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Epidemics!

by David Rosner, Feb 28, 2003
 

mosquito The discovery that seven elderly New Yorkers died from the West Nile virus last summer has sparked one of the most intense public health campaigns in the city's history.

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The Mayor has taken three basic steps. First, through press conferences and public service announcements, he has tried to awaken individual New Yorkers to the potential dangers of the disease, urging personal vigilance in emptying places where stagnant water can collect, wearing bug repellent, and keeping indoors during the early evenings when the mosquito tends to feed. Second, he has sought to calm public fears: We are told in virtually every public statement that no human cases of the mosquito-borne virus have occurred this year. Third, he has given broad authority to the Department of Health to spray wide swaths of the city with pesticides.

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The program thus tries to find a balance between sounding the alarm and preventing panic, between giving citizens a sense of personal control over the threat and demonstrating that officials are taking public action to address the crisis.

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But, as the finding of dead birds carrying the virus continues to mount, suspicions grow about the Mayor's program. Parents have protested the spraying of entire neighborhoods, worrying about the impact on children. Environmentalists worry that the pesticides will destroy useful bees, beautiful migrating Monarch butterflies, and other insects that pose little danger to humans. Lobstermen believe that the use of these pesticides has already led to the virtual destruction of the lobster industry in Long Island and Connecticut.

For the public health historian, the case offers an opportunity to reflect on the long history of New York's efforts to control epidemics.

A CITY OF EPIDEMICS

From its beginning, New York's mayors and public health leaders have been in a constant struggle to find ways both to protect the public from epidemics and to calm public fears regarding their consequences. Whether it be the efforts to prevent smallpox in the Colonial period; cholera, diphtheria, typhus, yellow fever and malaria in the nineteenth century; or influenza and polio in the twentieth century, public health officials have been forced to confront a variety of contradictory demands that often pit them against the very public that they are supposedly serving. Traditional tools of public health, such as quarantine, isolation, or institutionalization, have often been viewed as an infringement on individual rights, while massive fumigation efforts to eradicate rodents were easily seen as disrupting or even poisoning the communities that the city was seeking to protect.

In the Colonial era, the appearance of broad epidemics was a comparatively rare event in a city that was still relatively small and healthful. But, when disease did strike, the reaction was often one of surprise and religious fervor. During a period when little was understood about the methods by which infectious disease was transmitted back and forth among mosquitoes, ticks, rodents and humans, and nothing was known of germs and viruses, disease was seen as a form of Godly retribution. Individuals, then, were urged to engage in personal soul-searching, and ask for divine forgiveness. Political leaders, in the meantime, would sometimes seek ways of isolating the morally suspicious by keeping strangers out of town and quarantining homes of the sick. While today we may view these activities as misguided, their effect was to maintain order in a city where panic was all too possible.

CHOLERA AND GOD'S DISPLEASURE

In 1832, as cholera swept through Europe, most New Yorkers felt safe from danger. Because predominant views of disease linked its cause to immorality and corruption, the relatively small, homogenous and apparently moral majority of Anglo-Saxon New Yorkers believed that the city's virtuous citizens were virtually immune to its horrifying impact.

So, when the poor along the city's shoreline began to sicken, vomit, and die in the city's streets, some saw it as a sign of God's displeasure with the victim. The personal failings of any one individual, not a biological process rooted in viruses or germs, were understood to determine how susceptible someone would be to God's "terrible swift sword." As the death count mounted, however, it became difficult for anyone, no matter how virtuous he saw himself, to feel safe from an epidemic where victims could appear healthy in the morning and lie dead from dehydration by that night.

Some New Yorkers began worrying that it was an indication of God's displeasure with the community as a whole, perhaps with the city's burgeoning commercial activities. New York's Board of Aldermen (forerunners to today's City Council) formed a temporary committee of ministers and businessmen who joined with three physicians to address the issue. Calming the citizens of this city of nearly 200,000 was as central to the committee's mission as actually doing anything to stop the spread of the disease.

The committee ordered clean-ups of the city's streets, quarantine of foreign vessels, and implored the city's citizens to attend a special day of prayer set aside to ask for God's forgiveness for sins that had left the people vulnerable to His wrath. The activities seemed to work: in little more than a month, the cholera epidemic left the city, and New Yorkers were grateful to their leaders.

The quarantining of ships may have had a modest impact on the spread of disease, and the cleaning of the streets certainly improved the quality of life in the city, at least temporarily. But, as public health measures it is highly unlikely that they directly affected the course of this disease that rampaged through the city in July and August of 1832. What really happened is that colder weather set in, killing the bacteria responsible for the disease.

TYPHUS, YELLOW FEVER, AND BLAMING THE IMMIGRANT

By the late nineteenth century, as the city grew in size and as millions of non-English speaking immigrants poured into New York, the health crises became a more or less permanent fixture. Epidemics of measles, cholera, smallpox, diphtheria, yellow fever and malaria regularly swept through the city as poverty increased and as people were crowded into airless housing that lacked such rudimentary sanitary measures as plumbing. Thousands of children died in infancy every year from diphtheria, diarrhea and other childhood plagues. Death from tuberculosis claimed thousands upon thousands of city dwellers cramped in the Lower East Side's tenements. Death rates from infections in general sky rocketed.

Disease, still popularly understood as a sign of God's wrath, was linked to the growing numbers of Irish Catholics, Italians and Eastern European Jews. Nativist campaigns aimed at limiting immigration were linked to images of the immigrant as a "microbe," infecting a previously health body politic.

It is not too surprising then, that the city instituted some harsh measures: strict quarantining of arriving ships, the establishment of Ellis Island as a place for medical inspections however incomplete, and the periodic sweeps through poor neighborhoods by the police officers who had been deputized by the recently-created Department of Health as public health police. These actions were as much symbolic acts aimed at reassuring the population as they were logical, reasonable and effective public health activities. During the 1894 epidemic of typhus, for example, the city took an entire building filled with immigrants and placed them in the city's quarantine hospital on North Brother's Island in Long Island Sound which, while looking like decisive action, probably did little to stop the spread of the epidemic.

THE FLU AND FEELING GOOD WITH FACE MASKS AND FUMIGATION

By early in the twentieth century, the development of a more sophisticated understanding of germs and their relationship to infectious disease gave new authority to the now-permanent Department of Health. Killing the bacteria was now more important than improving morals or controlling people.

Still, there were many epidemics for which the precise cause remained unknown, and for which officials were therefore still in the dark about effective treatments or even sound preventive measures. Yet, these officials were still required to give the community a sense of control and a sense of reassurance.

During the epidemic of influenza shortly following World War I, for example, literally thousands of New Yorkers died as the flu swept through neighborhood after neighborhood. Although public health officials had no understanding of how to prevent it, very public measures were taken to make sure that the city remained calm and the public felt safe. City officials encouraged individuals to use face masks, and ordered massive fumigation campaigns, sweeping into poorer neighborhoods and especially homes where victims of the disease had died. There is very little evidence that these measures were useful in stopping the epidemic. They were certainly effective, though, in maintaining a sense of control and order during a period of real crisis.

THE MOSQUITO HAS HELPED SHAPE THE CITY

In certain ways, today's response to the West Nile virus plays out many of the themes that have marked previous public responses to epidemics in general and to those borne by the mosquito in particular. Both yellow fever and malaria, mosquito-borne diseases, have plagued the city literally from its founding in the seventeenth century. Yet, it was only at the beginning of the twentieth century that Walter Reed and others specifically identified the mosquito as the culprit transmitting these diseases to human beings.

This identification has played an important role in shaping the city. Mosquito eradication campaigns and the draining of mosquito breeding grounds became a central activity for the Department of Health. Between 1905 and 1918, the "Mosquito Extermination Division" of New York's Department of Health cleared and drained 25,000 acres of land (laying 2,600 miles of drain pipes) in an effort to get rid of the pest that had just recently been identified as a health threat. Entire neighborhoods were created out what was previously swampland. Ironically, some of these newly created communities were in Queens, adjacent to Jamaica Bay, where many decades later the West Nile virus was first identified.

THE MOSQUITO TODAY

The arousal of public attention to a potential disaster is absolutely necessary in any public health campaign, if it is to be effective in protecting the population. Throughout its history, New York officials have sought ways to encourage people to get immunized, improve their properties by installing water and sewerage lines, and clean up public nuisances that are potential breeding grounds for disease.

But a thin line separates effective and ineffective campaigns -- separates good public health education from the needless creation of anxiety and panic. It is this line that city officials softly tread upon as they seek to engage in attempts to stem a disease that is carried by birds over political boundaries and is transmitted by mosquitoes that may escape the carpet spraying that has transformed the summers of city residents.

As we watch the unfolding of this political, social and biological drama, we must wonder how to draw the line between public health interventions that are meaningful and those that are merely symbolic. We need to find a balance between alerting New Yorkers and unduly alarming them.

David Rosner is Co-Director of the Program in the History of Public Health and Medicine at Columbia University's Mailman School of Public Health.

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