Childhood's Deadly Scourge: The Campaign to Control Diphtheria in New York City, 1880-1930.
After some forty years of complacency, AIDS and Ebola awakened our dormant dread of an epidemic disease characterized by sudden onset, gruesome symptoms, and/or swift, excruciating death. This renewed focus on the drama of infectious disease roused an interest in the taming of older, equally scary killers. In Childhood's Deadly Scourge, Evelynn Maxine Hammonds recounts the complicated story of diphtheria, one of the first infectious diseases to be subdued by modern medicine.
In pre-bacteriology days, diphtheria was an enigma to physicians. As Hammonds explains, diphtheria's most salient characteristic--a lesion, usually in the larynx, called a pseudomembrane--did not always mean diphtheria, nor did its absence always mean something else. Treatment was ineffective. Between 25 and 55 percent of victims, usually children under five, died either from suffocation by the pseudomembrane or effects of the toxin produced by the diphtheria bacillus.
Because diphtheria was endemic to New York City, it did not elicit the wholesale terror and appeals for eradication that occasional cholera outbreaks did. Thus, as Hammonds explains, every effort to control the illness was contentious. When Edwin Klebs identified the diphtheria bacillus and Friederich Loeffler later isolated it in 1884, their discoveries offered a way to diagnose diphtheria more precisely. Yet many American doctors were skeptical of this European breakthrough and their doubt curtailed universal use of bacteriological diagnosis.
Eventually two determined public health officials--William Park, director of the New York City Health Department Bureau of Laboratories, and Hermann Biggs, the first director of the health department's Division of Pathology, Bacteriology and Disinfection--spearheaded the diphtheria-control drive in New York City. Biggs pointed out that New York already relied on bacteriological diagnosis for cholera. Why not diphtheria? After Park invented a "culture tube" to store cotton swabs rubbed against the tonsils or pseudomembranes of suspected diphtheria victims, the Board of Health established 34 depots where doctors could pick up and drop off the portable tubes and receive results by noon the next day. Private doctors remained reluctant to embrace the new technology, however. Testing for the presence of a specific bacterium intimated that clinical diagnosis was less reliable than laboratory diagnosis, and physicians feared usurpation of their authority in an era when it was no easy task to attract patients.
The city's newspapers soon took up the cause. In a series of articles in 1894-95 the New York Herald and the New York Times heralded antitoxin--a remedy for diphtheria if administered early enough. The Herald's persistent drive to raise money for the production and distribution of antitoxin made diphtheria control a public health program "that disparate ... social groups could support by linking the product of medical research to the unimpeachable humanitarian effort of saving children's lives" (89). Antitoxin offered such promise that it became "the cultural symbol of the power of medical research" (90).
Yet the promise of bacteriological testing and antitoxin went unfulfilled. Doctors feared that the health department might isolate patients with a confirmed but mild case of diphtheria for days or even weeks. In 1896 public health officials changed the city's quarantine regulations, allowing private doctors to determine how long to isolate patients living in single-family homes. Yet debate over how best to control the spread of diphtheria continued. Doctors still did not share the view of public health authorities that mild and convalescent cases posed a public health threat.
By the end of the nineteenth century, public health officials had done all they could given the barriers to diphtheria control: seemingly healthy carriers, a burgeoning population of children in tenements, unreported and unrecognized cases, and physicians' ongoing reluctance to administer antitoxin at the first sign of illness. Prevention, not cure, became the solution. In 1913 German researcher Emil Behring first injected toxin-antitoxin into humans to create an immunity to diphtheria over time. Almost simultaneously Bela Schick, a Viennese physician, developed a test to determine immunity to diphtheria. By 1921 Park and his colleagues had used the Schick test on more than 52,000 New York City schoolchildren. Children with a positive reaction, indicating no immunity, received an injection of toxin-antitoxin.
In 1929, newly-appointed New York City Health Commissioner Dr. Shirley Wynne launched the first public diphtheria immunization campaign in the United States. Wynne's Diphtheria Prevention Commission disseminated 7 million pieces of literature. Health mobiles traversed neighborhoods. Medical personnel administered free toxin-antitoxin injections at schools, public beaches, and parks. Health authorities rallied public cooperation by charging that the very presence of diphtheria in a city was "a disgrace, a visible sign of parental neglect and medical indifference" (193). Eventually, where private medicine had failed, public health efforts succeeded.
Drawing on her meticulous study of newspaper articles, health department bulletins and reports, the minutes of assorted medical societies, and material from the Metropolitan Life Insurance Company Archives, Hammonds argues that science alone did not eradicate diphtheria. Rather, a combination of science and politics and the nature of the disease dictated New York City's bumpy road to control. The fact that the diphtheria bacillus was common in healthy bodies, its easy transmission via respiratory droplets and secretions, and prevalence of the disease--not dispassionate science--shaped the public health policies, therapeutic options, and public perceptions that ultimately contained the disease. In an epilogue, Hammonds hesitates to draw any lessons from the diphtheria experience for our contemporary struggle with AIDS, but offers three observations. Testing for a disease must be linked with reliable treatment and prevention, public health education must be geared to diverse populations (a lesson forgotten bet ween 1930 and 1980), and public health messages must avoid social fragmentation and stigma.
Hammonds's study of the machinations of the private and public medical communities in their quest to tame diphtheria is an important and necessary one, but so detailed in its rendition of medical politics that it is often difficult to follow. If she had forgone some of the minutiae in favor of describing the tenement conditions that fueled diphtheria and the manner in which diphtheria shaped family life, she might have given the reader an easier-to-follow story and a more compelling interpretation. The book contains only one illustration--a blurred map of New York City that ostensibly shows death rates from diphtheria in different districts. Photographs of tenement living and reproductions of health department posters and pamphlets would have enlivened the book. While Hammonds's book will attract medical historians and public health practitioners, its relentless focus on the convoluted debates and recalcitrance of the medical community will be of limited interest to urban historians, social historians, and h istorians of childhood and the family, and of little use in the classroom.
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|Author:||Wolf, Jacqeline H.|
|Publication:||Journal of Social History|
|Article Type:||Book Review|
|Date:||Dec 22, 2000|
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