United States Office Of War Information. (1944) Health in a U.S. city - a serum and vaccine farm. Children await inoculation. New York, 1944. Retrieved from the Library of Congress
“It was an appalling summer,” wrote physician and public health official Josephine Baker of 1902 New York City, “with an average of fifteen hundred babies dying each week in the city; lean, miserable, wailing little souls carried off wholesale by dysentery.” Baker (no relation to the entertainer of the same name) would go on to serve as first director of New York's Bureau of Child Hygiene, a post she held from 1908 to 1923, and in 1917, she became the first woman to earn a doctorate in public health from New York University and Bellevue Hospital Medical College.
And at a time when the city’s poorest, most overcrowded neighborhoods were losing more infants per week than die here now in a typical year, Baker was part of a new generation of reformers, many of them women, who believed that a good number of those deaths could be avoided—and, crucially, that that it was society’s responsibility to protect its most vulnerable. They ultimately proved that the rates of “summer diarrhea,” which killed babies largely through dehydration, could be reduced through a combination of breastfeeding education, the regulation and distribution of pasteurized cow’s milk, and visiting nurse services supporting and assisting parents with infant care.
Sara Josephine Baker in 1925. Retrieved from the Library of Congress
That success story is just one of many that Perri Klass, NYU professor of journalism and peditatrics and co-director of NYU Florence, chronicles in her new book A Good Time to be Born: How Science and Public Health Gave Children a Future, which traces the dramatic decline of child mortality during the 19th and 20th centuries. The transformation of childhood death away from a grim inevitability, which it was for most of human history, to the rare tragedy it is in much of the world today “is in no way a single project,” she writes, “but it can be seen as a unified human accomplishment—maybe even our greatest human accomplishment, at least for parents and pediatricians.”
Among the significant medical advances that made that shift possible were antibiotics that treated infected wounds and diseases such as tuberculosis and scarlet fever; vaccines that conquered smallpox, polio, measles, and more; and, later, incubators and other equipment that helped babies born prematurely survive outside the womb. In the policy realm, safety regulations around everything from car seats to cribs further reduced deaths due to accidents and suffocation.
As compelling as the scientific details are, Klass argues that the revolution was as much philosophical as technological. At the end of the 19th and the beginning of the 20th centuries, with the rise of germ theory paving the way for other medical innovations, several European nations began, for the first time in history, “tracking infant mortality in the way we do everywhere today”—by counting live births and tracking how many died out of every 1,000, Klass explains. The British physician George Newman was among the first to articulate the goal of reducing that rate, which was then as high as 300 per 1,000, in an influential 1906 manifesto, Infant Mortality: A Social Problem. Other champions of the cause included Abraham Jacobi, the German-Jewish immigrant to New York who was highly influential in establishing pediatrics as a discipline in the United States, advocating what Klass calls “the idea that the diagnosis and care of children ought to be studied and taught and practiced as distinct from the care of adults.” His wife, fellow physician Mary Putnam Jacobi, was a pioneer of women’s medicine.
Klass notes that innovations in care haven’t benefited all groups equally: In the 1880s, one in four African American children died by age 5, compared to closer to one in five among white children, and today 10.8 in 1,000 Black infants die before their first birthday, more than double the rate among White babies.
But it wasn’t so long ago that even the most privileged families were powerless to protect their kids from threats that are now easily addressed through either prevention or treatment—a point that Klass illustrates through the stories of several US presidents who lost children while in office, from Abraham Lincoln, whose son Willie died, likely of typhoid from contaminated water, in 1862, to John F. Kennedy, whose baby Patrick died within two days after being born prematurely in 1963—and would be a relatively unremarkable patient in today’s newborn intensive care units. Even John D. Rockefeller—literally the richest man in America—lost a grandson to scarlet fever in 1901.
In addition to mining writings about these real-life historical tragedies, Klass also looks to popular literature from the past—think Charles Dickens, Harriet Beecher Stowe, Charlotte Bronte, and even Mark Twain—for clues about cultural norms around childhood death. She works to dispel the notion that ubiquitous loss made parents in previous generations love their kids any less, while observing that the miraculous promise of modern medicine and public health—that “barring rare and tragic events, your child will live to grow up—should live to grow up”—has “brought with it a sense of responsibility that can leave parents feeling tremendously uneasy.” If today’s unluckiest parents experience grief differently than did those in previous generations, she concludes, it may be in part because they “can suffer the double burden of guilt and isolation, in a world where childhood death has become ‘unnatural.’”
At a time when, as she writes, the current pandemic has “harshly reminded us all of the fear and uncertainty that a new and untreatable infectious threat can bring,” NYU News spoke with Klass about lessons from the historic fight to end child mortality that could be instructive in our current moment.
What made you want to tackle this topic?
For a number of years I’ve co-taught a course with my husband [history professor and NYU Florence co-director Larry Wolff] about children and childhood. He’s a historian, so the idea is that he would cover the history of childhood and I would cover the biology and medicine of childhood. But the place we kept crossing was around this question of infant and child mortality and what it meant. If a fifth or a tenth or a third or a half of children used to die and now they don’t, that represents a huge change in everything we see and do. I thought a lot about the implications of that for parents, but also for pediatricians.
Perri Klass
This is a relatively recent change. If you think back 100 years to my grandmother’s moment at the end of the 19th century and the beginning of the 20th, everyone was losing a child or two along the way—from the richest people in the world to immigrants in tenements. It was just something that happened. But by the time I was trained in pediatrics, that was a lost world. It’s forgotten. The whole rationale of my training is that we can save almost everybody, and we should.
What made you look to literature and personal accounts of the time when doing research for this book, what did you learn from them?
One of the things that I kept thinking about and wondering about was: What did it feel like to be a parent? Students often ask me, ‘Did people not get attached to their children in the same way when so many children died?’ And I don't think that makes any sense. But it’s hard to find out just by looking at the historical record. If you look at someone’s biography, you’ll often find a dead child relegated to a footnote. But by looking at literature and memoirs, you can see ways that that kind of loss permeated culture. It’s a way into that lost world, to see what people found interesting, what people found consoling, what people found moving, and what they wanted to cry over. I found it interesting that at one point, even in, say, in children’s literature, children died in books because children died in life.
You write that you feel a “special sense of identification” with some of the early women doctors who brought new energy to the project of reducing child mortality. What about these pioneers made them different from physicians who came before them?
Well, someone like Josephine Baker certainly has more of a public health approach as she starts thinking about these kids. She's really good at working with nurses going into homes, and she’s realistic about what is reasonable to ask of mothers. I tend to think that some of that probably has to do with her awareness of herself as a woman in a field that is not always welcoming to her. And then she credits one of her professors, Anne Sturges Daniel, also a pioneering female doctor, who taught a course on “The Normal Child” [at the New York Infirmary for Women and Children, founded by sisters Dr. Emily Blackwell and Dr. Elizabeth Blackwell]. You could easily hypothesize that this interest in the “normal child,” not just in pathology, not just in heroic measures, may have something to do with the women coming into medicine. But generalizations like that are always difficult, because I can point to excellent male physicians who were also heroes of public health. I write about Mary Putnam Jacobi and Abraham Jacobi and the astonishing amount of expertise in that one family. They were good doctors. She knew a tremendous amount about the diseases of women. He knew more than probably anyone in the world about diphtheria and had written a treatise about it in 1880. And yet they still lost their son to it in 1883. At that point, it didn’t matter how rich or knowledgeable you were, before there was an antitoxin and long before there was a vaccine.
Parental education campaigns have been a crucial part of successful public health efforts to protect kids. And yet you also write about the “long and not terribly honorable tradition in medicine” of “blaming mothers.” Can you give an example of those dynamics at work?
The single most important piece of advice a pediatrician could give to reduce infant mortality throughout most of human history would be breastfeeding, so let’s take that as an example. Now, if I'm just saying to you, the most important thing you can do is breastfeed exclusively for the first six months of life, and there’s no guaranteed parental leave and you have to go back to a job or your family will starve, or there’s no medical care for you, the mother, if you run into problems, or if there’s no way for you to express milk when you go back to work, then I’m just sort of waving my hands at you. Even if the information is correct, unless there are the social supports, and equity and access to those supports, then that advice may be not terribly relevant to a lot of families.
How do you explain an issue like vaccine hesitancy among parents today? Do you think some families take their children’s safety from once common diseases for granted?
I think that’s right. People are not scared of these diseases anymore and even as a doctor, it’s hard to be. Never in my whole life as a pediatrician have I known the feeling of lying awake at night and worrying that a child could have diphtheria. I’ve never seen it. I’ve never seen polio. And for parents now, too, these diseases seem very far away. So if someone scares you about the idea of choosing to give your child a vaccine, which is right here in front of you, people find that more immediately frightening than the distant prospect of a disease they’ve never seen. In pediatrics, we don’t really love scare tactics. But it's this tremendous luxury—a tremendous good fortune—that parents now feel that the risk of death, which was one just a reality in almost every family, is now very, very remote.
With so many childhood diseases eliminated, are there still lethal threats that pediatricians worry about?
Oh yes, of course. Gun violence. Accidents. Drownings. Car crashes, although obviously there’s been a tremendous amount of progress there. And then there are rarer things within a field like pediatric oncology, and we hope to continue to advance the ability to help children with all kinds of congenital problems, such as sickle cell disease and cystic fibrosis. But for children overall, I’d start with gun violence and the ability to play in your neighborhood and inside your house safely.
COVID-19 hasn’t proved as dangerous for children as for adults. But do you see parallels between our current crisis and public health threats previous generations faced?
The pandemic is a reminder that we live in a shifting balance with the microbial world around us. It reminds us that we are vulnerable and the people we love are vulnerable. But this should, I think, be a moment to think about how far we've come by trusting science and public health. Limiting child mortality is an amazing thing that we did as a species. And we should celebrate it. Then we should sign on to consider the current crisis as another question to be addressed with science and public health.