Infectious Diseases in the 19th-Century City

Today I want to talk about the role of medical science and the Amenities were very few. These so-called water closets were conquest of disease in the developed world. That's a very generally covered and surrounded by filth so as not to be grandiose title, but it's very easy for us to take for granted the approachable. Others were merely trenches, sunken one or two achievements that make the comforts of our everyday life feet into the ground. And the fluids in some instances were possible -- for example, clean water, food that is certified pure, allowed to run into the courtyards. And most houses had no sanitation systems for the easy removal of human waste, sewers, which made the stench that arose in the summer immunizations and preventive vaccines that protect us from "absolutely unbearable and perilous," as one observer noted. many infectious diseases. Well, in the 19th century, each of these things were very hard to come by for all but the most Those concerned about the city were most concerned about the privileged, and in the case of immunizations and preventive stench. I mean, if you can imagine garbage piled three feet vaccines, they only became widely available during the last high in the streets, this smelled very, very, very, very badly. decade of the 19th century. Infectious diseases affected And so people believed that this stench itself, the smell itself, thousands of people every year; therefore the control of these was the cause of disease. They believed that the garbage in the things is one of the great triumphs of modern medicine and streets produced these miasmas -- that is, the stench that public health. people smelled -- and these miasmas sort of polluted the air, spreading across the city, carrying disease with it. So I want to begin by describing the 19th-century city, and I'm going to use New York City as my case study. New York City It was also feared that unworthy and worthy, the rich and the in the 19th century was the most diverse city in America. By poor, all were susceptible to the fevers and plagues that were mid-century it had also the worst health statistics in the nation. carried throughout the air. And so in New York City, the Data gathered by the city showed that one out of every 36 observers of the conditions found that disease, debasement, people died in 1863, as compared to one out of 44 in Boston and pauperism -- that is, disease, immorality, and poverty -- and in Philadelphia. New York also compared poorly with were the major threats to the healthy conditions of the city. London and with Liverpool. New York did not turn its Throughout the city, dirty streets, clogged sewers, polluted attention to the conditions of its city until the middle of the wells were commonplace. century. And studies in the 1840s attributed the high rates of disease to the poor housing and also the immoral conditions As a result of all this garbage and stench and filth in New that certain susceptible or unworthy individuals in York City, epidemics of infectious diseases were communities had created. commonplace. In the 19th and early 20th centuries, there were four outbreaks of cholera in New York, where more than In 1864, the New York Citizens' Association organized a 5,000 residents died in 1849. Smallpox epidemics waxed and district-by-district and block-to-block inspection of living waned over the century, as did typhoid, typhus, malaria, conditions in Manhattan. What did they find? They found that yellow fever, pneumonia, diphtheria, and tuberculosis. I bet many of the cobblestone streets were very filthy with many of those things we don't even recognize their names accumulations of manure from the horses that traversed them. anymore, they have so much disappeared from our landscape. Dead dogs, cats, and rats littered the streets. Household and vegetable refuse collected in the cracks of the cobblestones to In 1881 and 1887, nearly 5,000 residents died of diphtheria, the depths of three feet or more in the winter. So-called while typhoid accounted for thousands of deaths in 1864 and garbage boxes were rarely emptied, and they overflowed with '65. The influenza epidemic in 1918 killed 12,562 persons in awful animal carcasses and household waste. There were one year alone. And one of the most disturbing statistics was pools of stagnant water collected in the carcasses of dead the large number of infants and young children who died of animals, and they collected also over sewer drains, and they diarrhreal diseases, especially in the summer. In 1840, were generally very clogged. So filth of every kind was approximately 190 of every 1,000 infants born in New York thrown into the streets, covering their surface, filling the City never reached their first birthdays. By 1930, however, gutters, obstructing the sewer culverts, and sending forth what fewer than 70 in 1,000 infants born in New York City died in were called the "perennial emanations which must generate the first year of life. Young adults also faced harsh conditions. pestiferous disease." In 1840 and 1870, nearly one-quarter of those reaching the age of 20 would not live to the age of 30. So filth of every kind was thrown into the streets at all times of the day, and poorly designed sewers had been installed Many of the diseases that caused all these deaths thrived in the throughout the city, but most of the population depended upon dirty water, unpasteurized milk, and untreated sanitation and these sort of outdoor water closets and privies in the deplorable housing conditions that were the normal conditions courtyards of their homes. And in tenement buildings, these of life for most of New York's inhabitants, especially its privies were often placed very close to the wells that people poorest inhabitants. It is also important to realize, in the deaths used to get their drinking water from. of children and youth, that because epidemic diseases took so many of these from these groups during this period, the expectation of many parents was that their children would not 1 live. Generally people thought that one or two of their children blaming the poor and the sick for their diseases as opposed to would probably die before they reached the age of 5 or the age saying that diseases lay outside of individuals. of 10. To have many children in a family survive to the age of 20 was not a usual condition, so there was a kind of fatalism But slowly, as medical experts carefully analyzed transmission among the population and the ways in which they accepted of diseases, of these infectious diseases, the belief grew that that many of their children might not survive. This, too, was a there were specific causes, specific pathogens associated with fact of life that has radically changed for us in the late 20th specific diseases, and these pathogens turned out to be century. microscopic organisms or bacteria. So beginning in [the] 1870s and 1880s, researchers abroad discovered the Now, despite the fact that widespread epidemic outbreaks in microorganisms associated with tuberculosis, with cholera, New York City were really relatively minor contributions to with typhoid, and with diphtheria. Now, American physicians the overall death rates, the problem is that these epidemics were initially a little bit skeptical that a little microbe, a little were highly visible and dramatic experiences where bacteria, could actually cause diseases that wreaked such inhabitants of the city often saw people literally dying in the havoc in the cities, but with the development of diphtheria streets. And it had an enormous impact on the psychological antitoxin in [the] 1890s, which dramatically reduced the feelings of people who lived in this city at the time. The rich, mortality associated with this disease, a number of physicians when these diseases would occur, often fled to the countryside were finally convinced that the germ theory was correct. when epidemics broke out. Others simply moved further and further away from whatever parts of the city the diseases had Now, for public health experts, the germ theory proved to be appeared. So many people who lived near the downtown especially rewarding, making visible the agents of disease in tenement house districts would just move uptown. Others water, food, and blood. And by the 1910s, physicians were would move out of the city altogether. provided with precise tests to identify a variety of diseases. And so the germ theory seemed to promise a precision, not In particular, port cities like New York, like Boston, like only in the diagnosis of disease, but also in the prevention of Philadelphia, were particularly susceptible to outbreaks of disease. And proponents of public health adopted a new infectious diseases because these were places where ships approach to their work. They rejected the idea that they had to coming in from other parts of the world also brought travelers simply clean up the environment and get rid of the filth. The who would have been exposed to these diseases in the cities new public health emphasized that germs were spread by where they had departed. Cholera, for example, had largely personal contact, and the new practices centered on educating been restricted to the Far East until advances in shipping individuals in their responsibility for the prevention of disease. shortened the travel time between the world's major ports. And In sum, the focus of public health work changed from citywide because cholera has a very short incubation period and a rapid sanitation and disease control to closer observation of course, the fact that there was more rapid transportation individuals, their habits, and their contagiousness. between the Far East and the U.S. increased the spread of this disease. And that brings us to the case of "Typhoid Mary." Typhoid was a significant problem in American cities. It is a water- and Now, one of the major changes that occurs toward the end of food-borne systemic bacterial infection. It is important to the 19th century, as people tried to figure out how to control know what it looks like when people saw it. Its symptoms are infectious diseases, was the introduction of the germ theory of sustained fever, headache, malaise, gastrointestinal problems. disease. It became clear that impure water, crowding, poor A few days following exposure, the patient experiences a housing, spoiled food, and other environmental conditions headache, loss of appetite, chills; and about 10 percent of were contributing factors to high rates of disease in the cities. those who are infected with it die. It struck mostly in cities As I said also, people believed that immoral behavior also that had untreated water supplies, and thus, it responded well facilitated the spread of infectious diseases. But during to the implementation of water-filtration systems and moments of crisis, some also sought to focus on personal sanitation. But as cities began to build these systems, they still hygiene, child care practices, as also leading culprits in the saw typhoid, and they couldn't understand it. Why do we still spread of disease. But these differing explanations for high have typhoid? We've cleaned up the water; we've cleaned up disease rates have profound implications for prevention the sewage. And it turns out that the answer was that there planning. The only means of preventing these diseases at this were typhoid carriers -- people who had either been exposed time was to clean up the city, improve the housing stock, to the disease and had an outbreak of it and recovered, or those reduce overcrowding, provide better sanitation, et cetera. who do not remember being sick at all, but who nevertheless carry typhoid bacilli in their bodies and could infect other Now, this environmental emphasis implied the need for people. massive social investment and a change in social and economic relationships; that is, to provide better housing for The most famous germ carrier, as you know, was an Irish people, to use taxpayers' funds to build major systems, like immigrant cook, Mary Mallon, and she has the distinction of sewerage systems. One of the causes of diseases that people being the first typhoid fever carrier to be identified and believed at this moment also implied that there had to be also charted in North America. Mallon worked for several wealthy an emphasis on personal hygiene, and placing the New York-area families, and in the summer of 1906, she responsibility for hygiene on individuals. This led to a kind of found employment in the rented summer home of a New York 2 banker. When typhoid fever struck six people in the household is that causes the disease to be transmitted. What are we going of 11, the owner of the home, thinking that he would be to do with them? unable to rent the property again unless he solved the mystery of these cases, hired a civil engineer whose name was George Ron Morrison: Isolate them. I mean, you bring them in, and Soper, known for his work on the epidemiology of typhoid, to you isolate them, if need be. investigate the outbreak. And Soper's report ruled out all the factors that might be contributing to these cases; that is, Professor Hammonds: So -- but it could happen now. That's contaminated water or milk and other possible sources. And the point I was trying to make. It could still happen. he concluded that the prime suspect had been the cook. By tracing the cook's job history and outbreaks of typhoid, he finally identified Mary Mallon. Ron Morrison: Yes. I agree with you wholeheartedly.

Now, when Soper met Mallon and tried to explain to her that Professor Hammonds: Other comments? I saw a couple -- she was a carrier of the disease, she threw him out of her yes? house. Soper then turns to the New York City health department, showed them his data, and convinced them that Larry David: One of the things that we discussed was, what Mallon should be brought in to have her urine and feces tested is the nature of a public health crisis? What determines what for the presence of the typhoid bacillus. And in 1907, she was crisis is in general? And we bandied that about in our group. forcefully apprehended by city health officer S. Josephine And one of the things we noted is that it changes with the Baker with the help of the police. She was taken against her time. Previously there hadn't been -- It hadn't been perceived will to the Willard Parker Hospital, which was New York's to be a crisis in the 1830s and 1840s, '50s, and '60s. While you hospital for contagious diseases, and there they subjected her have the disease, it's not perceived as a crisis. In the to careful laboratory tests. And the results showed high progressive era it is, because of the changing mind-set of the concentrations of typhoid bacilli in her feces. She was kept in public, and especially the middle class. health department custody in an isolation cottage on the grounds of the Riverside Hospital on North Brother Island. In Professor Hammonds: Well, no, I think outbreaks of disease, 1909, she unsuccessfully sued for her release. In 1910, she especially infectious diseases that cause large numbers of was freed, but she was arrested again later after officials traced deaths, are always perceived as a crisis. Even today they a house-hospital outbreak of typhoid fever to her kitchen. And would be perceived as a crisis. this time, when they apprehended her, she was placed in custody until her death in 1938. She lived in health Larry David: It depends on who is affected. It depends on the department-imposed isolation for a total of 26 and a half years. segment of the population.

Typhoid, Polio, and Diphtheria: Science and Class Issues Professor Hammonds: Well, does it depend on who is infected? Let me ask your colleagues to answer that. Does a crisis depend on -- calling it a crisis depend on who is Professor Hammonds: What conclusions did people come up infected? Or is it a crisis no matter who is infected? Yes? with about the health department's decision, the issues that her incarceration and isolation raise? Yes? Ed Morrison: She was poor; she was Irish; she was Catholic; she was an immigrant; she was a woman -- all people who Ron Morrison: I took the position of one of the health really had no status or perceived position in society at that officials, that isolating her, putting her in her own, separate point in time. I just think she was easy pickings. I think she cabin was the right thing to do. I sort of started off feeling bad. was victimized. And then as I -- as you gave me the other information, I said, well, maybe I wasn't too wrong in what they did, for the Professor Hammonds: So you think they were making an simple fact -- You know, isolating a few individuals for the example of her? good of the greater majority seems to be the way, or was the way back then. What we know now, we wouldn't have to do Ed Morrison: Exactly. An example. And then, to the extent what was done then. that that example even wasn't established to be looked upon as a precedent later -- I mean, I just feel it was an awful injustice. Professor Hammonds: Are you sure about that? Professor Hammonds: Okay. Other opinions? Yes? Ron Morrison: In some cases, yes. Yvonne Powell: And we've had more recent experience with Professor Hammonds: Suppose we faced a new disease, and the AIDS crisis. When that first started, they were we didn't quite know what was going on, and the only thing homosexuals, gay people, drug addicts, throwaways in our we knew was that there were some people out there who were society, and in more recent times, obviously African infecting other people. We tried to ask -- The public health Americans -- again, not the most prominent group of people officials asked them to stop. They don't stop doing whatever it that we address. So I agree. I think it's those who are the most 3 vulnerable, who are the least, that oftentimes are susceptible to health education efforts to encourage the rest of the public to be mistreated when a crisis comes, and their liberty taken comply with the kinds of things that are going to prevent the away. spread of these kinds of diseases. Yes?

Professor Hammonds: Does anybody else want to argue that Matthew DeBoer: Do you think that Mary posthumously there were good reasons for isolating Mary, that it makes became a martyr, and if so, what did her martyrdom represent? sense? Yes? Professor Hammonds: Yeah, I do think she becomes a Eugenia Rolla: They really needed to kind of legitimize their martyr, in the sense that what would most of us know about position within this kind of new, emerging, progressive time, "Typhoid Mary," just sort of a general kind of popular view? and so they needed to take a stand. That's not to say what they It's almost as if she was this woman who deliberately went were doing was correct or just. But from their perspective, about spreading disease and trying to hurt people, you know? from a bureaucratic perspective, in order to kind of say, "Hey, Even the cartoons that appear about her in newspaper accounts this is what our job is, and we're facing this crisis, and this is at the time show her as evil and malevolent in some kind of what we're doing," I think it was necessary for them to set a deliberate way, right? And I think the fuller context of the precedent to a certain extent story shows that she didn't set out to spread typhoid. She didn't set out to kill people. She didn't do it maliciously. I think after Professor Hammonds: You raise a good point. It is clear that the evidence is presented to her, she had a lot of doubts about they wanted to establish a precedent about what to do about the evidence. And I think the fundamental basis for her doubt carriers. What they're doing is, they have a new kind of issue is simply that she was never sick. And it's very hard, I think, to deal with: How do you control people who are otherwise for people to understand that you could transmit disease when healthy, are not sick themselves, but can cause disease? Now, you're not sick. She couldn't remember ever having typhoid. Mary Mallon is saying, "Well, I've never been sick. I don't Here the authority is telling her this. You know, it sort of gets know what these people are talking about. I don't understand picked up and exploded into this other set of issues, and I this. They tell me I have these germs, that I give the what? I think she comes down through history as, you know, "Typhoid don't know anything about this." And most people didn't Mary," as sort of the evil one. understand it. And it's a very abstract notion for most people that there is such a thing as a carrier, right? And so how is the There is another case that we might look at as just counter to health department going to have to make this abstract notion that is in diphtheria, which is childhood disease. In the case of concrete? In part because, as I said, the germ theory, as it is diphtheria, many, many adults are carriers. There are applied to public health, changed the focus of public health to thousands of diphtheria carriers in New York City. And one individuals' behavior and their responsibility in transmitting doctor says, "Well, I just think, you know, we just need to set infectious diseases. Yes? up a testing thing on every corner and just test all these people down here in the Lower East Side, in the tenements, and any Steven Seto: The evidence was brought to the board of health. of them that have diphtheria bacilli in their throats, they can't They didn't go search it out. And from the -- Given the be servants; they can't be teachers; they shouldn't be able to information that I have, it didn't sound -- it didn't seem as if work in candy stores," where it killed children, anywhere that they went out to look for anybody else afterwards. I mean, they could have any contact with children. And that's what he there were still over 4,000 cases of typhoid while they had wanted to do. And of course the public health officials said, Mary in isolation. "We can't do that. How are we going to do that?"

Professor Hammonds: What happens is, they began a much Yvonne Powell: It is rather interesting how impotent the more concentrated health education effort to get those people judicial system appears to be, however, in this process. I who work as cooks, who may have been exposed to typhoid, mean, the writ of habeas corpus is not -- is overturned. The to wash their hands; to really begin to mandate that people 14th Amendment is absolutely ignored. The judiciary is who work in restaurants, around food, who may have been almost an agent of the public health department. exposed to typhoid, to wash their hands. You've all seen those signs in the bathrooms. So they begin this kind of effort Professor Hammonds: I think that there are some interesting because they know they can't go hunting for these carriers. tensions there in what happened in the courtroom. My reading They don't have anywhere to put these people. They don't of that has to do with the authority of the scientific evidence have the manpower to trace whether each individual carrier is and the way in which the court deferred to that as the bottom- responsible for particular outbreaks of disease unless line explanation, and I also think because they don't put Mary something happens, and they, you know, they have to in jail, for example, that she is isolated in a cottage and that intervene. But by and large, they don't have the manpower to there are ways in which I think people might see that as a track down all these people. fairly benign kind of "punishment." My reading of the case sees it -- I think those factors play in as well, but I think the So again, as I say, in a strange kind of paradoxical way, Mary key of it is that the bacteriological evidence that the health becomes this sort of symbol for them of what can happen. But department presents and the stature of the health department at they know that they can't do this to everyone, so they institute that time carries the day in the court. 4 I also want to say that outbreaks of infectious disease raise a Placards identifying housing where there were many cases of whole host of issues beyond simply ones about individual the disease were placed outside tenement buildings, but these rights versus the public's health. And I want to turn to another placards were never placed outside of middle-class homes, epidemic -- the outbreak of polio in New York City in 1916 -- because it was at -- In one sense, the health officials believed as a good example to look at some of the other issues that that the disease was less dangerous in middle-class emerge. Poliomyelitis is a viral disease, characterized by communities than it was in the immigrant communities, so fever, headache, and sometimes stiffness of the neck and back. you see constantly the ways in which the fear of the immigrant In paralytic cases, the virus attacks the motor nerve cells in the classes and their threats to the city get pretty wrapped up in spinal cord, which governs your muscles, and if the muscles public health policies, even after the introduction of needed for breathing or swallowing are affected, the patient bacteriology and more scientific-based public health. may die. Now, unless weakness or paralysis of the muscles in the limbs is minor or improves after the acute attack, most The other thing that happened to poor parents is they were victims of polio will be crippled for life. In 1916, a national faced with the prospect of their children being removed from epidemic of polio emerged with 27,000 cases in 26 states, with their homes and taken to the contagious disease hospital if 6,000 deaths. In June 1916, New York City had the largest health officials felt that they couldn't provide adequate care for single incidence of the disease, with over 8,900 cases and the children inside of their homes. All manners of public 2,400 deaths, and a mortality rate of more than one child in gatherings were cancelled during the epidemic. Theaters... The four. health commission instructed all motion picture theaters to bar entry to children under 16. And even though the theater So again, we've just talked about typhoid in New York City. owners protested and said they were losing money, the city This is coterminous with typhoid. So you have outbreaks of maintained the closure of the theaters. Playgrounds were typhoid in New York City; you have outbreaks of diphtheria; closed. Sand piles were disinfected. Children's reading rooms you have this huge outbreak of polio. Again, look at the in public libraries were closed. And parents were also urged to landscape of the city at this point in time. This is not a healthy guard the behavior of their children. One official told parents place in many respects. to avoid caressing or kissing children, to forbid children from buying fruit or other exposed foods from street vendors, and to New York City remained a center for polio epidemics for the keep them from exchanging toys, marbles, candy, or chewing next four decades. And initially it was seen, as many gum with other children. infectious diseases were, as a disease of unsanitary living conditions and of the immigrants -- the immigrants' bad Now, despite the dominance of the new public health, the behaviors. But polio slowly became more associated with the department ended up blaming the epidemic on the middle classes by the 1930s, and then was considered as a irresponsible sanitary behavior of immigrants. But this began danger to all. The agent, the pathogen that causes polio was to wear thin, because this kind of explanation couldn't explain identified in 1908 as a filterable virus, but the 1916 epidemic the appearance of the disease in middle-class homes. And generated enormous fear in the public. Health officials had to eventually, epidemiological research would show that children deal with families fleeing the center of the disease, and they in more affluent homes were in fact more at risk to polio than also had to deal with people who stayed behind. The officials poor children. Poor children, in fact, were more exposed to the tried to restrict people's movement; they tried to identify the virus when they were very young, because the virus was very sick; they tried to placard people's houses where the sick were. prevalent in New York City. So they were exposed at a very They also tried to calm public fears, though they weren't quite young age and tended to have a mild reaction, in many cases. successful with that. And in New York City, as people, many Middle-class kids were not exposed to the virus. They're kept people, just, again, tried to leave, you know, it's like, time to inside much more, shielded from contact with other children leave, take the kids, get out of the city. much more as infants, and so they weren't exposed at the same early period, and when they were finally exposed, the virus To identify those free of the disease, the city's health had more severe effects. commissioner introduced a system of health certificates, in part because neighboring towns were restricting entry to So as historian Naomi Rogers has noted, the 1916 polio people from New York City who didn't have a certificate epidemic and the campaign to contain it, we have to certifying that their children were free of the disease. These understand this in the context of its time. These health certificates gave communities outside New York City one way officials, as someone mentioned earlier, were part of a to assess whether a child was free of infection. By the end of progressive reform movement, and they tried to use legislative the epidemic -- that is, it went into the early fall -- 68,000 power -- that is, the laws on the books that public health certificates had been issued. Even so, New York children were officials could invoke -- in the time of outbreaks of disease. frequently refused entrance to neighboring towns, are They also tried to use moral persuasion to address these kinds threatened with quarantines that lasted as long as four weeks. of outbreaks and to deal with a whole host of urban problems. In a few cases, like the city of Paterson, New Jersey, they said But one of the things that I think is an aspect of these kinds of until further notice, no nonresidents will be allowed to enter reformers in situations like this is that they believe that the city the city. And a city on Long Island just put big red signs up on was both an incredible place to be, but it was also a very the main road entering the town that all children who lived threatening place to be. It was dirty; it sort of had a kind of outside of the town would not be allowed to enter it. immoral cast to it. And these things had to be contained, 5 controlled, and regulated in order for the city to be a healthy [was] thought of to be a disease of gay men, of drug addicts, place for either the poor or the middle class to live. of people engaging in various sexual, sexually deviant behavior. The response did not evoke a great deal of And these reformers believed that regulation wasn't enough. compassion in the initial days. Once children became infected The behavior of individuals had to be altered, and that -- with AIDS, you know, I think you sort of see change in whether that behavior could be changed through education, people's willingness to think about ways we might contain the that was the best way, so to educate people about what to do in epidemic that were not so harsh. the face of these kinds of infectious disease outbreaks, including putting screens on their windows when it was After the discovery of the vaccine for polio, along with the widely believed that polio was being transmitted to humans development of other vaccines, the memories of fear and via flies, and that meant that everybody had to defer to stigma associated with outbreaks of these diseases tended to scientific authority. If the experts said it was time to get your fade from public view, and a kind of complacency set in. window screen, you had to get your window screen, or else People thought, well, we've conquered all the great infectious you were going to be stigmatized as someone who was diseases of the 19th century: tuberculosis -- we know how to threatening everybody else's health. deal with that; syphilis, gonorrhea, typhoid, typhus, yellow fever, malaria, polio, diphtheria, all the great killers -- we had In a sense, through this education campaign and deference to really effective means of controlling them. And people the authority of scientific experts, these reformers really hoped thought we were now entering the golden age when we would to transform the family, home, community, and ultimately the be free of infectious diseases. And then the 1980s came, and American society as a whole. And to achieve their goal, health AIDS came, and people said, "Uh-oh." Our complacency was officials really exalted the role of medical science and truly shattered. The control of infectious diseases, I want to supported the use of government power. Now, in this case, end by saying, is one of the great triumphs of public health exalting the role of medical science in the case of polio in and scientific research in this century. But I think the major 1916 turned out not to be such a great idea, because the point to take away is that with every success came very real medical, the scientific knowledge about polio was very challenges to the values that Americans hold dear. Thank you. uncertain. Though the virus was identified, they couldn't figure out how it was transmitted, and they could not figure out how to stop it. A number of vaccines were promoted and failed. And in the case of the 1916 epidemic in New York City, as it got colder -- you started in the summer -- as the winter came along, it seemed to die out. And that's how -- that's basically how it ended.

Polio continued to appear in the United States through the 1930s and well into the 1950s. And on April 12, 1955, on the 10th anniversary of the death of President Franklin Roosevelt, is when Jonas Salk announced the development of a vaccine to wide acclaim, huge acclaim. You know, this was really the conquest of something that had brought such fear and so many deaths and left such vivid memories -- and real people who were crippled -- around for people who had lived through this period. So in part, people were so enthusiastic and positive in their response because of the memories of the 1916 epidemic and outbreak, but also in the ones that followed, right? But this seemed as well to be a real triumph for science, conquering something that had caused so much pain and suffering.

So these two cases, "Typhoid Mary" and this polio epidemic in 1916, tells us that outbreaks of disease always engender fear, stigma, the need for government intervention. But the broader lesson is that societies can address these kinds of issues in ways that preserve certain values of equity, of justice, of community trust. Or you can address outbreaks of these diseases and institute rules that disrupt those kinds of values. And it's very interesting for historians of medicine to look at which choices are made, at which particular times, with which particular diseases, so diseases that are carrying with them an image of really irredeemable bad behavior, we can see that often societies and communities respond quite harshly. And someone mentioned earlier the AIDS epidemic. AIDS initially 6