New York City provides an ideal setting for historians to examine the interactions between elite reformers and the poor communities whose conditions they have sought to improve. In the early twentieth century, the city's Department of Health was arguably the most innovative in the country, and its philanthropic and human services sector—charitable organizations that linked improvements in health with moral uplift—was among the largest and most active. The immigrants who were drawn to the city from all over the country and the world navigated an urban environment that produced some of the unhealthiest conditions imaginable. And the gulf between poor communities' perceptions of their situations and the views of health professionals was often vast.
Tanya Hart's thoroughly researched monograph examines the maternal and child health programs that New York City created for poor mothers and families in the decade and a half following its first mortality survey in 1915, and the ways these efforts were received by their intended beneficiaries. She narrates the stories of three groups of women: African American, British West Indian, and Southern Italian. She situates the experience of these women—who were very different from each other culturally yet shared many commonalities by virtue of their poverty and vulnerability—within the broader social milieus of the Manhattan neighborhoods where they made their homes: Columbus Hill, Mulberry Hill, and East Harlem. The 1915 survey identified these areas as “sore spots” with particularly high infant and maternal death rates. In response, the New York City Department of Health contracted with a private charity, the Association for Improving the Condition of the Poor, to undertake health demonstration projects aimed at lowering mortality rates and improving the lives of neighborhood residents. These programs embodied the “maternalist” reforms that were so characteristic of the Progressive Era, when the confluence of social meliorism, eugenic beliefs, and the growing sophistication of laboratory methods resulted in disease prevention efforts that, although they had the patina of science, reflected deeply rooted cultural prejudices about the poor and immigrants of different backgrounds.
Hart's juxtaposition of the experiences of the three groups of women illustrates the ways that reformers' biases influenced the services they developed. In their programs for African American women, for example, health officials chose to implement one of their first health demonstration projects focusing on congenital syphilis because of the pervasive belief that blacks were hypersexual and prone to syphilis. Efforts to get Italian immigrant women to accept the delivery of babies by physicians instead of midwives was driven by health reformers' view of these women as uniquely backward and ignorant. Although Hart finds much to criticize in the top-down approach of health reformers and their racial and class biases, she acknowledges the beneficial effects these programs sometimes had. She also argues for the rational and constructive nature of poor women's health behaviors and practices, which outsiders saw as benighted.
Hart weaves other strands into her central narrative. She describes the evolution of the professions of medicine, public health, nursing, and social work during this period, and the growing significance of statistical analyses conducted by insurance company actuaries such as Louis Dublin that provided an empirical basis and a justification (however flawed) for the programs that were undertaken.
The book's chief strengths are its comparative approach and the variety of primary sources Hart draws upon. In addition to the records of the Department of Health and the Association for Improving the Condition for the Poor, she has consulted patient records from clinics in the affected neighborhoods, the files of other charitable organizations, and census data, and she augments these with cultural and artistic products such as literary works, folklore, and music. She interprets all these sources with a discerning eye, careful to note their biases and limitations.
Building on seminal studies such as Alan Kraut's work on the history of the immigrant experience, Susan L. Smith's analysis of black women's health activism, and Evelynn M. Hammonds's examination of Progressive Era health demonstrations, Hart's book offers important insights into the gendered and racialized notions of health and citizenship that animated public health programs in the early decades of the twentieth century and the attitudes and beliefs of the women who experienced these efforts.