The Cure for Panic: Ebola in Historical Perspective

This post is part of an exchange between “Books, Health, and History” at the New York Academy of Medicine and The Public’s Health, a blog of the Philadelphia Inquirer.

By David Barnes, Associate Professor of History and Sociology of Science at the University of Pennsylvania

The illness itself is scary: first the sudden aches, then the spikes of fever and chills, before the massive internal bleeding and copious vomiting and diarrhea. Death comes amid delirium and hemorrhaging from the nose, mouth, and other mucous membranes. A handful of isolated cases in the United States have been enough to spark a nationwide frenzy of fear and recrimination. Imagine what would happen if the nation’s capital lost a tenth of its population to the disease in the space of two months, and another half to panicked flight.  And imagine if it happened again in the same city a few years later, then again, and again—four times in seven years.

The time was the 1790s, and the place was Philadelphia Vice President Thomas Jefferson even called for the city to be abandoned. The disease wasn’t Ebola, but yellow fever, another of the viral hemorrhagic fevers that wreak such terrifying havoc on the body’s internal organs. Yellow fever was also known colloquially by its most distinctive symptom: “black vomit,” which occurred when large quantities of blood accumulated in the stomach. Its ravages in Philadelphia and other seaport cities in the nation’s formative years constituted a serious national crisis.

The public discourse surrounding the ongoing Ebola epidemic has been singularly unedifying. In the United States, news media outlets have eagerly stoked groundless fears, which public officials have rushed to appease with policy responses that will do nothing to stop the disease’s spread. Meanwhile, help has been slow to arrive where it is desperately needed, in Guinea, Sierra Leone, and Liberia. Rural health centers there turn away patients for lack of staff and equipment, while well-funded American hospitals prepare for an influx of patients that may never come.

>>Read the full post at The Public’s Health.

Polio: A Fearful Disease Nears Its End

By Paul Theerman, Associate Director, Center for the History of Medicine and Public Health

Friday, October 24, is World Polio Day. Inaugurated a decade ago, the day is promoted by the World Health Organization, UNICEF, and Rotary International to mark the coordinated battle to eradicate polio worldwide. The date for World Polio Day honors Jonas Salk, whose 1950s polio vaccine effectively ended the epidemic in the United States. World Polio Day comes just before Salk’s birthday on October 28.

Jonas Salk. Courtesy of  the Steeltown Entertainment Project. Click to enlarge.

Jonas Salk. Courtesy of the University of Pittsburgh, via the Steeltown Entertainment Project. Click to enlarge.

Jonas Salk was born in 1914, and on the centenary of his birth, many celebrations mark his achievement. Here at the New York Academy of Medicine, we are screening a documentary about Jonas Salk on November 18, The Shot Felt ’Round the World, with commentary from his son Dr. Peter Salk, Time magazine writer Jeffrey Kluger, and historian of medicine Dr. Bert Hansen. Elsewhere in New York both City College of New York and NYU Langone Medical School are hosting celebratory symposia, and the Jonas Salk Legacy Foundation maintains a list of events and exhibitions in many different venues.

Though every analogy is partial, the American polio epidemics of the 20th century bear resemblance to the current outbreak of Ebola in West Africa. Both diseases were around and known before their largest epidemics. In 1916 polio broke out in the United States, with New York City having more than 9,000 cases, a quarter of which resulted in death. Another major New York City outbreak occurred in 1931. Even by then, little was known about the disease: it fell under a category now known as “emerging infectious diseases.”1

In their 1934 book, Poliomyelitis: A Handbook for Physicians and Medical Students, NYAM Fellow Dr. John F. Landon and his co-author, Lawrence W. Smith, called it a “still obscure disease” (p. vii) with a “particularly baffling” origin and means of transmission (p. 1). There were no effective treatments; the most one could do was to relieve symptoms, which included fever and strong pain, especially in the head and neck. Prevention was difficult if not impossible. Like Ebola, the disease’s spread, write Landon and Smith, could be curtailed chiefly by taking extreme care in physical contact and by quarantining active patients. The Handbook provided several practical appendices on nursing care and aseptic techniques, so caregivers could protect themselves and others from contagion. One appendix reproduced the New York City Health regulations on polio, which specified a three-week quarantine for all patients and a two-week quarantine for those in contact with them, with placarding of premises with quarantine signs.1

Two polio quarantine cards, courtesy of the National Library of Medicine.

Two polio quarantine cards, courtesy of the National Library of Medicine. Click to enlarge.

Chart from Poliomyelitis: A Handbook for Physicians and Medical Students. Click to enlarge.

Chart of the 1931 New York polio epidemic, compiled by the New York Department of Health. In Poliomyelitis: A handbook for physicians and medical students. Click to enlarge.

And like Ebola, the disease had terrible effects. The virus can enter the central nervous system, causing both temporary and at times permanent paralysis long after the disease runs its course. And even if the paralysis is temporary, post-polio syndrome can debilitate people years later. But in the early 20th century polio was often fatal, at rates that in 1931 averaged about 10% to 15% overall, but rose to over 20% for those under six months of age, and over 30% for those 15 to 19 years old (p. 158).1 By the time of the post–World War II epidemics, the death rate had dropped, but with increasing numbers of paralyzed survivors.

In 1952, polio struck the United States hard, with 58,000 affected, of which more than 3,000 died and more than 21,000 were left paralyzed to some degree or other.2 This was a huge number, even given the size of the country. Polio was four times as prevalent in the United States then as Ebola is in Liberia today. And while death rates from Ebola are higher, overall death and disability rates are comparable.

With this as a backdrop, the possibility of an effective polio vaccine was electrifying. In 1954, Jonas Salk’s promising new vaccine started widespread field testing, with over a million children taking part. On April 12, 1955, Dr. Thomas Francis Jr., director of the Poliomyelitis Vaccine Evaluation Center at the University of Michigan School of Public Health, pronounced the vaccine safe and effective. Large-scale immunization campaigns quickly started up.3–5 Polio was under control in the United States by the 1960s.

"The 1954 Poliomyelitis Vaccine Field Trial Areas." In Evaluation of the 1954 field trial of poliomyelitis vaccine: Final report. Click to enlarge.

“The 1954 Poliomyelitis Vaccine Field Trial Areas.” In Evaluation of the 1954 field trial of poliomyelitis vaccine: Final report. Click to enlarge.

The disease is one of the few for which eradication rather than control is considered feasible, a goal announced in 1988 by WHO, UNICEF, and Rotary. As of 2013, only three countries worldwide still had polio endemic in their populations—Pakistan, Nigeria, and Afghanistan—and the number of cases stood at fewer than 500, in less than a dozen countries in all.6 Yet polio is in the news again, as war has hindered vaccination programs, health workers have been put under attack, and cases have spread.7 At the eve of eradication, polio is proving difficult, even if it no longer inspires the wholesale fear that it did 60 years ago.

References

1. Landon JF, Smith LW. Poliomyelitis: A handbook for physicians and medical students, based on a study of the 1931 epidemic in New York City. New York: Macmillan; 1934. All in-text page numbers come from this handbook.

2. Salk Institute for Biological Studies. History: Polio today. Available at: http://poliotoday.org/?page_id=13. Accessed October 22, 2014.

3. Francis T. Evaluation of the 1954 field trial of poliomyelitis vaccine: Final report. Ann Arbor: University of Michigan; 1957.

4. March of Dimes. April 12 1955: Polio Announcement. 1955. Available at: https://www.youtube.com/watch?v=2LlDn_MQDkc. Accessed October 22, 2014. The March of Dimes was known earlier as the National Foundation for Infantile Paralysis, the group that underwrote much of the research and testing on polio.

5. Progress report to physicians on immunization against poliomyelitis, advance briefing. Indianapolis: Eli Lilly and Company; 1955. This report was part of the campaign and excitement around the Salk vaccine.

6. World Health Organization. Polio Case Counts. Accessed October 22, 2014.

7. For example: Gladstone R. Amid Iraq’s Political Chaos, a New Polio Vaccination Campaign Faces Challenges – NYTimes.com. New York Times. http://www.nytimes.com/2014/08/12/world/middleeast/amid-iraqs-chaos-a-new-polio-vaccination-campaign.html?_r=3. Published August 11, 2014. Accessed October 22, 2014.