By Anne Garner, Curator, Rare Books and Manuscripts
It’s 1863. New York’s streets are dismal. Downtown, the scents of manure, garbage and chemicals permeate the air. The streets are littered with debris, and in some places, are navigable only by wading through standing water. The gaps between cobblestones catch sewage and other dirt discharged from nearby tenements.
Public health statisticians estimate that New York has upwards of 200,000 cases of preventable and needless sickness every year. The Board of Health, controlled by corrupt politicians, is ineffective. In newspapers like Frank Leslie’s Illustrated News and Harper’s Weekly, the condition of New York’s thoroughfares is a punchline. Editorials, cartoons and newspaper stories blame immigrant populations, the poor, and an indifferent municipal government. 
What to do? In December of that same year, a group of citizens met with Mayor Gunther, the recently elected reform candidate to consider the city’s social problems. The following year, these concerned citizens formed the Citizens’ Association of New York, dedicated to a cause they describe in simple terms: “public usefulness.”  The organization quickly determined that physicians should play a prominent role in sanitary reform, and organized the Association’s Special Council of Hygiene and Public Health. 
In May of 1864, the Council embarked on a street-by-street sanitary inspection of New York City. Medical inspectors – all physicians—were assigned to 31 districts throughout the city in an attempt to gather detailed information about New Yorkers and their living conditions. For seven months, the inspectors visited every household in Manhattan and used a nine-page survey as their guide. 
During the course of the survey, the inspectors filled seventeen volumes of observations and notes comprising the most “precise and exacting account of a city’s health and social conditions ever compiled.” Many of these notebooks, including some remarkable hand-drawn maps, are available at The New-York Historical Society. The image below is taken from the Society’s archives and shows a tenant house for 200 people at 311 Monroe Street, in the 9th District. 
This survey, presented by medical inspector William Hunter to former New York Academy of Medicine President Joseph M. Smith, records the living conditions of a family of three recent Irish immigrants living in a three-story tenement on W. 14th Street in late October of 1864. The unit was comprised of David, age 30, described in the survey as an “intelligent but uneducated” gardener, Ellen, age 28, and Margaret, age 6. The survey suggests that all three family members had typhoid fever, likely contracted on their journey to America from Ireland just a few months before. Though the family’s living conditions were described as “good,” Hunter notes that the six families in their apartment were living in close quarters in just six rooms, with only two windows as a source of light and ventilation, and in such proximity to the horse stable that the horse could freely wander into their hallway. 
Surveys of this depth and length were kept for every household throughout the city’s 31 wards. Wards were frequently assigned to physicians who knew the neighborhoods and the residents. Most of the residents were given a thorough medical exam, and the nuisances of their environment were recorded in detail.  Each ward’s physician contributed a district report, summarizing their findings. Ezra Pulling, who was the sanitary inspector for the fourth ward, contributed a report on his district and his data was poured into the making of this extraordinary map, published along with the report in 1865.
The long, rectangular building that you see here at the center of this detail is a tenant house called Gotham Court. The stars here indicate that outbreaks of typhus and smallpox have occurred in the house. Privies in the basement were discharged into subterranean drains or sewers that run through each alley and then outside through grated openings, blocking much of the waste. Inside, each individual has an average of 275 cubic feet. If these dimensions are difficult to picture, imagine a closet 5 feet square and 11 feet high, allotted per person, for their body and for everything they own as well. Nineteen children were recorded as unvaccinated for smallpox (the only vaccine available at this time) here, and it was also noted that clothes were being manufactured in the building as well—clothes that were exposed to cases of typhus and measles. 
In another section of the map, we see a number of tenant houses north of the Bowery surrounded by stables, with a brewery and a coal yard at the east. Less than 30 percent of the privies in this district are connected with drains and sewers, and at least ten of these, as marked on the map by black squares, are in extremely offensive condition. A number of these are indicated on the map below.
The impact of the publication of the Citizens’ Association report and the map itself was mixed. The report led to higher sanitation standards throughout the city, and forced the attention of government officials, who passed a law to create the Board of Health. Under this law, at least three of the Board’s nine commissioners needed to be physicians. Though the Council went to great lengths to visually and verbally document the city’s housing conditions, the Council didn’t investigate wage equity or the frequency and rate of unemployment. Historian Elizabeth Blackmar has argued that “the surveys fueled the movement for developing building codes and sanitary inspection as a means of guaranteeing better housing, but they also erased from discussion reflection on the larger economic relations that produced them.”  In some cases, the report’s writers unfairly drew a line of causation directly from better living conditions to economic security, implying that given the right housing, the poor could flourish, independent of employment opportunities, fare wages, and access to healthcare.
In spite of its shortcomings, the report offered keen observations about the city’s conditions, and was instrumental in inspiring great reform in the city. Today, IMAGE NYC, a project launched by the Academy with the CUNY Mapping Service at the Center for Urban Research / CUNY Graduate Center earlier this year, embraces the methodology the Citizens’ Association deployed over 150 years ago, and largely for the same reason: to better understand the social determinants of health. The site has an interactive map of New York City’s current and projected population, 65 and older. Much like the Citizens’ Association map, the idea is to determine environmental risks and benefits to certain populations. Here, instead of physicians canvassing the neighborhoods to note conditions, community members can use the 311 app to take pictures and send them to the city.
The Fourth Ward Map, published as part of the 1865 Report of the Council of Hygiene and Public Health, as well as the 1864 survey form documenting the household of the Irish immigrants living on 14th street, are on view in Germ City: Microbes and the Metropolis, until this Sunday, April 28th.
 Bert Hansen. “The Image and Advocacy of Public Health in American Caricature and Cartoons from 1860 to 1900.” American Journal of Public Health. Nov. 1997, v. 87, no. 11.
 Report of the Council of Hygiene and Public Health of the Citizens’ Association of New York. New York: Appleton, 1865, P. vii.
 John Duffy. A History of Public Health in New York City 1625-1866. New York: Russell Sage, 1968. Pp. 553-556.
 Report of the Council of Hygiene and Public Health of the Citizens’ Association of New York. New York: Appleton, 1865.
 Citizens’ Association of New York: Council of Hygiene and Public Health. Report of pestilential diseases and insalubrious quarters. New York: n.p., 1864.
 Duffy, p. 556.
 Report of the Council of Hygiene and Public Health…1865. P. 49-54.
 Duffy, 557.
 Elizabeth Blackmar. “Accountability for Public Health: Regulating the Housing Market in Nineteenth-Century New York City.” In Hives of Sickness, edited by David Rosner. Rutgers University Press, 1995. Pp. 42-64.