The COVID-19 pandemic has had a staggering economic impact in a short time. Jobless numbers in America are growing and food banks and other emergency relief efforts are struggling to keep up with demand. As we struggle to understand what long-term cultural and economic changes the pandemic might leave in its wake, it is worth exploring how earlier generations responded to similar catastrophes.
One example is the Children’s Nutrition Clinic in Mobile, Alabama, founded in 1930, less than a year after the stock market crashed. This was Mobile’s first well-baby clinic, designed to promote the health of undernourished children. It was established by the Mobile Charity League, a women’s volunteer organization that later became the Junior League of Mobile (JLM). The clinic was the most important community project that the MCL had ever launched, and its success was a major factor in gaining the organization admittance as a chapter of the National Junior League.
Much good came from the clinic’s founding. The clinic was supported for decades by Mobile’s first practicing pediatrician and its first pediatric dentist. Services included physical examinations, immunizations, nutritional counseling and food assistance. In an economically struggling southern city, years before the Food Stamp Program and Medicaid were established, the founding of the clinic must have seemed to many like a dramatic step forward in public health.
Yet, the clinic was not really designed to address the extreme racial disparities in nutritional and dental health caused by decades of legal segregation and environmental racism. It was managed by an all-white staff of volunteers and professionals and located in segregated facilities. Unlike the Mississippi Health Project, which was founded by a black sorority in 1936, the clinic did not engage in direct outreach to black communities or solicit help from black organizations or health care workers.1 This blind spot on race surely limited the community impact of the clinic in ways that may not have been readily apparent to its founders. In some ways, the work of the clinic, however well-intentioned, aligns with the interests of early twentieth-century eugenicists in maintaining good “racial hygiene.”
Founding the Clinics
The Mobile Charity League began planning a well-baby clinic soon after the organization was founded in 1925. After building and equipping a children’s ward at City Hospital, the League turned its attention to the clinic. In 1929, two League officers, Julia Roe “Dallas” Ward and Elizabeth Armbrecht Crichton, approached Dr. Bell about helping to staff the clinic.2 He agreed and outlined the free services that the clinic should provide.
Dr. Bell had completed pediatric graduate study at Harvard Medical School after receiving his M.D. from the Medical College of Alabama in 1915. As the first physician to practice pediatrics in Mobile, he saw a limited number of patients by appointment only. But, as he recalled in a 1976 interview, he agreed to serve the clinic because the League women “hit a soft spot in my heart. The idea originated in the minds of those girls…I had a few of them as patients, and they wanted to be anchored into something worthwhile…I was just thrilled to death! ”3 In 1932, Dr. Bell was joined by Dr. Sidney Van Antwerp, who had done graduate work in pediatric dentistry at the Forsyth Dental Hospital for Children in Boston. The JLM initiative became known as the Children’s Nutrition and Dental Clinics. Dr. Van Antwerp and fifteen other dentists contributed their services until 1952.
In its first year of operations, the CNC was located at the Y.W.C.A. headquarters, formerly a maternity hospital known as Southern Infirmary. The following year, the Mobile Charity League became an affiliate of the Association of the Junior League of America. The CNC was moved to City Hospital, Mobile’s public hospital, nearer to downtown. After it was launched in 1932, the Dental Clinic followed a similar path from the Southern Infirmary to City Hospital.
The JLM employed the area’s first professional social worker to manage clinic services. It also provided food, furnishings, equipment, and volunteer staff. Business hours were 9 am until 12 noon on Tuesdays and Thursdays, with Dr. Bell in attendance once a week. In 1942, management of the clinics was turned over to Mobile Community Chest, the predecessor of the United Way of Southwest Alabama.
“People had to be brought into a new environment”
While a range of general health care services were offered at the clinics, nutritional care was the primary focus. A trained nurse would weigh and measure children and prescribe a nutrient-rich diet, especially milk. Among the nutritional diseases mentioned in pediatric textbooks of the time are rickets, scurvy, marasmus, and pellagra.4
Dr. Bell mentioned rickets as a frequently diagnosed illness at the clinic. Since the process of fortifying milk with vitamin D was just getting underway in the 1930s, many physicians prescribed cod liver oil in orange juice.5 This was evidently Bell’s preferred treatment. However, he recalled that many patients resisted being given dietary supplements because they did not acknowledge them as “medicine.”6 Bell saw himself first and foremost as a public health educator, advising patients on everything from diet to mosquito screens. “People had to be brought out of [their environment] and into another environment.”
National Health and the Color Line
The clinics were founded at a time when fitness and nutritional health were closely watched metrics of national strength.7 A great power like the United States needed to do more to improve its standing in comparative health statistics. It was also a peak time for the American eugenics movement, with compulsory sterilization statutes in Alabama and thirty-two other states.8 Eugenicists regarded any philanthropic or altruistic support for people who they deemed “unfit” as being detrimental to the cause of racial improvement and, in turn, to national prosperity. From a eugenicist perspective, life expectancy and reproductive capacity were to be enhanced in people with desirable racial, intellectual, and physical traits and discouraged in all others. In the south, the white establishment was deeply unsettled by the prevalence of so-called “poor whites” and their susceptibility to debilitating diseases such as hookworm and rickets, which undermined the long-standing claim of white racial superiority.9 This was unacceptable.
The Junior League volunteers may not have been conscious of these ideological imperatives, but their organizing efforts tended to reinforce a status quo that prioritized and universalized the health care needs of white Mobilians. The clinics were always located in segregated facilities and staffed by all-white volunteers.10 Mobile’s census records from 1935 indicate that the rates of infant mortality and stillbirth were dramatically higher for “other races” than for whites.11 Yet there is only one archival record of a black child being treated at one of the clinics, from 1950.12
Without dedicated outreach efforts, the clinics would have failed to reach many residents of poor black neighborhoods, those who were most in need of food assistance and nutritional health services.13 Because of a long history of racial discrimination, involuntary experimentation, and support for eugenics, the medical establishment was deeply distrusted by poor black southerners.14 This distrust was so entrenched that when the Mississippi Health Project, organized by the black sorority Alpha Kappa Alpha, tried to set up free clinics in black churches and schools, even they struggled to overcome the fear and suspicion of the sharecroppers.15
End of an Era
Within a few years of the opening of the free clinics, physicians and nutritionists nationwide became increasingly skeptical of using anthropometric assessment to diagnose and treat at-risk individuals for malnutrition. By the late 1930s, there was an emerging consensus within the pediatric profession that malnutrition should instead be understood as a systemic problem to be addressed through broad-based, long-term public health campaigns, such as the fortification of foods and the dissemination of nutritional models and educational materials.16
In the postwar years, this shift in public health policy appeared to be working. Nutritional diseases such as rickets were thought to have been virtually eradicated in the United States. However, at the end of the twentieth century, the U.S. saw a resurgence of rickets, particularly among infants of color who had been exclusively breastfed.17
Likewise, epidemiological data on COVID-19 outbreaks in the United States indicate that infection and death rates are significantly higher in predominantly black counties than predominantly white ones. Clyde W. Yancy, a cardiologist at Northwestern University’s Feinberg School of Medicine, offers this early assessment: “consider the aggregate of a higher burden of at-risk comorbidities, the pernicious effects of adverse social determinants of health, and the absence of privilege that does not allow a reprieve from work without dire consequences for a person’s sustenance, does not allow safe practices, and does not even allow for 6-foot distancing.”18
Today we associate breadlines and soup kitchens with the Great Depression. But the Depression did not create a hunger and malnutrition crisis in the United States. It brought to the fore deep-seated structural weaknesses in our economic, political, and health systems that enabled this crisis to boil over. No matter how many grateful families were served by the Junior League’s free clinics, these structural weaknesses remained unexamined and intact, leaving African Americans, who comprised the vast majority of Mobile’s poor and undernourished, to fend for themselves.
In the early 1930s, a wide range of data was readily available for advocates and professionals to recognize racial disparities in public health. But they lacked the will or the perspective necessary to put this data to use. Nearly a century later, people of color are now helping to directly shape public health policy, pediatric care, and nutrition science in ways that were once unimaginable in a segregated society. Yet, the medical establishment is still overwhelmingly white and jealous of its privilege, unable or unwilling to discontinue what Yancy calls “this familiar refrain” of health care disparities. Clearly, radical changes are needed in how we think about, teach, structure, and fund health care if we are ever to put this refrain to rest.
- Thomas J. Ward, Jr., Black Physicians in the Jim Crow South (University of Arkansas Press, 2003), 240–248. Return to text.
- Junior League of Mobile Scrapbook. Box 15. The Doy Leale McCall Rare Book and Manuscript Library, University of South Alabama. Return to text.
- Cammie East, “Children’s clinics served Mobilians,” The Mobile Press Register, July 18, 1976, 4D. Return to text.
- See Charles Gilmore Kerley, The Practice of Pediatrics (W. B. Saunders and Company, 1916), 80–88; Roger H. Dennett, Simplified Infant Feeding, 3rd edition (J. B. Lippincott Company, 1926), 299–308; Langley Porter, Management of the Sick Infant (C. V. Mosby Company, 1922), 93–110. Return to text.
- Michael F. Holick, “The Vitamin D Deficiency Pandemic: A Forgotten Hormone Important for Health,” Public Health Reviews 32, no. 1 (2010): 267–283. Return to text.
- East, “Children’s Clinics,” 4D. Return to text.
- A.R. Ruis, “’Children with Half-Starved Bodies’ and the Assessment of Malnutrition in the United States, 1890-1950,” Bulletin of the History of Medicine 87, no. 3 (Fall 2013): 382-383. Return to text.
- Gregory Michael Dorr, “Eugenics in Alabama,” Encyclopedia of Alabama, October 10, 2007. Return to text.
- Rachel Nuwer, “How a Worm Gave the South a Bad Name,” NOVA, April 27, 2016. Return to text.
- City Hospital was known locally for its substandard treatment of black patients. See Shawn A. Bivens, Mobile, Alabama’s People of Color (Trafford Publishing, 2004), 203. Return to text.
- U.S. Department of Commerce, Bureau of the Census, Birth, Stillbirth and Infant Mortality Statistics for the Continental United States, the Territory of Hawaii, the Virgin Islands, 1935 in Twenty-first Annual Report, ed. Halbert L. Dunn (Washington, DC: United States Printing Office, 1937). Return to text.
- In 1950, a three-year-old black boy, diagnosed with rickets, was fitted with dentures at the Children’s Dental Clinic. Van Antwerp Dental Collection. 2001.004.002. Mobile Medical Museum, Mobile, Alabama. Return to text.
- Two African American residents of Mobile, both in their eighties, said that they had never heard of Drs. Bell and Van Antwerp or the free clinics. Interviewed by the author by phone, Mobile, Alabama, May 20, 2020. Return to text.
- See Vanessa Northington Gamble, “Under the Shadow of Tuskegee: African Americans and Health Care,” American Journal of Public Health 87, no. 11 (November 1997): 1773–1778. Return to text.
- Ward, Black Physicians, 244. Return to text.
- A.R. Ruis, “’Children with Half-Starved Bodies,” 378–406. Return to text.
- Kumaravel Rajakumar, “Reemerging Nutritional Rickets: A Historical Perspective,” Archives of Pediatrics and Adolescent Medicine 159 (April 2005): 335–341. Return to text.
- Clyde W. Yancy, “COVID-19 and African Americans,” JAMA 323, no. 19 (May 19, 2020): E1-E2. Return to text.