Polio
The third and final case study presented in this chapter deals with the serious epidemic of poliomyelitis, or infantile paralysis, which erupted among inhabitants of New York City in the year 1916. The disease had been rare before 1907, although minor episodes occurred in Austria (1898) and Scandinavia (Norway and Sweden, 1904). In Rutland, Vermont, an outbreak of polio was reported in 1894 which took the lives of 132 people before striking New York in 1907 and killing an estimated 2,500 persons. After 1907 polio epidemics became increasingly more frequent. Between 1910 and 1914 alone about five thousand deaths and thirty thousand cases were reported in the United States.[71]
As in previous instances, human actions contributed decisively to the creation of a favorable ecological setting for poliomyelitis. Ironically, the culprits were improved public sanitation and personal hygiene, slowly achieved after decades of cholera and typhoid fever. Such relative cleanliness presumably reduced the transmission of wild and ubiquitous polioviruses that had hitherto routinely infected most infants and young children without producing paralytic complications. As a consequence, these groups became increasingly unprotected and susceptible to the crippling form of disease. In fact, many children became polio victims soon after being weaned and thus deprived of maternal immunity.[72]
Ever since poliomyelitis had become a reportable disease in 1910,
public health authorities everywhere carefully monitored its appearance. This was especially true during the summer months, when polio was known to strike. Authorities in New York were especially on alert because the city had already suffered two serious epidemics of the disease in 1907 and 1910. The new administration of Mayor John P. Mitchell was proud of its Health Department. This unit was composed of competent professionals and led by Haven Emerson, a former medical practitioner who had treated the last cases of cholera. Successful campaigns against unsanitary boarding rooms, subway and streetcar crowding, as well as trade in patent medicines had bolstered the department's morale. In the eyes of its officials, a declining infant mortality rate testified to the city's sanitary standing. Its combined population from all five boroughs was estimated at 5,570,000.[73]
All but forgotten in the midst of an election year, the war in Europe, and a Mexican-American crisis prompted by Pancho Villa's raid, the first cases of polio in New York were reported on June 6. All of the sick children came from a densely populated section of Brooklyn near the waterfront, primarily populated by Italians. Visiting nurses making a house-to-house search soon discovered another twenty-two victims of the disease, some ill for several weeks but not severely enough to demand medical attention.[74]
There was no denying it. Polio had returned to New York. In the following days 327 new cases were disclosed in Brooklyn alone, with a mortality rate of about 20 percent. Before it was all over in November, New York City reported a total of 8,927 true cases of polio and 2,343 deaths, with the two less-populous boroughs, Richmond and Queens, actually showing the highest case rates. Nearly half of the victims—4,500, were seen in or admitted to the city's hospitals. Nationwide, the poliomyelitis epidemic of 1916 affected 27,000 people in 26 states and caused about 6,000 deaths.[75]
One of the first tasks of the New York Health Department was to ascertain the dimensions and geographic contours of the new epidemic, a coordinated process based on numerous field reports provided by an army of inspectors and nurses. As one publication stated: "It is the health officer's task in an epidemic to know where all cases are in his bailiwick."[76] Detection and disclosure of new cases was paramount to achieving control of the epidemic, and it could only be carried out with the help of the medical profession and the public. Neighborhood health stations were at the forefront of these search-and-report missions. Some infants brought in for regular visits could not hold on to their bottles.
Mothers were advised to bring all febrile children, especially those with "weak legs" or to send for a doctor.[77] All physicians in affected areas were urged to cooperate. Moreover, the authorities offered diagnostic lumbar punctures and spinal fluid examinations free of charge.
As the house-to-house searches were stepped up with the help of additional inspectors and nurses, quarantine procedures went into effect to isolate the suspected victims of polio.[78] Many children were promptly and forcibly separated from their parents and removed to specially outfitted pavilions at nearby hospitals for proper diagnosis and treatment. Initially, most patients arrived at Kingston Avenue and Queensboro hospitals.[79] Only two visits to the sick by members of the family were allowed over the next eight weeks. Confirmed cases of the disease were made public, and their names as well as addresses were published daily in the newspapers. Parents were urged to read the lists and keep their children far away from the infected places. Houses yielding victims of the disease were immediately placarded. Like a scarlet letter, the clearly visible sign was placed outside on the street front and in tenement buildings on the street door, entrance hall, and apartment door. Inspectors checked on the yellow signs daily, trying to discourage their removal, which was subject to a heavy fine.[80]
Well-off parents, of course, could keep their sick children if they could provide them with a separate room and adequate nursing as well as medical care. Such isolation lasted eight weeks and required comprehensive cleaning of the premises, provision of separate bedding and utensils, and careful disposal of bodily discharges. If a child died at home, coffins were immediately sealed and burial occurred without a church ceremony. Houses were thoroughly fumigated and new wallpaper installed. All surviving siblings under the age of sixteen were quarantined in the house for the next two weeks.[81]
To ensure public support for such draconian isolation measures, Haven Emerson and his Health Department prepared half a million yellow leaflets for distribution. New Yorkers were told that polio was "a catching disease," its method of spread "not yet definitely known." Its germ was present in discharges from the nose, throat, and bowels of ill and even healthy persons, and therefore it was essential for children to stay away from crowds in parks, swimming pools, movie houses, and stores. Fresh air, wholesome food, shower baths, and general cleanliness were recommended as the best prophylaxis.[82]
The role of filth in poliomyelitis and its implications for public and personal hygiene was ambiguous but attractive to public health officials.
Because the spread of the disease was unpredictable—ignoring class distinctions and geographical boundaries—the idea of an environmental factor responsible for transmission of the disease was quite appealing. Moreover, experiments carried out in 1912 by Milton Rosenau, a professor of preventive medicine at Harvard, suggested that flies, especially the biting stable fly, could transmit polio. Although the importance of this possible vector was still under investigation, the Health Department could not ignore it.[83] All scientific studies concerning infantile paralysis were problematic at this time. Although a virus believed responsible for the disease had already been isolated in 1909, virology was still in its infancy; given the contemporary climate of fear, no one could take any chances.[84]
The New York Health Department therefore embarked on a vigorous cleaning campaign. Four million gallons of water were dumped daily on the city's streets, paradoxically before the garbage was hauled away. Refuse and ash piles accumulating in halls of tenement houses and on sidewalks had to be removed. All stray cats and dogs were collected; according to the Society for the Prevention of Cruelty to Animals, three hundred to four hundred fifty cats and dogs were put to death daily in early July. Flyswatters and screens to fend off the gregarious stable fly and its less aggressive domestic cousin were widely dispensed. Parents were urged to keep their homes spotless, and to go over all woodwork daily with a damp cloth, sprinkling floors with damp tea leaves or shredded newspaper before sweeping; to take daily baths; and of course, to keep covers over each garbage pail.[85]
Homeowners caught depositing refuse on the streets were fined. Brooklyn, an early locus of the epidemic, became the black sheep in the eyes of Commissioner Emerson. He accused its citizens of lacking enough civil pride to keep their streets clean, suggesting that perhaps they were responsible for the abundance of cases there.[86] An army of thousands of volunteers began patrolling the neighborhoods on foot and on motorcycles, checking for violations of the Sanitary Code. By July 11 the authorities had already charged 148 individuals with violations; eventually 2,266 such summonses were listed.[87]
As most public health measures increasingly focused on environmental filth and garbage, polio began to be viewed as another plague of poverty primarily affecting the same marginal slumdwellers who had been blamed for previous epidemics. "If we could get rid of ignorance and the filth and superstition that go with it, there would be little need to hunt down the mysterious germs that no filter can stop and no microscope
disclose," wrote one editorialist.[88] Indeed, the poor lacked the airy, clean, and cheerful rooms which Emerson recommended for the domestic treatment of polio cases. They seemed unable or even resistant to following the rules of hygiene which presumably contributed to a disease-free environment. "Defilers of the streets are to blame," commented one writer.[89] Even New York's mayor stressed cleanliness. "There is no occasion for alarm or panic," read Mitchell's statement published July 9 "Careful observance of the simple directions given by the Health Department as to personal and household cleanliness will go far to prevent further spread of or exposure to infection."[90]
Not surprisingly, poor Italian families bearing the early brunt of the epidemic were suspected of having introduced polio from their homeland, although inquiries by Emerson to the quarantine station at Ellis Island failed to confirm such an impression. Both the immigration authorities and American consular staff in Italy declared that no polio cases had been reported in that country. In spite of such reassurances, suspicion lingered and quickly included Lower East Side Jews and Poles, who also furnished a disproportionate number of polio cases. Certain neighborhoods appeared to be especially dangerous. One of them was "Pigtown," an Italian section of Brooklyn around Albany Avenue and Maple Street.[91]
As the toll from the epidemic mounted in July, the New York Health Department increased its "war" against the crippling scourge. Among the newly recruited "forces" were 21,000 citizens organized by the city's police commissioner under the banner of "Home Defense League." Its members spread out to every precinct, where they worked thirteen-hour shifts accompanying policemen on patrol and searching for violations of the sanitary code. Grocery stores, fruit markets, and street vendors came under strict surveillance. One hundred and fifty gangs with water trucks were placed into service. All theaters and movie houses were closed to children under the age of sixteen.[92]
Public acceptance of and cooperation with such a health campaign were critical, and Emerson was quite aware of the difficulties awaiting him if he failed to persuade the community through educational means about the importance of sanitary and quarantine measures. "Anything which causes antagonism of the public to the policy of reporting and removal to isolation hospitals, develops deception, hiding of cases, and such methods of obstruction as to frustrate to a great degree any approach to successful separation of the sick from the well."[93] But how could the public be convinced? Repeated visits by public health nurses
trying to educate families at risk proved only partially successful. The pitch was directed to the children of immigrants themselves, who apparently grasped the importance of the measures before their parents; because of cultural and language barriers, these parents were less amenable to the sanitary gospel. "Results obtained among adults were largely due to fear of authority and the force of the department and not to voluntary action on their part," commented one newspaper editorial.[94]
There was, of course, resistance to the actions of the Health Department. As the seemingly conflicting messages of environmental hygiene and personal contagion took hold, fear began to grip the wary. "Many a family of children was housed for weeks, often in tight-shut rooms, the children's pale faces pressed against the window panes, mute evidence of their unreasonable imprisonment," recalled Emerson.[95] Others slammed the door in the faces of visiting nurses, who were suspected of carrying polio from one family to another. One nurse stationed at a pediatric clinic in Brooklyn, who had repeatedly reported cases of the disease as well as violations of the sanitary code in "Pigtown," received a life-threatening "black hand" letter and from then on had to be escorted by a policeman between her home and place of work.[96]
The Red Cross, in turn, provided its nurses for home visits because they apparently generated less fear among mothers who worried that their children would be summarily confiscated and removed to hospitals. The latter were rumored to be hotbeds of polio infection easily transmitted to arriving children and health personnel. Even many private schools and colleges refused to admit students on trivial grounds.[97]
By mid-July publicity surrounding the polio epidemic in New York City prompted a major effort by neighboring communities and indeed the rest of the nation to confine the city's children within the metropolitan area, thus avoiding a possible spread of the disease to other cities and villages. Towns on Long Island, a favorite summer destination for countless New York families, placed billboards at their city limits urging city dwellers with children to return home. Hotel-owners admitting them overnight were heavily fined. At numerous railroad stations families traveling with children were turned back or placed under observation.[98]
With assistance from the U.S. Public Health Service, the New York Health Department agreed to issue one-day health certificates or traveler's identification cards, certifying that the child was free of symptoms and did not come from an infected household. The same document could also be obtained from a private physician after an examination.
The certificate was routinely requested from all children under the age of sixteen before embarkation for travel at all ferry and rail terminals as well as steamboat piers. Those who managed to leave without such cards were not allowed to disembark at their destination.[99]
Although thousands of certificates were issued in the following weeks, many communities around New York City refused to accept them. Some demanded similar documents from the accompanying adults, and other communities, such as those in Connecticut, quickly escorted arriving families out of town and abandoned them in open fields. One child from Brooklyn, who possessed a health certificate, came down with polio in Rochester, forcing Emerson to reiterate that the examination given prior to issuance of a permit card could not detect disease during the early stages of incubation.[100]
Given the presence of large numbers of healthy carriers, Emerson actually questioned the ban on travel out of New York City. In his view, such quarantine measures were futile and had no effect on the spread of the epidemic. "I know that nothing has developed so many automobile detours, such ingenuity in the violation of the laws, and such wholehearted disrespect for reasonable sanitary law and its enforcement."[101] Strangely enough, Emerson's opinion about quarantines outside New York was totally at odds with his strong belief in their utility within the city.
Emerson's reference to travel detours was pertinent. Anxious parents planning summer outings or more extended vacations flooded the Automobile Club of America with requests for routing around the more than five hundred quarantines imposed by towns and villages bordering New York City. In many instances guards with red flags were posted at the entrance of such towns, stopping every automobile and carefully searching for concealed children. Those carrying anybody under the age of sixteen had to report to police stations or health offices.[102] "I hardly need to recall the countless instances of inconvenience, hardship, yes, real brutal inhumanity which resulted from the application of the general quarantine," admitted Emerson.[103] No wonder so many people "developed a most perverse ingenuity in discovering automobile detours."[104]
During the month of August, reported cases of polio began to ebb, and doubts were increasingly voiced concerning the success of Emerson's quarantine measures. The vector theory of the stable fly was discredited;"[105] dissemination of polio was now thought to occur mostly via unrecognized carriers through person-to-person contacts. It was also thought that the decline in polio cases resulted from the depletion of
susceptible children who lacked natural immunity.[106] "Perhaps twenty-five years from now our present prophylactic efforts may appear to have been too troublesome, over strenuous, or even ill advised," conceded one editorial in a medical journal.[107] With the epidemic now abating, it was safe to criticize such measures. In nearby Oyster Bay irate fathers interrupted a town council meeting on August 28 demanding the return of their children who had been removed to isolation hospitals. The local quarantine was branded as another instance of "propaganda to terrify the people."[108]
One cannot avoid noticing a sobering skepticism which overtook public health officers, medical practitioners, and scientists as the polio epidemic of 1916 came to an end. The New York City Health Department had tried in part to control the outbreak by teaching the public everything known about the disease with the help of professional groups, volunteer organizations, the press, and leaflets. After all, responsibility for infectious diseases had significantly shifted in the twentieth century from the environment to individuals, their way of life, and behavior. But public education alone was certainly not enough; it only heightened the fears of many, failed to reach others because of ethnic and social barriers, and, moreover, failed to stem the epidemic.
Emerson was persuaded to adhere to sanitary principles and isolation methods employed since the Renaissance. As he wrote: "Health of the individual is a public asset in which the civil government has an interest and for the protection of which broad police powers may be exercised."[109] Such functions were specifically authorized by law, then executed and enforced for the public good at the expense of individual rights. Environmental sanitation, quarantines, and isolation of the sick were among the key objectives of such a campaign.
None of the approaches was entirely successful. "As to the lessons we have learned during the epidemic," declared one physician, "we have learned very little that is new about the disease, but much that is old about ourselves."[110] Scientists were still debating the nature of the agent causing polio and its method of transmission. Physicians, while expressing appreciation for the great clinical opportunities furnished by the epidemic, argued about the usefulness of spinal fluid examinations and convalescents' serum treatments.[111] Five hundred children with varying forms of paralysis presented formidable challenges to those entrusted with their rehabilitation.
And then there was public health. Isolation and quarantine had appeared to help stem the onslaught of polio. But, did they really, or was
the waning of the epidemic during autumn just part of a natural cycle? No matter. Again ethnic minorities and the powerless poor had been stigmatized in the name of established public health dogma.[112] "The sanitary code is a body of sanitary law passed by the Board of Health in the last fifty years," asserted Haven Emerson, "it is the substance of the best that the medical profession has been able to produce for the community control of disease."[113] Residents of Oyster Bay saw it differently. Their resolutions lifting the local quarantine concluded with the statement that "both profane and modern history are replete with the medico-politico barbarism of which we are now receiving a sample as anyone who knows the history of quarantine must understand and acknowledge."[114]