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Public Health Before 1917

The young boomtown of Birmingham was born with formidable health problems. It grew around a railroad junction that had been build on the low-lying swampy floor of Jones Valley rather than on the plateau north of the town of Elyton, for which it had originally been planned. The promise of employment in mining and manufacturing drew throngs of people from other parts of the state, and even from neighboring states. Sanitation problems mushroomed as the city grew. Dry privies abounded, and at many houses human wastes were discarded in backyards – or even in front yards. Flies and mosquitoes swarmed.

Although public water systems were constructed, many residents drew their water from an unprotected well in the center of town. When this well was once cleaned it was found to contain a large amount of debris, a dead cat and carcasses of a number of rats. Some residents purchased their water from vendors who carted it in barrels from a spring at Avondale, with flies swarming around the uncovered barrels.

Infectious diseases were rampant. Asian cholera threatened to wipe out the young community in 1873, when the town was just two years old. The disease was brought by a transient man who, seriously ill, left the train he had boarded in Nashville and found help from a local family who provided him care. In a community of 2,500 people, 1,100 fell ill and nearly 200 died. Many fled the town during the epidemic that raged from May to August of that year.

With no organized disease control structure, epidemic followed epidemic in the early decades of the City’s history. Typhoid fever was epidemic in 1881. Physicians reported treating 349 cases, but reporting was voluntary and, therefore, incomplete. Forty-nine deaths were recorded. Dr. Mortimer Jordan, a prominent physician in the City’s early years, wrote a report to the Medical Association of the State of Alabama in which he said the symptoms of victims indicated both typhoid and malaria. He reported that the sanitary conditions in Birmingham were bad and the atmosphere "impure." Smallpox was epidemic in 1898, scarlet fever in 1901, and diphtheria in 1911. Leading causes of death in those early years included typhoid fever, tuberculosis, infant mortality, and diarrhea illnesses of children under two years of age.1

Roots of Public Health
weigh-in Landmark legislation of 1875 established an Alabama Department of Health, designated the Medical Association of State of Alabama as the State Board of Health, and declared MASA’s Board of Censors to be the State Committee of Public Health.2 Legislation adopted the following year authorized the development of county health departments, establishing the same governing relationship between the county departments and the county medical societies. The medical societies were given authority to name municipal and county health officers. Despite this authorization, no full-time county health department was organized for more than 40 years. The first one was established in Walker County in 1914. Tuscaloosa County followed in 1915.3 The Jefferson County Department of Health, the third in the State, was established amid dissension and turmoil in 1917.

Until 1917, Jefferson County and its municipalities was served by part-time health officers, physicians who each maintained a private practice and received a small salary from the county or municipalities they served. Their responsibilities included maintaining morbidity reports and vital records and recommending needed ordinances to local government bodies.

Part-time municipal health officers served many of the municipalities that later became a part of Birmingham, including Ensley, Woodlawn and North Birmingham. Beginning in 1880, a single part-time physician was appointed to serve both the City of Birmingham and Jefferson County. In succession, Drs. James B. Luckie, Henry J. Winn, and John C. Dozier held this post.

In January, 1890, Dr. Henry J. Rosser was appointed to the combined post. Birmingham’s Town Council also appointed two sanitation inspectors, one to work on Northside and the other on Southside, at salaries of $80 a month. The community, thus, had acquired a rudimentary department of health.4

Dr. Rosser held the post for four years, during which he worked vigorously for improved sanitation. At his urging, the Birmingham City Council adopted an ordinance making it compulsory for all residents to provide receptacles for their garbage and requiring contract collectors to make regular pick-ups. The City also responded positively to other recommendations from him. Persons to whom sanitary sewers were accessible were served notices to connect to them within a reasonable time. At least 20 persons were arrested for non-compliance. In 1906, an outbreak of meningitis claimed more than 70 lives. Scarlet fever and typhoid both were epidemic in 1907.

The Laboratory Battle
Two years after the bacteriological laboratory was established, the City Council decided to remove it from the jurisdiction of the Health Officer. The meat and milk inspectors went with the laboratory. The bacteriologist and inspectors were reporting directly to the Mayor. The embryonic Health Department had been all but aborted.

The Jefferson County Board of Health released a statement urging City Council to reunify the Department. The Council refused. The Jefferson County Medical Society filed what is called a "friendly suit" petitioning the courts to reunify the Department. The Council did not regard the step as friendly. In March 1909, a judge in Circuit Court ruled for the City and the Medical Society took the case to the State Court of Appeals.

Duncan, the bacteriologist, gave the press statements describing steady improvements in the quality of local milk supply while Dr. Harkness continued to issue contradictory statements of concern about milk quality. In May 1909, Dr. Harkness gave the press his monthly morbidity report in which he attributed a rising infant mortality rate directly to contaminated milk. On May 14th, the day following publication of the report, Duncan and Harkness got into an argument in a corridor at City Hall and exchanged blows. The incident was witnessed and reported by the press.8

An angry City Commission announced its firing of Dr. Harkness and asked the Medical Society to name a new City Health Officer. The Medical Society replied that the Council had no authority to fire the Health Officer, citing the State law that gave county medical societies exclusive right to name county and municipal health officers, and declared that Dr. Harkness’ appointment still held. The Council retaliated with a threat to sharply reduce his salary.

Mayor Frank P. O’Brien, who had succeeded George Ward, attempted to act as peacemaker. He praised Dr. Harkness’ record and urged the Council to retain him. When the Court of Appeals handed down a decision supporting the City'’ position with regard to the laboratory, Mayor O'Brien confidently announced to the press that the quarrel was over and that he expected the Council to rescind its action at its next meeting. The Council, however, met and reiterated its position on firing Dr. Harkness.

The Alabama Legislature, then in session, stepped in to relieve the tense situation by passing a bill that restated provisions of the 1878 legislation giving medical societies the right to elect municipal and county health officers.9

The matter thus settled, Dr. Harkness held the post another 14 months before retiring to private practice.

Old Problems, Unresolved
The new Health Officer, Dr. Robert Nelson, served a city that had doubled in size in the preceding year. The Greater Birmingham Bill, adopted by the Legislature in January, 1910, provided for annexation of the communities of Avondale, Woodlawn, East Lake, North Birmingham, Graymont, Pratt City, Ensley, Wylam, Elyton and West End. The 1910 census put the population at 132, 685. Leading causes of death still included tuberculosis, violence, infant mortality and pneumonia.

There were other problems posed by the community’s lack of a full-time health department. Early in 1912, Dr. Nelson received a scathing letter from Creasy L. Wilbur, the Federal government’s chief statistician in Washington, D.C., calling Birmingham’s keeping of vital records the worst in the nation. He wrote that more Birmingham deaths were attributed to "unknown causes" than those of any other city. He criticized private physicians for negligence in filling out reports and blamed the Health Officer for lack of persistence in getting the correct information. He said that in the nation as a whole, 3 percent of all deaths were listed as "cause unknown," whereas in Birmingham 79.5 percent were so listed. 10

The City Health Department had shown some growth after city expanded its boundaries. Dr. Nelson and his successor, Dr. R.N. Cunningham, directed a staff that included 12 sanitation inspectors, two meat inspectors and two milk inspectors. The laboratory had been returned to the supervision of the Health Officer. In June, 1915, with the aid of funds made available by a local church, Dr. Cunningham was authorized to hire a nurse to work with sick infants and children of low-income families.

Nevertheless, Birmingham retained its reputation as the unhealthiest city in the Southeast and one of the unhealthiest in the country. Infectious diseases were poorly controlled. The recorded death rate approached 75 percent of the birth rate. Among the growing black population, the death rate exceeded the birth rate, although this circumstance probably was partly due to inadequate records. It was necessary to get a death certificate in order to obtain a burial permit. Births sometimes went unrecorded. 8

Among members of the Jefferson County Medical Society, many were urging the city and county governments to establish a unified health department directly by a full-time health officer. 11 It was in the year 1916 that the need for such a strong, unified department became undeniable.

1917 Forward

Outhouse Thus the Jefferson County Department of Health was established in 1917. In September 1917, Dr. Judson D. Dowling, was named as the first full-time county-wide Health Officer. Environmental challenges facing the newly organized Birmingham-Jefferson County Health Department in 1917 were formidable. More than 8,000 dry privies were known to exist inside the city limits. Thousands of homes had been built without bathrooms. The Department was organized on the heels of a typhoid epidemic that was found to be milk-borne. Food service inspections were haphazard.

The struggle to achieve a safe milk supply was perhaps the most dramatic of the department's early challenges. In 1917 the death rate from diarrhea and enteritis among children under the age of two was 182.5 per 100,000 population. These deaths were largely attributable to the unprotected milk supply. Fifty percent of the milk sold to the public was found to be adulterated to the extent of 10 percent added water. The average bacteria count was 780,000 per cubic centimeter.

Most of the suppliers were small, independently operated dairies. Cows were hand-milked and the milk sold raw. More than 100 such dairies were operating the county, many within the city limits.

By 1920, Dr. Dowling had persuaded the city government to adopt an ordinance prohibiting the sale of milk with bacteria count exceeding 60,000 per cubic centimeter, a level difficult to achieve without pasteurization. The law provided for regular inspections of dairies and excluded sales of milk from dairies not passing inspection.

The dairy operators fought back. Dr. Dowling was kidnapped from his home, taken to a remote area where he was flogged and warned to leave town within 30 days. This act outraged the community and infused both the public and the local governments with enthusiastic support for Dr. Dowling's efforts.

By 1923, adulteration was limited to 3 percent of the milk supply, 80 percent of the milk sold here was pasteurized, and the death rate from infant diarrhea and enteritis was down to 29 per 100,000 population. Further, per capita milk consumption had increased 91 percent. In 1948 all sales of raw milk were prohibited by law.

Inspections of food service establishments kept pace with the growth of the community through the 1920's, but fell on hard times during the Depression, when operating funds were sharply curtailed. By 1933 the Department's budget was down to half its 1929 level and the food service was among programs that were hit hard.

In 1936 an outbreak of foodborne illness struck 122 people, most of them students at Ensley High School. Many of them were ill enough to require hospitalization. The problem was traced to cream puffs purchased from a local bakery and served in the school cafeteria as well as in a local restaurant. After an inspection at the bakery, Dr. Dowling sent the City Commission a blistering report on the filthy conditions found. He pointed out that because of the fund shortage no regular inspections had been made of food service establishments in three years. As the Depression waned funding improved, but new staffing shortages occurred when the armed services impacted manpower in the early 1940's.

Food service inspections grew to encompass not only restaurants and grocery stores but also bars, lounges, school lunchrooms, food processing plants, institutions, itinerant services at athletic events and the state fair and street vendors. Of continuing concern through the years was adequate regulation of open-air markets and roadside vendors. Refining and updating regulations is a continuing process. In 1992, the department had 1,771 food service establishments under inspection. This number now exceeds over 3500 facilities that are inspected on a regular basis.

Birmingham's growth in its early years came in rapid spurts that often outdistanced the development of sewer systems. A large number of low-cost houses had been built without plumbing and owners were often reluctant to add it later, even after water mains and sewers became accessible. There were 8,000 dry surface toilets in the city at the time the Department was organized.

In 1920 the Health Officer faced stiff opposition from powerful real estate interests, but he vowed to enforce a new city ordinance requiring one bathroom per dwelling unit where the sewer was accessible.

Houses without sewer connections continued to be a problem into the 1940's. A milestone was the adoption of regulations by the Jefferson County Board of Health in 1950 to govern the development of subdivisions utilizing septic tanks as a means of sewage disposal. These were the first regulations addressing on-site disposal system in the state.

The same year the Board also adopted regulations governing the construction and operation of public bathing places and swimming pools. These, also, were the first such regulations in Alabama.

Refinements to regulations since 1950 also address alternate systems for wastewater disposal and require the certification of all companies that install, repair or maintain on-site disposal systems. Today, repairs and clean-outs of septic systems are inspected by the Health Department. Computer-generated reminders are sent to homeowners when their tanks are due for cleaning.

Pursuant to a State legislative act of 1979, health clubs were added to swimming pool inspections. Revised regulations adopted in 1988 added specific requirements concerning whirlpools and spas.

Another important facet of the program today is swimming pool seminars taught each year to provide pool operators and managers information on safe and sanitary pool management. During 1992, this program was upgraded to become the county's first Certified Pool Operators training course designed to prepare participants to meet national certification standards.

Throughout the first forty years of the Health Department's history, rabies was a deadly threat to people and their pets throughout the county. Newspaper accounts of attacks by rabid dogs were common. Birmingham was frequently referred to as "rabies capital of North America."

In February 1934, the Health Department laboratory found that 41 heads of animals tested in a single month were positive for rabies. In the first five months of that year, 832 residents of the county took treatment for rabies after having been bitten. Dr. George Denison, then Director of the Laboratory, pointed out that 95 percent of the estimated 21,000 dogs in the city were running at large. At the Department's urging the City of Birmingham adopted an ordinance providing a $2 fee for dog licensing and a fee of $1 for inoculation. By the end of the year about 100 unlicensed dogs per day were being impounded. In the first two months of 1935 a sharp decline was seen in the number of rabid animals. The improvement didn't last. Many neighboring municipalities did not have licensing laws or impoundment programs.

In 1954 the City of Birmingham and the Jefferson County Department of Health negotiated a contract giving the Department responsibility for operating the City Pound. The contract also authorized the Department to negotiate with other municipalities to provide impoundment services. During the first year the Department operated the program, the numbers of rabid animals dropped--but not enough. Enforcement activities were stepped up in areas where a rabid dog was known to have run at large. Pound trucks put in extra hours picking up unconfined dogs. Sanitarians went door to door identifying dogs that were not vaccinated. Owners of unvaccinated dogs were arrested. Rabies began to wane. The last human death from rabies in the county was recorded in 1959. That same year, the Department took its dog-catching activity into unincorporated areas of the county where large numbers of dogs ran at large. The number of positive animals identified dropped from 134 in 1959 to 36 in 1960 and to 17 in 1962, to zero in 1963.

On October 19, 1960, the Jefferson County Board of health adopted regulations on control of ionizing radiation, and radiological health inspections became a part of the Department programs. For 22 years the radiological health program has been protecting patients and operators from excessive exposure by regularly inspecting all x-ray facilities in the county. Other types of exposures have also been of concern. In the 1970's the program conducted a microwave oven survey. In recent years the radiological health division has supplied the public basic information on radon through presentations that explain what it is and how to get rid of it.

In 1941 a sanitary survey conducted by local women's clubs and civic groups cited the presence of animals such as cows, mules, and even hogs within the city limits as indications of poor sanitary control. Animal wastes fostered swarms of flies. Improved sanitation laws, regular inspections, and follow-up on citizens' complaints have brought about steady improvements, abating public health nuisances caused by mishandled garbage, insanitary animal yards, pests, and sewage problems. Over the years, regulations have been added to provide for regular inspections of hotels, motels, mobile home parks, jails and prisons, schools, and summer camps. In 1984, with funds provided by Jefferson County, the Department began a program of enforcing regulations to control illegal dumping of solid waste.

Pollution Air pollution was a common urban problem throughout the early and middle years of the twentieth century. Extensive air sampling programs done in the 1960's by the Department of Health under federal grants established the extent of Birmingham's problem. Concentrations of some pollutants, especially particulate matter or solid particle pollution, far exceeded national averages and frequently reached levels known to cause adverse health effects. The first statewide control law was adopted in 1969. It had many weaknesses and the federal agencies refused to provide funding for any program developed under it.

The Federal Clean Air Act Amendments of 1970, part of the package of environmental legislation under which the Environmental Protection Agency was created, required states to enact control laws that EPA would approve. With this impetus, the Alabama Legislature adopted its Alabama Air Pollution Control Act in August 1971. The law vested rule-making authority to a commission to be appointed by the governor. Governor George Wallace announced his initial appointments to the commission on November 13, 1971. The commission had the responsibility for adopting rules and regulations for appointing an administrator and granting him authority to oversee the program, including authority to act in emergencies. The first emergency arose before this process could be completed.

On November 15, 1971, the National Weather Service issued an Air Stagnation Advisory for central Alabama. By the following day, concentration of particulate matter in the downtown and North Birmingham areas far exceeded levels at which EPA says emergency action should be taken. The Health Department notified local industries requesting temporary cutbacks in emissions. From their responses, the department could not project adequate voluntary reductions to abate the emergency. No one at the state or local level yet had authority to order reductions. Representatives of EPA and the U.S. Department of Justice came to Birmingham and obtained a federal court order requiring temporary closure of the 23 industries. This was the first and only exercise of the injunctive authority granted EPA by the Clean Air Act Amendments of 1970. Rules and regulations were adopted at both the state and county levels in January 1972, and the control program began functioning. From 1972 to 1977, 23 air pollution episodes requiring temporary emission reductions occurred. In the 20 years the Air Pollution Control Program has functioned, it has made dramatic reductions in pollution levels in Jefferson County. Concentrations of particulate matter, the pollutant of primary concern when the program began, have dropped to levels within the National Ambient Air Standards.
In earlier decades of the century, board homes were residences for working people, both singles and those with families. Today boarding homes and other communal living facilities mainly serve elderly or disabled persons who are on limited incomes and who usually have no families. In 1989 the Department of Health adopted revised regulations for communal living facilities to provide a healthful and appropriate environment for this growing segment of the population. The revised regulations prohibit boarding and rooming homes from admitting persons who need a higher level of care than the homes can provide. They also address safety, sanitation and nutrition concerns.
  1. "History of Public Health in Alabama," 1941; Alabama Writers’ Project, an incomplete work financed by the U.S. Works Progress Association.
  2. Memoranda and lecture notes, George A. Denison, M.D., Health Officer, 1941-1962.
  3. "Public Health in Alabama,"
  4. The Birmingham News: January 1, 1890; March 30, 1891; May 7 and May 20, 1891; March 8, 1892.
  5. The Birmingham News: June 5, 1905.
  6. The Birmingham News: June 10, 1905; January 12, 1906.
  7. The Birmingham News: February 2, 1906; April 3, 1906; May 6, 1906; January 1, 1907.
  8. The Birmingham News: May 14, 1909.
  9. The Birmingham News: August 20, 1909.
  10. The Birmingham News: February 11, 1912.
  11. Diaries of Thomas D. Parke, M.D. (Birmingham Public Library Archives.)