“In the face of probes . . .”
1920 – 1924
The tuberculosis hospital of the city of Lowell, the construction of which has been delayed for years, has now been practically completed for the past six or seven months. Apparently the actual opening of this hospital is as far away at the present time as it was a year ago. It is to be hoped that public opinion in this large city, which for so many years has been urgently in need of a local tuberculosis hospital, and which city for an equal number of years has managed to successfully evade the law on this subject, will bring about the opening of this institution in the near future.
Thirteenth Annual Report, Trustees of Massachusetts Hospitals for Consumptives, November 30, 1919
* * *
In the face of probes, aspersions and inferences the Lowell Isolation hospital is today busier than at any time since its erection. Whether the advertising the institution has received has helped business would be hard to say, but the fact remains incontrovertible.
There are today 58 patients at the hospital, 46 of them tubercular and 12 suffering from contagious diseases. Of this last number nine are children ill with measles, removed to the hospital from the Ayer home. Three cases of scarlet fever are also confined there. Two years ago, there were 55 patients at the hospital and up to now that has stood as the high mark.
Lowell Sun, May, 2 1924
Introduction and overview
The focus of Part 12 of this series will be on first years of the Isolation Hospital. The story will begin in late 1920 when the Isolation Hospital officially opened as hospital for tuberculosis and other contagious diseases. Before that, I want to present an overview of the state of contagious diseases in Lowell at that time.
Figure 1 below shows that, with the exception of smallpox, serious contagious diseases were still present in Lowell during these years. While there were still cases, outbreaks, and epidemics of contagious diseases in Lowell, the numbers of cases, frequency of outbreaks, severity of cases, and mortality from these diseases were decreasing compared with previous decades. This shows, among other things, that public health measures need not be perfect to have a positive effect on human beings.
Figure 1 - From the Forty-Seventh Annual Report of the Board of Health of The City of Lowell for the Year 1924
While the numbers for many contagious diseases were trending in the right direction, tuberculosis continued to be both too common and deadly. In general, and over a longer period of time, the numbers for tuberculosis were coming down even though a cure was over two decades in the future. Figure 2 below shows the decrease in mortality in Massachusetts and nationally over the decades since the mid-1800s. Again, the measures that were being taken were not 100% effective, but they were making a difference.
Figure 2 [https://commons.wikimedia.org/wiki/File:Tuberculosis_in_the_USA_1861-2014.png]
As shown in Figure 3 below, the number of cases of and deaths from typhoid decreased regularly over 35 years. In the year following the last year in the table, 1925, for the first time in Lowell since typhoid deaths were recorded, the number of deaths from typhoid would be zero.
Figure 3 - From the Forty-Seventh Annual Report of the Board of Health of The City of Lowell for the Year 1924
One last example of health trends during this period is shown in Figure 4 below. This shows that the overall death rate (deaths per 1,000 inhabitants, indicated in the right-hand column) was almost half in 1924 (13.70) of what it was in 1890 (25.21). This was the overall death rate, not just the death rate from contagious diseases, but the trend was still in the positive directions, so many factors were at work and working.
Figure 4 - From the Forty-Seventh Annual Report of the Board of Health of The City of Lowell for the Year 1924
While considering an alternate version of history is pure speculation, we can still think about what might have been different if the Isolation Hospital opened five, ten, or twenty years earlier. For that to have happened, there would have had to be an agreement on a location less remote than West Meadow Road. There was evidence at the time that the hospital would not have been a danger to the health of nearby residents in any of the other locations considered. And there was available evidence that property values in nearby neighborhoods would not have been affected. For examples, see The Effect of Tuberculosis Institutions on the Value and Desirability of Surrounding Property by The National Association for the Study and Prevention of Tuberculosis published in 1914.
On the other hand, there was no outspoken and effective messenger, either an individual or a group, disseminating the available data, nor is there reason to believe that the messenger would have been listened to or believed by enough people to make a difference. There were many other public health issues that suffered the same treatment locally and nationally. For one example, why did it take until 1915 for pasteurization of milk to become standard practice, 50 years after Pasteur’s discoveries, with clear evidence that unpasteurized milk could cause illness and death in children?
Once the hospital formally opened, new controversies emerged. Some criticisms seemed significant and legitimate while others seemed trivial. And discussions about the hospital weren’t always criticisms; there were also compliments and praise, along with objective reports, current events, and human-interest stories.
Throughout its history, the hospital seemed to be a projective psychological test that indicated ideology rather than personality. Many people at the time could only see infectious disease as a medical problem and somebody else’s medical problem, not as a public health problem and everybody’s problem. Even communicable illness was often considered an individual issue, not a community responsibility.
The overriding issue was often, but not always, economic. Who was responsible for the costs of caring for patients with infectious diseases? As has been mentioned in previous sections, medical expenses were the responsibility of the individual and family first, the local government second, the state government third, and rarely the federal government at all. Health insurance was in its very beginning stages and was not a factor in health policy. For contagious diseases, the cost burden shifted to the local government first with the individual or family responsible to pay if it was determined that they could afford it. The state did provide subsidies though they only covered a portion of the costs.
The economics of the hospital certainly included budgets issues, and the budget was a regular source of contentious debates. However, this is true for any municipal issue anywhere, so when I state that the overriding issue was economic it wasn’t just about budgets. The economic arguments were often existential – should the hospital even exist? Or should another level of government, i.e., county or state, be paying for it?
Another factor to consider is that, because of the nature of this type of hospital, there were many periods of time when the hospital was at less than full capacity. While the tuberculosis wards would not always be filled to capacity, these wards would always have patients. On the other hand, the contagious wards might at certain times be well under capacity or even empty. Vacancies could be seen a positive because it meant that contagious disease rates were down; however, this also meant that there would be costs even when there were no patients.
A matter that I keep returning to while writing this history is the fact that it was designed to be a hospital for tuberculosis and other contagious diseases. While the missions and goals of tuberculosis hospitals and hospitals for other contagious diseases are similar in some ways, there are also key differences. In retrospect, 100 years later, it seems like the institution would have been better understood and accepted if it had been characterized and presented as two hospitals sharing the same campus, administration, and some resources.
The facts the hospital had one name and that the three buildings for patients all looked like tuberculosis wards made it more difficult to talk about the whole hospital and its purposes and goals. Given the limited understandings of, and different treatment options for, the diseases that the hospital was dealing with, a clearer message that the hospital was responsible for a variety of different and complex issues might have been helpful. It was about a lot more than just isolation. The dual mission of the hospital was not the problem but, without clear messaging about the distinction, there was confusion or an over-simplification of the purpose.
Another distinction that I couldn’t find any local messaging about was mentioned in the Tenth Annual Report of the Trustees of Massachusetts Hospitals for Consumptives., dated November 30, 1916:
It is customary among health authorities and those interested in the suppression and control of tuberculosis all over this country to divide institutions for the treatment of this disease into two classes, “hospitals” and “sanatoria.” Tuberculosis hospitals are intended for patients in the far advanced and progressive stages of the disease, for emergency cases, for cases awaiting admission to a sanatorium, and for incorrigible consumptives. Such hospitals should be easily accessible to the friends and relatives of the inmates. The sanatoria, however, play a different part. The word “sanatorium,” coming from the Latin “sanare,” to heal, implies that active efforts are made in these institutions to cure or at least to arrest the disease. This can be done only for patients in the early and favorable stages of tuberculosis and for those who are willing to give their active co-operation. Although every sanatorium should be as accessible as possible, the outlook and general surroundings and morale of the institution are of far greater import. In accordance with this generally accepted policy regarding the distinction between tuberculosis hospitals and sanatoria, this Board of Trustees is making every effort to make the four institutions under its charge true sanatoria in every sense of the word, for the active treatment and arrest of early and favorable cases of pulmonary tuberculosis.
THE CLASS OF PATIENTS ADMITTED TO THE STATE SANATORIA.
The Rutland Sanatorium will be reserved as in the past for patients in the early and favorable stages of the disease. The Westfield Sanatorium is coming to be more and more an institution for children. The North Reading and Lakeville Sanatoria will continue to accept only those patients, not necessarily in the incipient stages of tuberculosis, but who at least are regarded as curable or capable of great improvement or ultimate arrest.
Tenth Annual Report of the Trustees of Massachusetts Hospitals for Consumptives (1916)
I did not find any information about admissions criteria to the Lowell Isolation Hospital, or of the different criteria used for the city “hospitals” versus the state “sanatoria.” If these different criteria were in place, it seems that they should have been part of the public discussion and messaging. It would have been a significant piece of information for those concerned with the institution and those who were comparing institutions with each other.
In the book Nightmare Scenario (2021), about the federal government’s response to COVID, a “senior administration official” was quoted as saying “What happens when you mix politics and public health? You get politics.” While the quote came 100 years after the decade being discussed here, it seems to sum up many of the issues and problems of the hospital’s beginnings.
So, what were the politics? The problems that occurred and reoccurred during the location battles continued in different forms. The lack of consistent laws and messages from the state made the hospital an easy target for anyone who wanted to criticize a city department or demonstrate fiscal accountability.
While public health measures were making progress and the Isolation Hospital was providing an important service, some saw the hospital as expendable with plenty of other options available to deal with patients with contagious diseases. There were other options, but none of them gained enough traction to shut down the hospital. The directives from the critics of the hospital often seemed to be telling the hospital administration to spend less money without asking what was needed, what was being tried, and what could be done differently and better.
Table 1 above lists the mayors of Lowell during this decade and the years of their terms. The other elected politicians, the members of the Board of Health, other city officials, and employees of the hospital all played a role in the functioning of the hospital and will be mentioned in this section. The Superintendent of the hospital was selected for the position by the Municipal Council in January 1919, well before the hospital was opened. The person chosen for the position was Dr. Forster H. Smith, a Lowell resident and a physician with a practice in Lowell.
To present the history of the hospital in its first years, I will present selected stories that give a sense of the challenges and problems encountered and the successes achieved under very difficult circumstances. We will be able to see the changes in medicine, society, and people’s attitudes and understanding of disease over the almost four and a half decades of the hospital’s existence.
Between the opening of the hospital on October 26, 1920 and January 1, 1921, there were 30 tuberculosis patients and 25 contagious patients. On January 1, 27 of the 30 tuberculosis patients were still in the hospital, two had died, and one had been discharged for an infraction of the rules. Of the 25 contagious cases, all except two were discharged well by January 1, and the two remaining were well and waiting for their release from quarantine.
The first annual report from the hospital superintendent to the Board of Health for the year 1921 was reported in the newspapers. Although there were line items about the hospital in the City Documents for that year, they did not contain the entire report. According to the report, the per capita cost per day that year was $4.74, or $71.28 in 2021 dollars.
During the year 1921, the first full year that the hospital was open, 81 more tuberculosis patients were admitted for a total of 108. The daily average was 32.27 and the largest number at any one time was 40. There were 16 deaths in the tuberculosis ward, and it was stated that “many have shown great improvement.”
The contagious ward was open for a total of 152 days in 1921. There were three deaths in the contagious ward; two from diphtheria and one from spinal meningitis. It was noted that these deaths occurred within five minutes, a half hour, and 24 hours of admission. The report states that the contagious ward should have been used more and its underutilization resulted in what appeared to be excessive per patient costs.
New financial issues emerged right away once the hospital was up and running. It was destined to be a lightning rod for scrutiny after the resistance to build it in the first place, the location battles, and the cost overruns. Added to this, the lingering prejudices and biases that blocked and delayed the building of the hospital remained in force. The state’s lack of clear messaging, leadership, and responsibility, in addition to the often-blurred boundaries between county government and state government, added to the mixture of criticisms, ambivalence, and indifference.
The issue of who pays for the patient care was unresolved at the hospital’s opening, which meant that ultimately it would be the taxpayers of the city. As we will see, the state did reimburse the city for some of the per patient cost, but there was confusion at first about how much and for whom these contributions would be. There would also be a requirement that patients who were considered able to contribute something towards the costs should do so. A few cities and towns also paid to have their own residents cared for at the hospital.
Other important public health issues were being discussed in Lowell during the earliest years of the hospital involving the hospital and the city as a whole. After a pamphlet was issued by the state on the control of communicable diseases, a Lowell Sun article on March 3, 1921 compared the periods of isolation required by the local health department and the state. Table 2 was created using the information in the Sun article.
As the first summer for the hospital approached, the mayor was granted authority to enter a contract to install copper window screens for a sum not to exceed $650 per shack ($9,770 in 2021 dollars). A Lowell Sun article on May 21, 1921 mentioned an emergency clause that was part of the vote that gave the mayor the authority to spend the money on the screens. The mayor explained that patients would be subjected to “considerable annoyance if the buildings were not screened,” and mentioned that there was some swampy land in the vicinity of the hospital where mosquitos breed. One of the few treatments for tuberculosis was fresh air, so windows were supposed to be kept open as much as possible. Although there were no known mosquito-borne diseases at that latitude at that time, it is difficult to imagine a summer anywhere in Massachusetts, not just in the vicinity of swampyland, with open windows and no screens. The idea that this was an afterthought and not part of the original plan seemed worthy of mention.
Two new interventions to deal with tuberculosis were considered in 1921. One was a marketed as a possible treatment and the other was purported to be a possible cure. A brief account of each of these provides examples of some of the thinking about a disease and the efforts made to defeat it.
Early in the hospital’s history, it was decided that there would be a three months’ trial of the Alpine Sun Lamp, which was a lamp that emitted ultraviolet (UV) rays. It has been stated above that the only known treatments for tuberculosis were sunlight, fresh air, and wholesome food, and the lamp was a way to deliver UV light to patients in a more controlled and comfortable way. While the lamp was not a cure as it was hoped to be, it might have had some positive effects with few or no negative ones.
While Vitamin D hadn’t yet been discovered at that point, the UV light from the lamp and the time spent in the Sun were increasing the Vitamin D level in patients, which is important for health and for fighting disease. UV light is currently used in medicine in carefully prescribed and controlled ways. Here we are seeing a result of the move away from traditional unquestioned and even quack remedies to a more scientific approach with trials and experimentation, though still without a thorough understanding of the underlying science.
An article in the June 18, 1921 edition of the Lowell Sun, announced that there would be a “TRIAL OF A NEW CURE FOR ‘T.B.’” at the Isolation Hospital. Lowell physician Dr. John Gatsoupolis had recently returned from a trip to Paris that was made to investigate treatments for tuberculosis that were being tried there. The “serum,” which was said to be manufactured under the supervision of the French government, was reported in the article, replete with superlatives, to have miraculous effects for serious cases of tuberculosis. A sub-headline stated that a “Young Girl Already Treated Said to Have Made Remarkable Recovery.” This was an unnamed girl in “one of the state sanatoriums” (unnamed) and had “startling results” with the patient “apparently cured.”
Dr. John M. Drury, tuberculosis specialist on the Lowell Board of Health, presented the information about the serum to Mayor Perry D. Thompson. The mayor granted permission to give it to 12 of the most seriously ill patients volunteers at the Isolation Hospital.
Days later, a June 21 Sun article announced “SMITH VETOES USE OF NEW T. B. SERUM.” Dr. Forster H. Smith reversed the decision of Mayor Thompson to administer the potential treatment “until the serum has had a more extensive test.” Dr. Smith quoted the opinion of Dr. John B. Hawes of Boston in explaining his decision.
So, what was the serum? It was in fact a vaccine, not a treatment or cure.
In 1905, French scientists Albert Calmette and Camille Guerin began working to develop a vaccine against tuberculosis. They found that small doses of the weakened animal bacillus could be used as a protective vaccine against tuberculosis in cattle and monkeys. They then found that successive culturing produced a series of weaker and weaker strains. By 1921, the tubercle bacillus had been successively cultured 230 times and was attenuated to the point that it was thought that it could produce immunity in humans without causing disease.
The BCG (abbreviation of Bacillus Calmette-Guerin) vaccine was first used in a human in 1921 when it was given to a child in Paris. The baby’s mother, who had tuberculosis, died just after the baby was born, and the baby was to be brought up by his grandmother who also had tuberculosis. The baby was given an oral dose of BCG, and was said to have developed into a healthy boy. During the next three years, 317 infants were also vaccinated.
The BCG vaccine has been used for almost a century and is still today the only vaccine available for tuberculosis. Though it is safe, its efficacy is variable and it is not universally administered. While BCG is used in countries with a high prevalence of tuberculosis to prevent childhood tuberculous meningitis and miliary disease, it is not recommended for use in the United States today because of the low risk of tuberculosis infection. The vaccine reduces the chance of infection by 20 percent, while the vaccine for measles reduces infection by 95 percent or more.
This brief and local case study exemplifies the trust in science that followed the Golden Age of Bacteriology and the adoption of germ theory. It demonstrates the optimism and sometimes overconfidence of physicians and the public during this period. It also shows the lack of regulation of medicine and how decisions were left to local authorities with no requirement for testing, clinical trials, and official approval.
The Second Annual Report of the Superintendent of the Lowell Isolation Hospital for the Year 1922 presented the net expenses of the hospital for the year and shows the sources of money used to meet those expenses. The expenditure for the hospital in 1922 was $58,453.05 ($936,333 in 2021 dollars). Of this total $43,453.38 ($696,269 in 2021), was for the tubercular ward and $14,904.67 ($238,814 in 2021) was for the contagious ward.
Of the $58,453.05, the amount of $8,528.79 was received from various sources bringing the city’s net cost to $49,829.26 ($798,435 in 2021). The various sources were tubercular patients ($627.50 in 1922 dollars), other cities and towns for the care of tuberculosis patients ($105.66 in 1922 dollars), the state for tuberculosis patients ($478.50 in 1922 dollars), and the state for tuberculosis patients for the previous year, 1921, ($6,997.82 in 1922 dollars). So, using these numbers for an idea of the state’s contribution, the state contributed about 12% of the cost of running the hospital. While not an unfunded mandate, it was certainly underfunded. The cost burden for constructing the hospital and running the hospital was clearly on the local government.
The per capita cost of the tubercular ward for the year 1922, as reported in the Second Annual Report, was $18.83 per week and the per capita cost of the entire hospital was $24.27 per week. The daily per capita cost for the tuberculosis ward was $2.69 and $3.47 for the entire hospital.
The February 6, 1922 Lowell Sun included a short article with the all-caps headline “CHARGES AGAINST SUPT. OF HOSPITAL.” The article stated that Walter C. Bruce who was formerly a clerk in the office of the city’s purchasing agent was going to appear before the Board of Health that afternoon to bring “charges of incivility” against the Superintendent of the hospital, Dr. Forster H. Smith. According to the article, Mr. Bruce said that his action was taken “as the result of treatment accorded a woman employe [this was the common spelling of the word at that time] of the hospital who was sick” and “he also alleges poor treatment of patients in one or two instances.” Mr. Bruce lived on Varnum Avenue near West Meadow Road, which is the road where the hospital was located.
An article about the hearing appeared in the next day’s Sun. The article states that a Mrs. Haley, who worked in the laundry room and boarded at Mr. Bruce’s house, was too ill to go to work one Wednesday and Mr. Bruce telephoned the hospital to get some “nourishment” sent to her. Mr. Bruce was quoted as saying that “I asked the doctor [Smith] what he intended to do about it and he replied that he was running the hospital and that it was none of my business what he intended to do.”
Speaking in rebuttal, Dr. Smith said that Mr. Bruce had for some reason concerned himself with the affairs of the hospital for more than a year past and that he had taken every opportunity to plant a seed of discontent among employes and patients.
He said that neither he nor Mrs. Smith [Dr. Smith’s wife and a nurse at the hospital] knew anything about Mrs. Haley’s illness until about 5:30 o’clock on Wednesday afternoon and that Mrs. Haley’s sister, who also worked at the hospital, had not mentioned it to him.
He characterized Mr. Bruce’s conversation over the telephone as “blustering” and admitted that he resented his method of interrogation.
“When Mrs. Haley’s sister came to me at 7:30 o’clock that evening I told her to go to the kitchen and get anything she wanted for Mrs. Haley and also gave her the privilege of so doing at any time,” said Dr. Smith.
Lowell Sun, February 7, 1922
The allegation of the “poor treatment of patients in one or two instances” mentioned in the earlier article was not mentioned at all in the article about the hearing. A brief article in the Sun on February 14, 1922 with the headline “SMITH EXONERATED BY HEALTH BOARD” also made no mention of the alleged poor treatment. The article did say that in the opinion of the Board of Health regarding the charge of incivility that “the evidence introduced was insufficient to allow for substantiation of the charge.”
Deep inside a Sun article with an unrelated headline there is a series of one-sentence paragraphs that say a lot about some of the local politicians’ perceptions of the hospital. The article in the March 11, 1922 paper was about a City Council meeting where a number of items werediscussed including the need for better fire alarms and apparatus. Concerning the Isolation Hospital were the following one-sentence paragraphs:
Dr. Smith explained the estimates of the Isolation hospital. Dr. Bagley asked if the hospital is full at present.
Dr. Smith said it was practically filled with 47 patients.
He explained the item of $1200 for a superintendent of nurses with Mrs. Smith in mind for the position.
Councilor Moriarty moved that $1200 be allowed for this place.
Councilor Stearns wondered whether or not the superintendent couldn’t get along without a stock clerk if $1200 is allowed for Mrs. Smith.
Tyler A. Stevens said that considering the number of patients the per capita cost is the highest for any hospital in the state.
Councilor Sadlier asked if all of the enployes of the hospital are voters of Lowell. Dr. Smith said he couldn’t say offhand.
Tyler Stevens said that the supply schedule had been cut because during the month of December last Dr. Smith had bought supplies of all kinds costing about $13,000 instead of turning it back into the general treasury.
No action was taken on the hospital appropriation in total as one or two of the councilors expressed a desire to go over the figures further.
Lowell Sun, March 11, 1922
The Lowell Sun in March contained a sad story of two families afflicted with Erysipelas. Erysipelas is a bacterial infection on tissue just below the skin's surface that is most often caused by streptococcal bacteria. The bacteria have to enter the body through broken skin, such as a cut, insect bite, or a scratch, so it is does reach the level of being an epidemic disease and it is not contagious like diseases that spread through the air. While today, erysipelas can be treated with antibiotics, in 1922 it was a potentially fatal disease.
ERYSIPELAS CASE AT ISOLATION HOSPITAL
Catherine Coffey, aged 35 years, a member of the Coffey and Shea families, three of which have succumbed to the dread disease of erysipelas Tuesday was taken to the Isolation hospital, with a very serious case of the same disease.
Dr. Forster H. Smith, hospital superintendent. said today that everything possible is being done for her: that special nurses have been provided and that today her condition showed a little improvement.
Miss Coffey is a sister of Jeremiah Coffey and Mrs. Michael Shea, both of whom died recently as the result of the disease and a sister-in-law of Michael Shea, motorman on the local street railway, whose death came shortly after that of his wife.
The circumstances surrounding the afflictions of the two families make one of the saddest cases within memory.
Lowell Sun, March 16, 1922
While tragic for these families, erysipelas was not typically as contagious as it seems to have been in these cases. It serves as an example of the unknowable and uncurable nature of many diseases at that time, the attempts to control and treat them, and the expectations placed on a hospital for contagious diseases.
Along with the challenges, there was always, it seems, a watchful eye or eyes to oversee the minutiae of running the hospital. While fiscal oversight is important, sometimes it seemed to be excessive and distracting. One example occurred in April, 1922 when the mayor’s office held up payments for food delivered to the hospital because the costs exceeded the prevailing market prices. It was reported in a Sun article on April 24 that the hospital paid too much for pie fillings, mince meat, and fresh pork. It seems, as reported on April 25, that through a clerical error the pork order should have read “fresh fowl.” Also, the pie fillings and mince meat, according to Dr. Smith, did not go to his hospital and “he knows nothing whatever about them."
The state, while with good intentions, put Lowell in a difficult position with mandates to build a contagious disease hospital. The Federal government, at the same time, left states in very difficult positions because collective, national, and centralized responses were what was needed, and were not made. Over time, while some Presidential administrations and Congresses learned from history, others failed to learn, and in the case of the COVID pandemic we were doomed to repeat it.
Lowell’s difficult position was in large part economic, but the state was also mandating care for individuals with a disease for which there was no cure and no treatments beyond palliative ones; fresh air, sunlight, good food, and rest. In addition, Lowell had to create the new institution from scratch, and the institution was created in an atmosphere of negativity with location battles, cost overruns, and delays.
Many of the criticisms focused on the attempts to provide the essentials of fresh air, sunlight, good food, and rest. The buildings or “shacks” were designed to maximize sunlight and fresh air for the patients, but this meant spreading out the buildings and constructing tunnels to connect them, which added to the cost. The food costs were a frequent target of criticisms, but good and plentiful foods were another of the only treatments available. While the rest treatment does not seem at first glance to involve immediate costs, having adequate staff, recreational activities, and comfortable beds and surroundings, important factors in a restful environment, all cost money as well. The last factor I want to mention is proximity to family and friends. Sending all of the patients to a state facility was often touted as a money saver; however, given the types of cases and admissions criteria mentioned in the 1916 state report above, was this even an option?
While the hospital went over budget from the beginning, any proposed budget had to predict the future demands that would be put on the hospital without knowing what those demands would be. Predicting the frequency and severity of contagious disease outbreaks in the 1920s was impossible.
Was there another reason for politicians and others to want the institution to not exist as a local contagious hospital for the residents of Lowell? In the 1920s, like now, contagious diseases outbreaks were seen as bad for business, which of course they were. That is why it is best to contain an outbreak as early and as effectively as possible. Denying or pretending a contagious disease doesn’t exist might work to slow economic problems in the very short term, but beyond that denial is neither good for the economy nor for humanity.
Having a local contagious hospital made it easy to tell if there was contagious disease in a locality, and the death notices in the newspapers complete with the cause of death were even more ominous. A state, county, or regional hospital was more anonymous and removed from a specific locality, creating some distance from any potential stigma and resulting loss of business and revenue. This was, in practice, the “not in my backyard” idea spread to a whole city. It seems that many of the nickel and diming attacks on the budget and criticisms of mismanagement might have been attacks on the existence of the local institution. Whatever the true motivations of the attacks were, they started early in the hospital’s history and continued throughout.
The year 1923 began with disagreements about appropriations. The health department asked for $66,019.52 for the year, which was about $7000 more than was spent in 1922. The budget and audit commission reduced the amount to $57, 000, and the mayor cut it to $53,202.90.
The per capita cost of the tubercular ward for the year 1923 was $23.80 per week and the per capita cost of the entire hospital was $29.54 per week. The daily per capita cost for the tuberculosis ward was $3.40 and $4.22 for the entire hospital.
Things heated up in August when some city departments submitted supplemental budgets to maintain services for the rest of the year. The Isolation Hospital requested an additional $8,000 for the rest of 1923. While the mayor allowed the additional amount, the Sun on August 7 reported that he commented that in his opinion the institution is “extravagantly managed.” The Sun also printed the letter from the mayor to the city council that covered a number of city departments where he wrote that
little heed has been given by the superintendent [of the isolation hospital] to reduce expense. I am not opposed to proper care being given to patients at the institution but a per capita cost of $24.37 weekly [about $390 in 2021 dollars] for each patient is excessive, and unfortunately the patients are not the primary cause for such excessive upkeep. [Note: the $24.37 figure was the per capita cost for the entire hospital, it was $18.83 for the tubercular ward.]
Moderation in the purchase of supplies for the administration building of the institution could easily be effected without lowering the standard of living enjoyed by the average American citizen in his home, and on his table. I have no hesitancy in saying that if I possessed executive power to make a change in the management of the Isolation hospital I would be inclined to do so. I am communicating with the board of health recommending a thorough investigation of the conduct and management of the Isolation hospital and to report their findings to this office within one month.
The Lowell Sun, August, 7, 1923
Between this pronouncement in August of 1923 and June of 1924, there were, from my available information, three investigations of the operation of the Isolation Hospital. The first was an investigation by the Board of Health that was recommended by the mayor, the second was an investigation by a local firm of public accountants as directed by the mayor, and the third was a special committee comprised of five city councilors. In my attempt to present the best possible historical record of these hearings, I will quote extensively and present some of the Lowell Sun articles in their entirety because they are the best and often the only primary sources of them.
The first investigation
The following article appeared in the September 12, 1923 Lowell Sun with a series of six descending headlines of different sizes and fonts from the frontpage full banner down to a column width. The article contained the full board of health’s report. Unfortunately, the online reproduction of the newspaper was difficult to read and this was the only copy of the report I found. While it was possible to guess at the words that were hard to read, this was not true with some of the numbers. I used a bracketed question mark if I was unsure of the number. I made my best guess and then tried to confirm them in the context of the other numbers presented here and in other sources.
Board of Health Vindicates Dr. Smith
Board of Health Reports to Mayor Isolation Hospital is Not Being Operated Extravagantly MAYOR TAKES BOARD TO TASK
Says Report “Too Good to Be True” and Brands it “Superficial" Says Investigation Was Conducted Along Lines of Least Resistance
Will Make Investigation on Own Hook and Promises Startling Disclosures
The report of the Board of Health upon conditions of management at the isolation hospital submitted to Mayor John J. Donovan yesterday and made public today, in which it is stated that in the board's opinion the institution is not extravagantly managed, that the general overhead expense is not excessive and that the no evidence has been found which would warrant drastic action, is caustically criticized by His Honor who brands it “superficial” and expresses disappointment at its lack of thoroughness and the apparent disposition of the board “to follow the line of least resistance.”
“The report at best indicates but a very superficial investigation,” the mayor declares, and adds that he will make a personal investigation at the earliest opportunity. “I feel satisfied,” he continues, “that I will be in a position to offer to the present or next year’s government recommendations relative to the contract and management of this institution that will bring about a much more economical and sound business policy in the conduct of the hospital.”
The report is the direct result of a written request for an investigation of the hospital sent to the board of health to the mayor on August 11, in which the chief executive expressed
the belief that the management of the institution was extravagant and that he was willing to back up the board and any drastic remedial action recommended.
The report seems to be a complete vindication of Dr. F. H. Smith, superintendent, although the mayor takes direct issue with the board in the tenor of the document. It states that the cost of operation compares most favorably with other similar institutions in the state and is far superior to many in its equipment and facilities for carrying on its work.
The complete report follows:
The Report in Full
Lowell September 10, 1923
Hon. John J. Donovan
Mayor Lowell Dear Sir:
In your communication of Aug. 11, 1923 to the board of health an investigation was requested to be made is in the conduct and management of the isolation hospital, it being alleged that the institution is extravagantly managed and that the administration part of the hospital and general overhead expenses are excessive this investigation has been made by the board of health, it being their wish at the start to set forth the position namely - that the conduct of the hospital, the purchasing of all material and supplies are functions over which they are directly responsible.
Having therefore in mind their interest in the outcome of such investigation they nevertheless pursued it earnestly and impartially and present you with the following report:
First. The Lowell Tuberculosis hospital and Contagious hospital comprises five units situated at some distance from one another - namely - administrative building, power plant and laundry, and three shacks. These separate units are connected with one another by some half-mile of tunnel. This scheme while ideal for the care of tubercular cases necessarily entails a higher cost of maintenance than that which would be experienced in a single unit institution.
There is no difference in the maintenance of the administrative unit of the institution and the other parts of the hospital. The help employed in the administration building have duties also in other parts of the hospital. The food consumed in the administration building is the same as, and for the most part, cooked in the same manner and place as that consumed by the other inmates. Twenty-nine employes are housed in this building, the services of three maids being required to care for their quarters.
The employes consist of the following:
One superintendent, one superintendent of nurses, one office clerk, nine nurses, one baker, one chef, one kitchen woman, two waitresses, three ward maids, three domestics, two orderlies, one laundryman, two assistant laundresses, one engineer, three firemen [these men tended the coal-fire boiler, they were not firemen (fire fighters) by today’s definition].
This number of employees is made necessary by the separation of the different units of the institution and by reason of the eight-hour labor law.
Requisitions for the purchasing of supplies are passed upon by the board. The checking system of materials received is adequate. Charts are kept, showing instantly the amount of money that has been paid for every article purchased however small in the last two years.
Entertainment has been furnished by the St. Vincent DePaul Society on six occasions; by the Broadway social club on one occasion. The total cost of maintenance therefore for the first seven months of this year amounted to $37,582.00. The average cost per day per individual is taking into consideration the total number of patients and employes housed and fed was $2.51.
This average cost has been compared with similar institutions in other localities, and tubercular hospitals have been visited in Lynn and Cambridge. Our hospital compares favorably in its cost of maintenance and is far superior to many in its equipment and facilities for carrying on its work.
It is to be noted that the average cost per patient per day of $4.27 is not strictly fair because it is based upon money expended for materials which have not been entirely used, but will last well into the year, so that the actual per capita cost is less than $4.27, but cannot be accurately figured until this year has expired. The per capita cost is founded upon the average number of 41.5 patients whereas if the institution were filled to capacity the average cost would be very materially reduced.
Fourth. The question at issue in this investigation as to whether or not the local tuberculosis hospital being managed extravagantly and whether or not the administrative part of the institution and general expenses excessive
Fifth. Upon the facts set forth in the above report it is the opinion of the board that the institution is not extravagantly managed; that the general overhead expense is not excessive and that no evidence has been found which would warrant any drastic action being taken.
Following is the mayor’s comment prepared and given out for publication with the report:
“I’ve read over the report very carefully. Everything is pictured as being such perfect order at the institution that is almost too good to be true. The report at best indicates but a very superficial investigation. I am disappointed at the lack of thoroughness and the apparent disposition of the board of health to follow the line of least resistance.”
“However, I am satisfied that there has been much extravagance at the institution. I will make a personal investigation at the earliest opportunity and feel satisfied that I will be in a position to offer to the present or next year's government recommendations relative to the conduct and management of the institution that will bring about a much more economical and sound business policy in the conduct of the hospital.”
Lowell Sun, September 12, 1923
So, that was the result of the first investigation. A vindication of hospital administration by the investigators, and a dismissal and rebuke of the investigators by the mayor who requested the investigation. The annual budget for the hospital was about 0.13% of the city’s budget for the year. The cost overruns for the building were still in memory, but these were not part of this criticism.
A few points that stand out in the report will be addressed here before moving on to the other investigations that would soon follow. It is interesting and telling that the report called the hospital “The Lowell Tuberculosis hospital and Contagious hospital.” The board seemed to want to emphasize the dual mission of the hospital, explain the expenses of having a dual mission, and offset any comparisons to institutions that were only sanitaria for tuberculosis.
Another consistent problem in the criticizing or explaining per patient or per capita costs at the hospital in this and other investigations is the lack of consistency in the figures and the formulas used. Some of these problems include: calculating per patient costs on the tuberculosis wards, the contagious wards, or the combined wards; factoring in the room and board costs of employees who lived and dined at the hospital; the underutilization of the hospital; the time of year that the calculations were made; the figures and formulas used to compare institutions; the level and quality of care and treatment used at institutions used for comparison; and whether money received from the state of other cities and towns is factored into the calculations.
The next investigation will be referred to as the second investigation or the mayor’s investigation. It seemed to have begun soon after the mayor’s rejection of the board of health’s findings, but I didn’t find any record of it until the mayor’s inaugural in the City Documents. The inaugural mentioned the report, but the report was not included in the City Documents and I have not found a copy of the report. The mayor’s discussion of the Isolation Hospital was two pages of a 12 - page address. The hospital took up 18% of the inaugural and 0.13% of the annual budget. I will use the two pages of the mayor’s inaugural as a substitute for the report, though many details of the report are alluded to but not mentioned. The following is that two–page section.
Early in the summer of last year, I requested the Board of Health to conduct an investigation of the conduct and management of the Isolation Hospital, a sub department under their control. A report was submitted to me which did not indicate much thoroughness in investigation. Rather it would seem the Board of Health was content to simply go through the formality of a visit to the hospital one day. No patient was apparently asked any questions about food or treatment. In fact, one patient attempted to volunteer information, but was not given an opportunity. All the figures used in the report were, it appears, prepared by the hospital staff, and accepted without verification. Subsequent investigation does not seem to bear out the contention of the Board of Health that the investigation was “pursued earnestly and impartially” on their part.
Not satisfied that a thorough and business-like investigation had been made by the Board of Health, I directed a local firm of certified public accountants to make an exhaustive and impartial investigation. The report submitted to me justified such action. Let me summarize a few important references to the report: No card system is in operation for the principle 'articles of food, such as milk, cream, meats, eggs, butter, etc., because they were not requisitioned; while minor articles such as sputum boxes and paper napkins, etc., are entered on a card system. It is passing strange that articles that run into the largest amounts are not kept track of, although minor ones are. From an examination of the report you will undoubtedly conclude there is no curtailment in the purchases of the finest table delicacies, although from affidavits of patients corned-beef and cabbage and stews is the regular hospital fare. If patients are not equal to the hospital fare, then they suffer for want of proper nourishment. It would seem from the report and affidavits filed by patients that regulation of diet depending upon a patient's physical condition is given little if any consideration.
At the time of investigation of the hospital, there were 37 patients and 32 employees. The employees almost equalled the number of patients. I have stated that the operation of the hospital is on an extravagant basis. This is not altogether due to personal management, but includes general conditions. The State Department of Public Health compiled figures as of 1921 showed per capita cost per day of our Isolation Hospital to be $6.21; while the Rutland State Sanitarium is but $2.47; the Haverhill Sanitarium $2.59 and the Lawrence Hospital $3.44. The per capita cost of our institution is by far the highest in the state. At the time of investigation the per capita cost was shown to be $4.79; while the Haverhill hospital for the year 1922 was $2.42 or about one-half of the cost in Lowell.
I would recommend that an ordinance be drafted making the Isolation Hospital a separate and distinct department, with the head of the institution answerable to the Mayor and city council for its conduct and management. I would suggest that the city council consider the feasibility of a change in management with a matron in charge and a hospital staff of visiting physicians. I would have you consider the advisability of negotiating with the county commissioners for the purpose of taking over in whole or in part at least the hospital as a county institution. Under the provisions of Chapter 111, section 28 of the General Laws, County Commissioners are required before September 1, 1925, to provide such kind of hospital care. I do not believe Middlesex County Commissioners have as yet complied with this law. It would seem that some arrangements could be made to lessen the present expense to the city. With only an average of 37 patients, the hospital appropriation for last year amounted to $61,403.21. This is out of all reasonable proportion.
In view of existing circumstances I will make no comment as to the competency of the present head of the institution. I would prefer that you analyze the report of investigation, together with the affidavits from nurses and patients and draw your own conclusions. Something must be done, and done immediately. The report is herewith submitted for your consideration.
Lowell City Documents, January 7, 1924
Dr. Smith’s third annual report of the Isolation Hospital was included in the same set of City Documents as the mayor’s inaugural:
REPORT OF THE SUPERINTENDENT OF
THE LOWELL ISOLATION HOSPITAL FOR THE YEAR 1923
To the Board of Health, of the City of Lowell Gentlemen:
I have the honor of submitting to you the third annual report of the Lowell Isolation Hospital for the year ending Dec. 31, 1923.
On Jan. 1st, 1923 there were in the hospital 36 tubercular patients and 5 contagious patients, a total of 41. There have been admitted 34 males and 34 females in the tubercular ward and 67 patients in the contagious ward. These figures show that we have treated 104 tubercular cases and 72 contagious cases. On Dec. 31, 1923 there were 38 patients in the hospital; 19 males and 16 females in the tubercular ward and 1 case of infantile paralysis, 1 of scarlet fever and 1 of erysipelas in the contagious ward.
The lowest number of patients during the year was 33 and the highest number of patients was 52. The daily average in the tubercular ward was 35.2 and the daily average in the contagion ward was 4.4 a daily average in both departments 39.6, or 6.5 less than last year. The total number of hospital days was 14468 for the year.
'There were 69 patients discharged from the tubercular ward; 1 quiescent, 5 apparently arrested, 21 improved, 18 unimproved and 24 died. The average duration of residence in the hospital was 123.5 days.
The contagious ward has been open every day but one during the entire year and 67 cases have been admitted during the year; 15 cases of diphtheria 6 of erysipelas, 24 of scarlet fever, 10 of measles, 8 of infantile, 2 of whooping cough, 1 of spinal meningitis, and 1 of tubercular meningitis. Of these, 57 were discharged entirely recovered. Two measles cases died, one within the first 24 hours; 2 diphtheria cases died, one a few hours after entrance; 1 scarlet fever case died; 1 spinal meningitis case died within the first 24 hours; 1 infantile case died; and 1 tubercular meningitis case died. Three patients were still in the contagious ward Jan. 1, 1924.
The total expenditures for the year ending Dec. 31, 1923 were $61,038.93. These expenditures were divided as follows: $43,745.32 for the tubercular ward and $17,293.61 for the contagious ward.
The per capita cost of the tubercular ward for the year 1923 was $23.80 per week and the per capita cost of the entire hospital was $29.54 per week.
The per capita case has been somewhat higher than that of the previous year. This is accounted for by two facts. In the first place, the daily average of patients has been somewhat lower than for the year 1922; and secondly, it has been necessary to spend considerably more for coal. The fact must be borne in mind that a very large part of the expenses for the year is consumed in overhead charges and that it would be possible to take care of a much larger daily average of patients without increasing very much the total amount spent. With a larger daily average of patients, the per capita cost would naturally be brought down to a much lower figure.
I recommend that everything possible be done to induce the many cases of consumption now sick throughout the city to avail themselves of one of the best hospitals in the state. By so doing we shall be able to show a very much lower per capita cost.
However, to offset these expenditures it must be remembered that the City Treasurer has received the sum of $13,963.98 from various sources for the care of patients at this hospital, which sum considerably lowers the actual cost to the city and brings down the net per capita cost to $22.75 per week. It must also be remembered that the contagious hospital is an entirely separate unit, and so long as it is occupied by even one patient it is necessary to maintain an extra list of employees. This fact, of course, makes the cost much greater than would be entailed by the tubercular hospital alone.
[The remainder of the report is presented in Figure 5 below.]
Figure 5: From the Report of The Superintendent of The Lowell Isolation Hospital for The Year 1923
The third investigation was carried out by a special committee composed of five City Councilors; John W. Daly, Joseph A. N. Chretien, Eugene A. Fitzgerald, John J. McFadden, and Frank K. Stearns. A special appropriation of $1000 was approved for the investigation. The first meeting of the special committee was on February 12, 1924 at 7:30 p.m. in the mayor’s reception room at Lowell City Hall. John W. Daly was made chairman of the committee.
This investigation consisted of a series of hearings and visits to the Isolation Hospital and other tuberculosis hospitals in other towns. The hearings included the testimony from witnesses questioned by committee members as well as written affidavits and other documents. Here, as with the other investigations above, I presented some of the Lowell Sun articles in their entirety because they include a lot of important details as well as some verbatim accounts of the testimony.
The first hearing was held on March 31 and was reported in detail in the Lowell Sun the next day:
After the NIMBY battles, the struggle against the ledge under Varnum Ave., and the political foot-dragging to evade the state law, the Isolation Hospital was finally opened and patients were admitted. In the hospital’s first years, the institution unwittingly became the target of a new series of conflicts, this time in the form of “probes.”
It is easy to explain these probes with the catch-all term of “politics,” meaning political self- interest and narrow political aims rather than wider economic and social benefits, but we will never know the reasoning and motivation behind the mayor’s actions. While his criticisms seemed to be out-of-proportion to the allegations of mismanagement and extravagance (“e.g., the purchases of the finest table delicacies”), maybe there were abuses that deserved attention and scrutiny.
Looking at this a century later, four problems stand out that made the hospital open to attacks in its early years. First, there was a lack of advocates for the hospital in the local government and the community. Second, there was a lack of good public relations that could have explained the missions (plural) of the hospital and the needs for it. Third, there was a lack of consistent laws and clear messaging from the state government. And fourth, there was a lack of consistent calculations of costs and explanations of why costs were what they were. Also in hindsight, there were some actions that might have averted some of the probes and attacks.
Similar to the location problems and the reasons for them mentioned in Part 11 of this series, there remained a lack of political will and leadership to guide and support the hospital in its early years. Also, like with the location problems, there was no individual or group of advocates or champions for the cause either within the local government or in the general public. In contrast, as mentioned above, when a delegation from Lowell visited the hospital in Lynn, a committee from the Rotary, Lions, Kiwanis, other clubs, the Chamber of Commerce, and a delegation of local newspapermen was on hand to greet the committee.
This is not to blame the residents of Lowell at the time who did not hold political office. They certainly had enough to deal with, and they were paying the bills through local taxes. The Health Department report presented above mentioned St. Vincent DePaul Society and the Broadway social club visited the hospital to entertain the patients, so some community involvement was beginning. We will see later on that over time community organizations did become involved in important ways.
The hospital was created to care for people with tuberculosis and other contagious diseases, it was not solely a sanatorium. Good public relations could have emphasized the dual mission of the hospital, explain the expenses of having a dual mission, and offset any comparisons to institutions that were only sanitaria for tuberculosis.
One of the reasons, but not the only reason, that it took so long to locate and build Lowell’s Isolation Hospital was the lack of consistent laws and clear messaging from the state government. This lack of consistency and clarity continued after the hospital was opened and negatively affected the perception of the hospital by politicians and the community. This problem would continue to affect the hospital in future years as we will see in future parts of the series.
A large part of the mixed messaging came down to the role of county government in Massachusetts at that time. In 1921, the Essex County Tuberculosis Sanatorium. opened in Middleton, Massachusetts. The Essex County Tuberculosis Sanatorium was filled to its 350-patient capacity in its first year of operation. Essex County was the neighboring county to Middlesex County where Lowell was located, and the idea of a county takeover of the Lowell hospital was captivating to some Lowell politicians throughout the life of the hospital. The Middlesex County Tuberculosis Sanatorium in Waltham, MA opened ten years later in 1931.
Figure 6 - Map of Middlesex and Essex Counties. The red circle indicates the location of Lowell, the blue dot indicates Middleton, and the blue rectangle indicates Waltham. Salem was the County Seat of Essex County and Cambridge was the County Seat of Middlesex County (indicated by black dots)
Though a recurring issue over the years and decades, it is difficult to see the speculative takeover of the isolation hospital by the county as any more than wishful thinking or a red herring. This statement of course benefits from the knowledge that the takeover never happened. However, there were reasons why the takeover wouldn’t have taken place in the 1920s. One was that the Lowell hospital not a sanatorium and it was a both a contagious disease hospital and a tuberculosis hospital.
Also, many more buildings would have to have been built. As seen in Figure 6, Lowell was in one corner of a large sprawling county, distant from the county seat. This was at a time when travel of even short and moderate distances was difficult and challenging. When a county sanitorium for Middlesex County was opened in Waltham in 1931, it was much more centrally located as seen on the map in Figure 6. Even with the county sanatorium, the Lowell Isolation Hospital would continue in operation for over three decades, when the state ultimately took over responsibility for tuberculosis cases.
The final problem that will be addressed in this conclusion is the lack of consistency in the figures and the formulas used to address per capita costs of treatment. The different formulas to determine cost used at different times for the same hospital and to compare different hospitals with each other were not based on any consistent formula. There were also numbers tossed out with no context for how they were derived.
While some growing pains are always expected for a new institution, especially one without a lot of precedents, the Isolation Hospital seemed to attract an inordinate amount of criticism and scrutiny. Meanwhile, the fight against contagious diseases continued with increasing understanding, a lot of diligent efforts, but no cures.