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Maria Smilios, The Black Angels – The Untold Story of the Nurses Who Helped Cure Tuberculosis.  New York, G P Putnam’s Sons, 2024, 428 pp., $30.  ISBN 978-0593544921

Reviewer:  Richard Marfuggi, MD, DMH

June 19, 2024

The Black Angels – The Untold Story of the Nurses Who Helped Cure Tuberculosis, by Maria Smilios (who holds a Master of Arts in religion and literature from Boston University, where she was a Henry Luce Scholar and a Presidential Scholar), is a powerful, meticulously researched, historical account that unsparingly examines one of medicine’s great challenges under conditions redolent with the stenches of poverty, injustice, misogyny, and bigotry. The work, detailing the devastation wrought by “the Great White Plague, the robber of youth, and the Captain of the Men of Death,” spans the Great Depression through World War II and beyond to shine a light on the unsung heroism of Black nurses who played a vital role in the fight against tuberculosis.

The construction of the mise en scene for The Black Angels began well before the book’s first pages. Robert Koch and Friedrich Loeffler’s four postulates of 1884* changed the world of medicine and, more specifically, the fields of bacteriology and infectious diseases. The new thinking impacted both the public and the professional perceptions of tuberculosis.

In Latin, the disease was “tabes” (emaciation) while, in Hebrew, it was “schachepheth” (a wasting disease - Leviticus 26:16 and Deuteronomy 28:22). In Greek, the term was “phthisic.”

A “phthisic beauty” was a description that romanticized the disease because consumption, also know as the “white death,” was associated with beauty (striking the young in the bloom of life) and creativity, given the pedigree of its victims. A brief list of those laid low by the bacillus includes John Keats, Robert Burns, Frédéric Bartholdi, Frédéric Chopin, D H Lawrence, Emily Brontë, Jacques Offenbach and Aubrey Beardsley.

The initially fashionable, and even sexy, beauty of pale skin (anemia) with rosy, pink cheeks (fever) became embodied in the courtesan Violetta Valery (1853). The four postulates helped change that perception and Mimi, a poor seamstress (1895), became a more accurate personification of the tuberculosis patient living in squalor.

In the late 18th and early 19th centuries, New York City health authorities established multiple venues to “protect” its residents by isolating the sick, the criminally insane, the destitute, and other social misfits, from the general population. The remote, albeit inhabited, Staten Island joined the uninhabited Blackwell’s Island, Wards Island and North Brother Island in providing locations for the primarily charity institutions such as the Bethlehem Orphan and Half Orphan Asylum, the Blind Asylum, the Hospital for Incurables, the Smallpox Hospital, and the House of Refuge for juvenile delinquents.

New York City planned and built Sea View Hospital between 1905 and 1938. It was, in its time, the largest and most costly municipal facility in the United States designated for the treatment of tuberculosis. A disproportionate number of Sea View’s patients were immigrants who came from tenements akin to those described by Dickens.

Sea View was a medical citadel in an integrated but nonetheless bigoted New York City. Throughout the book, each act of kindness, each act of heroism, and each act of discovery takes place against the backdrop of resistance, tacit or explicit, to desegregation. A Black nurse may have been able to sit in any public transportation seat on her way to hospital, but she would have been unable to escape the looks from her white counterparts and fellow citizens unwilling to acquiesce to that reality.

In the early days of its existence, white nurses were in the majority at Sea View. They were unmistakable in their heavily starched caps and pristine uniforms. They constituted an elite sorority grounded in the strict traditions established by Florence Nightingale. There was no toleration of deviation from even the most minor of prescribed regulations. (One telling example was the requirement for two minutes of hand washing before each patient contact and two minutes of hand washing after each patient contact to reduce cross contamination.) A second infraction was grounds for dismissal.

For over thirty years the Sea View campus grew, yet the expanded capacity never was adequate to accommodate patient need. With increased capacity came the commensurate need for more nurses. The nursing staff increased without significant interruption until something changed. Smilios writes, “No one knew exactly how it started or who set it in motion, but in the spring of 1929, suddenly, inexorably, the white nurses at Sea View Hospital began quitting.” 

While the nursing exodus was undeniable, the reasons for their departures were less well defined. Caring for tubercular patients was exhausting. Shifts were long. The commute from Manhattan was long and, at times, arduous. It is likely that one of the most dominant, albeit less expressed, reasons was fear of contracting the disease. By one account, as tuberculosis spread throughout the city, one in seven died.

To fill the nursing void, administrators followed the example of other industries and advertised in southern states for nurses, promising jobs, education, and good salaries in the “free” North. This was the era of Jim Crow; to escape those restrictions, young Black women answered, “the call.” Those who left family and friends received their education at the Harlem Hospital School of Nursing. Once trained, Black nurses received $720 a year, compared to their white peers who received $1,100 per year.

Smilios beautifully details the personal stories of the Black women, as exemplified by Edna Sutton, who recounts her experiences dealing with grueling 12-hour shifts, staffing shortages, racism within the medical establishment, and the constant risks of contracting the very disease they were treating. (While there are no exact numbers, most nurses had positive reactions to the Mantoux test and an estimated 5-12% went on to develop tuberculosis.) Eventually, Black nurses dominated Sea View’s nursing staff. Once that happened, Sea View became one of four municipal hospitals that did not discriminate against, or have quotas for limiting, the number of Black nurses.

One of the major contributions of Florence Nightingale was her emphasis on detailed record-keeping. The data thus collected proved invaluable for the researchers who conducted the clinical trials leading, eventually, to more effective treatments for tuberculosis.

For those interested in the often-tedious processes of medical research, Smilios provides detailed accounts of the drug developments that saved countless lives. For this reviewer, the most informative, interesting, and personal details that make this book so unique and valuable came from a series of interviews with the last known surviving Black Angel, Virginia Allen. The reader learns that she, along with the other “Angels,” provided not only compassionate care under ineffably taxing conditions, but also helped ensure the success of the clinical trials that led to the discovery of effective tuberculosis drugs. According to Ms. Allen, the Black nurses themselves risked their lives as “guinea pigs,” testing experimental, and sometimes deadly, tuberculosis drug candidates on themselves.

Until now, only white male physicians received credit for all those contributions. Through her meticulous research—a process that consumed more than a decade—Smilios goes a long way in righting this wrong.

The Black Angels did more than revolutionize patient care at Sea View; they also, by their presence and sheer numbers, played an unrecognized role in desegregating New York City’s hospital system. Prior to their arrival, most hospitals refused to hire Black nurses. Through their successes at Sea View, Black nurses demonstrated that they were as capable and as knowledgeable as their white counterparts. This alone helped counter prejudice and made a case for the desegregation of New York City’s other hospitals.

Though it may not have been their primary intent, the Angels exerted political influence, working closely with the National Association of Colored Graduate Nurses (NACGN) to fight discrimination against Black nurses. Another one of the Black Angels, Kate Gillespie, leveraged the mayor’s need for Black votes to pressure the city into hiring more Black nurses at municipal hospitals. In 1944, Eleanor Roosevelt joined with the leader of the NACGN to successfully lobby the U.S. military to eliminate discriminatory quotas for hiring Black nurses.

The Black Angels is a history of epic proportions, taking the reader on a journey of discovery that defies simple categorization. It is at once a tour through the laboratories of medical history and, simultaneously, a very personalized account of the lives risked in the endeavor to rid the world of one of its most deadly scourges. 

*The Koch-Loeffler postulates state:  (1) The microorganism must be found in diseased but not healthy individuals; (2) The microorganism must be cultured from the diseased individual; (3) Inoculation of a healthy individual with the cultured microorganism must recapitulate the disease; and (4) The microorganism must be re-isolated from the inoculated, diseased individual and matched to the original organism. 

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