Chapter 18: Neeley and Francie have been making mud pies, and they arrive at a clinic to be vaccinated against smallpox looking very dirty. The doctor, who has been forced to do community medicine in a free clinic, sees the dirt on Francie and begins disparaging the poor, whom he calls filthy and not even capable of using soap and water. Francie is deeply ashamed and hurt by the comments. When her vaccination is finished, she tells the doctor that he does not need to repeat his comments for her little brother.
After the vaccination, Francie's arm becomes infected. Katie has told the children that if they scratch the injection site that the wound will become infected and their arms might turn black and fall off. Francie lies awake at night, afraid that she is going to die. When Johnny comes home, he cleans the wound and re-bandages it, soothing Francie, whose arm is much better in the morning.
Chapter 19: Although Francie had been looking forward to school, she realizes right away that she will never be the teacher's pet. The teacher likes only the rich children, who arrive in fancy clothing. The poor children, with their threadbare clothing, are forced to sit in the back of the classroom. The bullies rule the recesses and do not allow the poor children to use the bathrooms. Likewise, the teachers will not allow the poor children to use the bathrooms except at recess. Half of the children learn to hold their urine, while the other half wet their pants. One day, Sissy arrives as school is letting out and takes Francie for a soda. Francie is deeply ashamed that she has wet her pants and knows that her mother will scold her. The next morning, Sissy goes to Francie's teacher. Sissy threatens and intimidates the teacher, who does not believe all that Sissy says, but in the future she allows Francie to use the bathroom.
Chapter 20: Many children at school have lice. Children with lice are unmercifully teased, and their parents feel great shame. When Katie learns of the lice epidemic, she scrubs Francie's head with the harsh soap that she uses to clean the floors, and then combs kerosene through Francie's hair. Francie smells of kerosene, which also causes the classroom at her school to smell. Katie rejects the teacher's pleas not to use kerosene on Francie and continues the same regimen. Francie never gets lice in her hair. In the same way, Katie combats the mumps epidemic by tying garlic around the children's necks. Once again the children do not get sick. The kerosene and garlic further isolate Francie, however, who still has no friends.
The doctor's cruelty when Francie goes for her vaccination is one more example of how easy it is for those who have privilege to mistreat the poor. The doctor is not accustomed to treating the poor and plans on going into private practice in Boston when he completes his training. He has no connection to the poor and no interest in helping them. The nurse and the school teachers, however, are from the community. They have been poor, but teaching and nursing are two ways in which the poor can escape poverty. At that time in history, neither job required the kind of education that was required by the end of the twentieth century. Most nurses at inner-city clinics are on-the-job practical nurses, and many teachers have completed only the eighth grade. Although the women in these professions are only just a step away from the poverty of Williamsburg, they have forgotten their origins and the compassion that they should feel for those who have not escaped.
The story of the vaccinations and the fear they evoke in the poor immigrant community is a reminder that everything that immigrants encounter once they arrive in the United States is new to them and is often quite frightening. They cherish their children's health. Most came from countries and small villages with high mortality rates, where their children's good health was not taken for granted. Now they are being asked to surrender their healthy children for a vaccination that will give them what they have fled across the ocean to escape. Vaccinations make no sense to the new immigrant population, who instinctively fear what they do not understand.
The school symbolizes a larger problem for the immigrant community. The flood of immigrants into some areas of New York City has put a strain on all public and social services. Children attend neighborhood schools, but when tenements and apartment buildings are crowded with families and many children, neighborhood schools become crowded, as well. Francie's school has three times the number of students it was designed to hold. There are few bathrooms, but they must accommodate these extra children. The poverty in the area makes poor children behave cruelly to one another. Some children become bullies, who then bully their classmates by not allowing them to use the bathrooms.
In contrast to the cruel teachers and children Francie encounters at school, her Aunt Sissy's reappearance in her life brings some relief for Francie. Katie has apparently not delved into Francie's problems at school. There is a reason why Francie is wetting her pants, but Katie works hard and is undoubtedly so focused on the survival of the family that she is oblivious to the torture Francie is enduring every day. Sissy, whose mothering instincts are very good, is able to quickly assess the situation and act upon it. Sissy's wonderful mothering is contrasted, however, with the news that she has lost yet another baby. Sissy may be injudicious in her sexual choices, but there is never any doubt what a wonderful mother she would make, if only she can be given the opportunity. Sissy serves as a good contrast to Katie. Although much of Katie's energy goes toward supporting the family her husband fails to support, it is worth remembering that Neeley is her favorite child. Francie needs an advocate, and her Aunt Sissy is always on her side. Johnny's rejection of Katie's sexual advances after the vaccination signal his anger that Francie has not been given Katie's support.