1989); Keith Wailoo, Dying While in the City (Chapel Hill: University of North Carolina Press, 2001); Vanessa Gamble, Germs Have No Color Lines: Blacks and American Medicine 1900–1940 (New York: Garland Publishing, 1989); Sam-uel Kelton Roberts Jr, Infectious Fear: Politics, Disease, and the Health Effects of Segregation (Chapel Hill: University of North Carolina Press, 2001).

2. The poor health of Blacks during the early 20th century captured the atten-tion of a wide range of scholars and public health commentators. See: W.E.B. Dubois, “The Health of Negroes,” in The Philadelphia Negro: A Social Study (Phil-adelphia: University of Pennsylvania Press, 1899), 147–63; C.R. Grandy, “The Control of Tuberculosis in the Negro,” Virginia Medical Monthly 54 (1927): 566–71; C. Guild, “A Five Year Study of Tuberculosis among Negroes,” Journal of Negro Education July (1937): 548–52; Henry R.M. Landis, A Report of the Tuberculosis Problem and the Negro (Philadelphia: Henry Phipps Institute, 1923), 10a, table 7.

3. Suellen M. Hoy, “‘Municipal House-keeping’: The Role of Women in Im-proving Urban Sanitation Practices, 1880–1917,” in Population and Reform in American Cities, 1870–1930, ed. M.V. Melosi (Austin: University of Texas Press, 1980), 173–98.

4. Susan L. Smith, Sick and Tired of Being Sick and Tired: Black Women’s Health Activism in America, 1890–1950 (Philadelphia: University of Pennsylva-nia Press, 1995), 32. See also: Darlene Clark Hine and Kathleen Thompson, A Shining Thread of Hope: The History of Black Women in America (New York: Broadway Books, 1998).

5. The formation of Black churches and other social and benevolent societies represented an important antidote to anti-Black sentiment, social isolation, and prejudice. Philadelphia’s Free Afri-can Society, established in 1787 by Richard Allen and Absolam Jones, is an example of such an organization. For further reading on benevolent societies, see Hine and Thompson, A Shining Thread of Hope, 39.

6. US Bureau of the Census, Negro Pop-ulation in the United States, 1790–1915 (Washington, DC: Government Printing Office, 1968), 350–51; Allen F. Davis, The Peoples of Philadelphia: A History of Ethnic Groups and Lower Class Life, 1790–1940 (Philadelphia: Temple Uni-versity Press, 1973). For more on the migration patterns of Blacks entering Philadelphia, see: Armstrong Associa-tion, “Report of Negro Population and Industries in Philadelphia,” 1927, mim-eograph, Armstrong Association Papers, Urban Archives, Temple University Li-braries.

7. Sadie T. Mossell, “The Standard of Living among One Hundred Negro Mi-grant Families in Philadelphia,” Annals of the American Academy of Political and Social Science 98 (1921): 174–75.

8. Franklin VP. The Education of Black Philadelphia: The Social and Educational History of a Minority Community, 1900–1950 (Philadelphia: University



the Whittier Centre. Whittier Centre, “Annual Report,” 1915, p. 4, Wharton Center Collection.

41. Whittier Centre, “Annual Report,” 1917, pp. 7–8, Wharton Center Collec-tion.

42. Henry R.M. Landis, Whittier Centre, “Annual Report,” 1916, p. 2, Wharton Center Collection.

43. First annual message of John Rey-burn, 1908, p. 96, City Archives, Phila-delphia.

44. Bureau of Health, “Annual Report,” 1918, City Archives, Philadelphia.

45. Mossell, A Study of the Negro Tuber-culosis Problem in Philadelphia, 18.

46. Barbara Bates, “P.S. I Am . . . Col-ored,” in Bargaining for Life: A Social History of Tuberculosis, 1876–1938 (Philadelphia: University of Pennsylva-nia Press, 1992), 288–310.

47. Landis, A Report of the Tuberculosis Problem and the Negro, 1. See also: Henry Phipps Institute, “Fifth Annual Report,” 1909, pp. 10, 19, Philadelphia College of Physicians. In his annual re-port to the Phipps Institute, Lawrence Flick, head of the institute’s Clinical and Sociological Departments, noted the low percentage of Blacks treated at the insti-tute since its inception. Blacks repre-sented 6.63% of the total percentage of Phipps patients during its first year (1904), 5.65% in 1905, 5.96% in 1906, 9.83% in 1907, and 7.68% in 1908. He further reported that Blacks held nearly the highest rates of single visits with no return follow-up, com-pared with other racial/ethnic groups. Lawrence Flick, “Clinical and Sociologi-cal Report,” 1909, Phipps Institute Re-ports, Van Pelt Library, University of Pennsylvania.

48. Whittier Centre, executive board meeting minutes, 1913, p. 1, Wharton Center Collection.

49. Ibid.

50. Ibid.

51. Tyler’s work as a public health nurse is consistent with the efforts of her peers in the profession during this period. For further reading on Black public health nurses, see: Marie O. Pitts Mosely, “Satisfied to Carry the Bag: Three Black Community Health Nurses; Contributions to Health Care Reform, 1900–1937,” Nursing History Review 4 (1996): 65–82. Also, on Black hospital nurses, see: Darlene Clark Hines, Black Women In White: Racial Conflict and Cooperation in the Nursing Profession, 1890–1950 (Bloomington: Indiana Uni-versity Press, 1989).

52. Lawrence Flick, “Report of the Henry Phipps Institute,” 1904, pp. 4–5; “The Phipps Gift,” Gazette, March 5,

35. It remains a mystery why, after so many years of work with the Black community, the Starr Centre Associa-tion jettisoned those relationships and handed them to Wharton. I suspect that the needs of the community were out-pacing the Starr Centre’s capacity. Also, the Black community’s growth was so tremendous that the Starr Centre may have been increasingly regarded as an “organization for Blacks,” which might have reduced its viability for other needy sections of the community. These thoughts, however, are purely conjec-ture; the historical record is silent about the real motives behind the center’s re-sistance to expansion of services tar-geted toward Blacks.

36. Whittier Centre, “Annual Report,” 1914, Wharton Center Collection. One of the Whittier Centre’s earliest collabo-rations was with the Philadelphia Hous-ing Commission, a privately funded as-sociation working toward housing reform. In 1914 the commission con-ducted a study on the housing condi-tions of the city’s Black residents, and the Whittier Centre offered the services of its visiting staff to collect data for the study. Data collectors visited 1158 homes, where 4891 Blacks lived. The results of this study were published in the Whittier Centre’s “Annual Report” (1914) and summarized by Bernard J. Newman, executive secretary of the Philadelphia Housing Commission.

37. Henry R.M. Landis was a key figure during the Phipps Institute’s first three decades of operation. Born in 1872, Landis was a leading clinician and re-searcher in the field of TB and was per-sonally chosen by renowned TB special-ist Lawrence Flick to work at the institute. After graduating with an AB from Amherst College in 1894 and completing medical school at Jefferson Medical College in Philadelphia in 1897, Landis embarked upon a career specializing in the treatment of TB. Landis was renowned both nationally and locally, serving as the founder of the National Tuberculosis Association and presiding over the Pennsylvania Tuber-culosis Society from 1928 to 1932. While at Phipps he functioned as an as-sistant professor of medicine and direc-tor of the Clinical and Sociological De-partments, and he served as visiting physician to the Commonwealth of Pennsylvania’s White Haven Sanato-rium. He was also connected clinically with Philadelphia General Hospital until 1909.

38. Whittier Centre, “Annual Report,” 1914, Wharton Center Collection.

39. Ibid.

40. By 1914, half of the former respon-sibilities of the Starr Centre rested with

gender, made them uniquely fit to bring about the salvation of the race. These assumptions often led to tension be-tween middle-class and poor club mem-bers. See: Smith, Sick and Tired of Being Sick and Tired, 18–21.

19. Susan P. Wharton, “Negro Branch of the Starr Centre,” 1909, Starr Centre Collection.

20. Starr Centre Association, “Annual Report,” 1911, p. 7, Starr Centre Collec-tion.

21. Starr Centre Association, board of directors meeting minutes, July 13, 1911, Starr Centre Collection.

22. Starr Centre Association, “Annual Report,” 1911, p. 10, Starr Centre Col-lection.

23. Wharton, “Negro Branch of the Starr Centre,” p. 16, Starr Centre Collec-tion.

24. Sadie T. Mossell, “A Study of the Negro Tuberculosis Problem in Philadel-phia,” 1923, p. 18, Starr Centre Collec-tion.

25. Whittier Centre, “Annual Report,” 1917, p. 7, Wharton Center Collection, URB 30, series I, box 1, Urban Ar-chives, Temple University Libraries.

26. Wharton, “Negro Branch of the Starr Centre,” 1909, p. 4, Starr Centre Collection.

27. Ibid.

28. Ibid.

29. Starr Centre Association, “Annual Report,” 1911, p. 7, Starr Centre Collec-tion.

30. Starr Centre Association, “Annual Report,” 1909, pp. 4–5, Starr Centre Collection.

31. Ibid.

32. For further reading on interracial and class tensions, see: Gerda Lerner, “Early Community Work of Black Club Women,” Journal of Negro History 59, no. 2 (1974): 158–97.

33. Starr Centre Association, board of directors meeting minutes, May 28, 1912, p. 1, Starr Centre Collection. Wharton’s full plan for expanding ser-vices for Black club members included the establishment of a separate neigh-borhood house for Blacks, with the ad-dition of a head social worker to coordi-nate services. The board considered whether it would continue its work with Blacks should Wharton depart; they de-cided instead to allow Wharton to as-sume responsibility for all services pro-vided to the Starr Centre’s Black club members.

34. Starr Centre Association, board of directors meeting minutes, June 11, 1912, p. 2, Starr Centre Collection.

1926; “Dedication of the Phipps Insti-tute,” news clipping, December 1909. All items in Information Files Collection, UPF 8.51, University of Pennsylvania Archives. See also: Bates, Bargaining for Life.

53. Bates, Bargaining for Life, 108.

54. Whittier Centre, “Annual Report,” 1915, pp. 4–5, Housing Association of the Delaware Valley (HADV) Collection, Urban Archives, Temple University Li-braries.

55. Whittier Centre, “Annual Report,” 1916, p. 2, HADV Collection.

56. Whittier Centre, “Annual Report,” 1924, p. 13, HADV Collection. It is worth noting that the local health inter-ventions of the Whittier Centre and the Phipps Institute were not isolated initia-tives to improve health in Black com-munities; they in fact ran parallel to na-tional efforts such as National Negro Health Week, which Booker T. Wash-ington launched in 1915 to increase health awareness among Blacks.

57. The Starr Centre and Whittier Cen-tre represent just two examples of inter-racial cooperatives run collaboratively by Blacks and Whites. Other historical examples reveal the importance of building trust and improving communi-cation across race and class lines to ad-dress health and social inequities. In Chicago, for instance, White settlement workers joined Black reformers in founding the Frederick Douglass Center, an interracial settlement that cam-paigned for equal treatment for Blacks. For further reading on interracial coali-tions in Chicago, see: Steven J. Diner, “Chicago Social Workers and Blacks in the Progressive Era,” Social Service Re-view 44, no. 4 (1970): 393–410. Inter-racial cooperation also emerged through evangelical and religious efforts, such as the Young Women’s Christian Associa-tion (YWCA). The YWCA experienced both interracial discord and coopera-tion, but it remains an illustrative exam-ple of the triumphs and complexities of building community networks. For fur-ther readings on the history of the YWCA, see: Nancy Marie Robertson, “Kindness or Justice? Women’s Associa-tions and the Politics of Race and His-tory,” in Private Action and the Public Good, ed. Walter W. Powell and Elisabeth Stephanie Clemens (New Haven, CT: Yale University Press, 1998), 193–96.

58. Nina Wallerstein and Bonnie Duran, “Community-Based Participatory Re-search Contributions to Intervention Re-search: The Intersection of Science and Practice to Improve Health Equity,” American Journal of Public Health 100, no. S1 (2010): S40–S46.

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