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Infectious Diseases in the 19th-Century City Today I want to talk about the role of medical science and the conquest of disease in the developed world. That's a very grandiose title, but it's very easy for us to take for granted the achievements that make the comforts of our everyday life possible -- for example, clean water, food that is certified pure, sanitation systems for the easy removal of human waste, immunizations and preventive vaccines that protect us from many infectious diseases. Well, in the 19th century, each of these things were very hard to come by for all but the most privileged, and in the case of immunizations and preventive vaccines, they only became widely available during the last decade of the 19th century. Infectious diseases affected thousands of people every year; therefore the control of these things is one of the great triumphs of modern medicine and public health. 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 in the 19th century was the most diverse city in America. By mid-century it had also the worst health statistics in the nation. Data gathered by the city showed that one out of every 36 people died in 1863, as compared to one out of 44 in Boston and in Philadelphia. New York also compared poorly with London and with Liverpool. New York did not turn its attention to the conditions of its city until the middle of the century. And studies in the 1840s attributed the high rates of disease to the poor housing and also the immoral conditions that certain susceptible or unworthy individuals in communities had created. In 1864, the New York Citizens' Association organized a district-by-district and block-to-block inspection of living conditions in Manhattan. What did they find? They found that many of the cobblestone streets were very filthy with accumulations of manure from the horses that traversed them. Dead dogs, cats, and rats littered the streets. Household and vegetable refuse collected in the cracks of the cobblestones to the depths of three feet or more in the winter. So-called garbage boxes were rarely emptied, and they overflowed with awful animal carcasses and household waste. There were pools of stagnant water collected in the carcasses of dead animals, and they collected also over sewer drains, and they were generally very clogged. So filth of every kind was thrown into the streets, covering their surface, filling the gutters, obstructing the sewer culverts, and sending forth what were called the "perennial emanations which must generate pestiferous disease." So filth of every kind was thrown into the streets at all times of the day, and poorly designed sewers had been installed throughout the city, but most of the population depended upon these sort of outdoor water closets and privies in the courtyards of their homes. And in tenement buildings, these privies were often placed very close to the wells that people used to get their drinking water from. Amenities were very few. These so-called water closets were generally covered and surrounded by filth so as not to be approachable. Others were merely trenches, sunken one or two feet into the ground. And the fluids in some instances were allowed to run into the courtyards. And most houses had no sewers, which made the stench that arose in the summer "absolutely unbearable and perilous," as one observer noted. Those concerned about the city were most concerned about the stench. I mean, if you can imagine garbage piled three feet high in the streets, this smelled very, very, very, very badly. And so people believed that this stench itself, the smell itself, was the cause of disease. They believed that the garbage in the streets produced these miasmas -- that is, the stench that people smelled -- and these miasmas sort of polluted the air, spreading across the city, carrying disease with it. It was also feared that unworthy and worthy, the rich and the poor, all were susceptible to the fevers and plagues that were carried throughout the air. And so in New York City, the observers of the conditions found that disease, debasement, and pauperism -- that is, disease, immorality, and poverty -were the major threats to the healthy conditions of the city. Throughout the city, dirty streets, clogged sewers, polluted wells were commonplace. As a result of all this garbage and stench and filth in New York City, epidemics of infectious diseases were commonplace. In the 19th and early 20th centuries, there were four outbreaks of cholera in New York, where more than 5,000 residents died in 1849. Smallpox epidemics waxed and waned over the century, as did typhoid, typhus, malaria, yellow fever, pneumonia, diphtheria, and tuberculosis. I bet many of those things we don't even recognize their names anymore, they have so much disappeared from our landscape. In 1881 and 1887, nearly 5,000 residents died of diphtheria, while typhoid accounted for thousands of deaths in 1864 and '65. The influenza epidemic in 1918 killed 12,562 persons in one year alone. And one of the most disturbing statistics was the large number of infants and young children who died of diarrhreal diseases, especially in the summer. In 1840, approximately 190 of every 1,000 infants born in New York City never reached their first birthdays. By 1930, however, fewer than 70 in 1,000 infants born in New York City died in the first year of life. Young adults also faced harsh conditions. In 1840 and 1870, nearly one-quarter of those reaching the age of 20 would not live to the age of 30. Many of the diseases that caused all these deaths thrived in the dirty water, unpasteurized milk, and untreated sanitation and deplorable housing conditions that were the normal conditions of life for most of New York's inhabitants, especially its poorest inhabitants. It is also important to realize, in the deaths 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 live. Generally people thought that one or two of their children would probably die before they reached the age of 5 or the age 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 among the population and the ways in which they accepted 1 that many of their children might not survive. This, too, was a fact of life that has radically changed for us in the late 20th century. Now, despite the fact that widespread epidemic outbreaks in New York City were really relatively minor contributions to the overall death rates, the problem is that these epidemics were highly visible and dramatic experiences where inhabitants of the city often saw people literally dying in the streets. And it had an enormous impact on the psychological feelings of people who lived in this city at the time. The rich, when these diseases would occur, often fled to the countryside when epidemics broke out. Others simply moved further and further away from whatever parts of the city the diseases had appeared. So many people who lived near the downtown tenement house districts would just move uptown. Others would move out of the city altogether. In particular, port cities like New York, like Boston, like Philadelphia, were particularly susceptible to outbreaks of infectious diseases because these were places where ships coming in from other parts of the world also brought travelers who would have been exposed to these diseases in the cities where they had departed. Cholera, for example, had largely been restricted to the Far East until advances in shipping shortened the travel time between the world's major ports. And because cholera has a very short incubation period and a rapid course, the fact that there was more rapid transportation between the Far East and the U.S. increased the spread of this disease. Now, one of the major changes that occurs toward the end of the 19th century, as people tried to figure out how to control infectious diseases, was the introduction of the germ theory of disease. It became clear that impure water, crowding, poor housing, spoiled food, and other environmental conditions were contributing factors to high rates of disease in the cities. As I said also, people believed that immoral behavior also facilitated the spread of infectious diseases. But during moments of crisis, some also sought to focus on personal hygiene, child care practices, as also leading culprits in the spread of disease. But these differing explanations for high disease rates have profound implications for prevention planning. The only means of preventing these diseases at this time was to clean up the city, improve the housing stock, reduce overcrowding, provide better sanitation, et cetera. Now, this environmental emphasis implied the need for massive social investment and a change in social and economic relationships; that is, to provide better housing for people, to use taxpayers' funds to build major systems, like sewerage systems. One of the causes of diseases that people believed at this moment also implied that there had to be also an emphasis on personal hygiene, and placing the responsibility for hygiene on individuals. This led to a kind of blaming the poor and the sick for their diseases as opposed to saying that diseases lay outside of individuals. But slowly, as medical experts carefully analyzed transmission of diseases, of these infectious diseases, the belief grew that there were specific causes, specific pathogens associated with specific diseases, and these pathogens turned out to be microscopic organisms or bacteria. So beginning in [the] 1870s and 1880s, researchers abroad discovered the microorganisms associated with tuberculosis, with cholera, with typhoid, and with diphtheria. Now, American physicians were initially a little bit skeptical that a little microbe, a little bacteria, could actually cause diseases that wreaked such havoc in the cities, but with the development of diphtheria antitoxin in [the] 1890s, which dramatically reduced the mortality associated with this disease, a number of physicians were finally convinced that the germ theory was correct. Now, for public health experts, the germ theory proved to be especially rewarding, making visible the agents of disease in water, food, and blood. And by the 1910s, physicians were provided with precise tests to identify a variety of diseases. And so the germ theory seemed to promise a precision, not only in the diagnosis of disease, but also in the prevention of disease. And proponents of public health adopted a new approach to their work. They rejected the idea that they had to simply clean up the environment and get rid of the filth. The new public health emphasized that germs were spread by personal contact, and the new practices centered on educating individuals in their responsibility for the prevention of disease. In sum, the focus of public health work changed from citywide sanitation and disease control to closer observation of individuals, their habits, and their contagiousness. And that brings us to the case of "Typhoid Mary." Typhoid was a significant problem in American cities. It is a water- and food-borne systemic bacterial infection. It is important to know what it looks like when people saw it. Its symptoms are sustained fever, headache, malaise, gastrointestinal problems. A few days following exposure, the patient experiences a headache, loss of appetite, chills; and about 10 percent of those who are infected with it die. It struck mostly in cities that had untreated water supplies, and thus, it responded well to the implementation of water-filtration systems and sanitation. But as cities began to build these systems, they still saw typhoid, and they couldn't understand it. Why do we still have typhoid? We've cleaned up the water; we've cleaned up the sewage. And it turns out that the answer was that there were typhoid carriers -- people who had either been exposed to the disease and had an outbreak of it and recovered, or those who do not remember being sick at all, but who nevertheless carry typhoid bacilli in their bodies and could infect other people. The most famous germ carrier, as you know, was an Irish immigrant cook, Mary Mallon, and she has the distinction of being the first typhoid fever carrier to be identified and charted in North America. Mallon worked for several wealthy New York-area families, and in the summer of 1906, she found employment in the rented summer home of a New York banker. When typhoid fever struck six people in the household of 11, the owner of the home, thinking that he would be unable to rent the property again unless he solved the mystery of these cases, hired a civil engineer whose name was George Soper, known for his work on the epidemiology of typhoid, to 2 investigate the outbreak. And Soper's report ruled out all the factors that might be contributing to these cases; that is, contaminated water or milk and other possible sources. And 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. Now, when Soper met Mallon and tried to explain to her that she was a carrier of the disease, she threw him out of her house. Soper then turns to the New York City health department, showed them his data, and convinced them that Mallon should be brought in to have her urine and feces tested for the presence of the typhoid bacillus. And in 1907, she was forcefully apprehended by city health officer S. Josephine Baker with the help of the police. She was taken against her will to the Willard Parker Hospital, which was New York's hospital for contagious diseases, and there they subjected her to careful laboratory tests. And the results showed high concentrations of typhoid bacilli in her feces. She was kept in health department custody in an isolation cottage on the grounds of the Riverside Hospital on North Brother Island. In 1909, she unsuccessfully sued for her release. In 1910, she was freed, but she was arrested again later after officials traced a house-hospital outbreak of typhoid fever to her kitchen. And this time, when they apprehended her, she was placed in custody until her death in 1938. She lived in health department-imposed isolation for a total of 26 and a half years. Typhoid, Polio, and Diphtheria: Science and Class Issues Professor Hammonds: What conclusions did people come up with about the health department's decision, the issues that her incarceration and isolation raise? Yes? Ron Morrison: I took the position of one of the health officials, that isolating her, putting her in her own, separate cabin was the right thing to do. I sort of started off feeling bad. 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 simple fact -- You know, isolating a few individuals for the 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 what was done then. Professor Hammonds: So -- but it could happen now. That's the point I was trying to make. It could still happen. Ron Morrison: Yes. I agree with you wholeheartedly. Professor Hammonds: Other comments? I saw a couple -yes? Larry David: One of the things that we discussed was, what is the nature of a public health crisis? What determines what crisis is in general? And we bandied that about in our group. And one of the things we noted is that it changes with the time. Previously there hadn't been -- It hadn't been perceived to be a crisis in the 1830s and 1840s, '50s, and '60s. While you have the disease, it's not perceived as a crisis. In the progressive era it is, because of the changing mind-set of the public, and especially the middle class. Professor Hammonds: Well, no, I think outbreaks of disease, especially infectious diseases that cause large numbers of deaths, are always perceived as a crisis. Even today they would be perceived as a crisis. Larry David: It depends on who is affected. It depends on the segment of the population. 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 infected? Or is it a crisis no matter who is infected? Yes? Ed Morrison: She was poor; she was Irish; she was Catholic; she was an immigrant; she was a woman -- all people who really had no status or perceived position in society at that point in time. I just think she was easy pickings. I think she was victimized. Professor Hammonds: So you think they were making an example of her? Ed Morrison: Exactly. An example. And then, to the extent 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 the AIDS crisis. When that first started, they were homosexuals, gay people, drug addicts, throwaways in our society, and in more recent times, obviously African Americans -- again, not the most prominent group of people that we address. So I agree. I think it's those who are the most vulnerable, who are the least, that oftentimes are susceptible to be mistreated when a crisis comes, and their liberty taken away. Professor Hammonds: Suppose we faced a new disease, and we didn't quite know what was going on, and the only thing we knew was that there were some people out there who were infecting other people. We tried to ask -- The public health officials asked them to stop. They don't stop doing whatever it is that causes the disease to be transmitted. What are we going to do with them? Ron Morrison: Isolate them. I mean, you bring them in, and you isolate them, if need be. 3 Professor Hammonds: Does anybody else want to argue that there were good reasons for isolating Mary, that it makes sense? Yes? Eugenia Rolla: They really needed to kind of legitimize their position within this kind of new, emerging, progressive time, and so they needed to take a stand. That's not to say what they were doing was correct or just. But from their perspective, from a bureaucratic perspective, in order to kind of say, "Hey, this is what our job is, and we're facing this crisis, and this is what we're doing," I think it was necessary for them to set a precedent to a certain extent Professor Hammonds: You raise a good point. It is clear that they wanted to establish a precedent about what to do about carriers. What they're doing is, they have a new kind of issue to deal with: How do you control people who are otherwise healthy, are not sick themselves, but can cause disease? Now, Mary Mallon is saying, "Well, I've never been sick. I don't know what these people are talking about. I don't understand this. They tell me I have these germs, that I give the what? I don't know anything about this." And most people didn't 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 health department going to have to make this abstract notion concrete? In part because, as I said, the germ theory, as it is applied to public health, changed the focus of public health to individuals' behavior and their responsibility in transmitting infectious diseases. Yes? Steven Seto: The evidence was brought to the board of health. They didn't go search it out. And from the -- Given the information that I have, it didn't sound -- it didn't seem as if they went out to look for anybody else afterwards. I mean, there were still over 4,000 cases of typhoid while they had Mary in isolation. Professor Hammonds: What happens is, they began a much more concentrated health education effort to get those people who work as cooks, who may have been exposed to typhoid, to wash their hands; to really begin to mandate that people who work in restaurants, around food, who may have been exposed to typhoid, to wash their hands. You've all seen those signs in the bathrooms. So they begin this kind of effort because they know they can't go hunting for these carriers. They don't have anywhere to put these people. They don't have the manpower to trace whether each individual carrier is responsible for particular outbreaks of disease unless something happens, and they, you know, they have to intervene. But by and large, they don't have the manpower to track down all these people. So again, as I say, in a strange kind of paradoxical way, Mary becomes this sort of symbol for them of what can happen. But they know that they can't do this to everyone, so they institute health education efforts to encourage the rest of the public to comply with the kinds of things that are going to prevent the spread of these kinds of diseases. Yes? Matthew DeBoer: Do you think that Mary posthumously became a martyr, and if so, what did her martyrdom represent? Professor Hammonds: Yeah, I do think she becomes a martyr, in the sense that what would most of us know about "Typhoid Mary," just sort of a general kind of popular view? It's almost as if she was this woman who deliberately went about spreading disease and trying to hurt people, you know? Even the cartoons that appear about her in newspaper accounts at the time show her as evil and malevolent in some kind of deliberate way, right? And I think the fuller context of the 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 the evidence is presented to her, she had a lot of doubts about the evidence. And I think the fundamental basis for her doubt is simply that she was never sick. And it's very hard, I think, for people to understand that you could transmit disease when you're not sick. She couldn't remember ever having typhoid. Here the authority is telling her this. You know, it sort of gets picked up and exploded into this other set of issues, and I think she comes down through history as, you know, "Typhoid Mary," as sort of the evil one. There is another case that we might look at as just counter to that is in diphtheria, which is childhood disease. In the case of diphtheria, many, many adults are carriers. There are thousands of diphtheria carriers in New York City. And one doctor says, "Well, I just think, you know, we just need to set 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 of them that have diphtheria bacilli in their throats, they can't be servants; they can't be teachers; they shouldn't be able to work in candy stores," where it killed children, anywhere that they could have any contact with children. And that's what he wanted to do. And of course the public health officials said, "We can't do that. How are we going to do that?" Yvonne Powell: It is rather interesting how impotent the judicial system appears to be, however, in this process. I mean, the writ of habeas corpus is not -- is overturned. The 14th Amendment is absolutely ignored. The judiciary is almost an agent of the public health department. Professor Hammonds: I think that there are some interesting tensions there in what happened in the courtroom. My reading of that has to do with the authority of the scientific evidence and the way in which the court deferred to that as the bottomline explanation, and I also think because they don't put Mary in jail, for example, that she is isolated in a cottage and that there are ways in which I think people might see that as a fairly benign kind of "punishment." My reading of the case sees it -- I think those factors play in as well, but I think the key of it is that the bacteriological evidence that the health department presents and the stature of the health department at that time carries the day in the court. I also want to say that outbreaks of infectious disease raise a whole host of issues beyond simply ones about individual rights versus the public's health. And I want to turn to another epidemic -- the outbreak of polio in New York City in 1916 -- 4 as a good example to look at some of the other issues that emerge. Poliomyelitis is a viral disease, characterized by fever, headache, and sometimes stiffness of the neck and back. In paralytic cases, the virus attacks the motor nerve cells in the spinal cord, which governs your muscles, and if the muscles needed for breathing or swallowing are affected, the patient may die. Now, unless weakness or paralysis of the muscles in the limbs is minor or improves after the acute attack, most victims of polio will be crippled for life. In 1916, a national epidemic of polio emerged with 27,000 cases in 26 states, with 6,000 deaths. In June 1916, New York City had the largest single incidence of the disease, with over 8,900 cases and 2,400 deaths, and a mortality rate of more than one child in four. So again, we've just talked about typhoid in New York City. This is coterminous with typhoid. So you have outbreaks of typhoid in New York City; you have outbreaks of diphtheria; you have this huge outbreak of polio. Again, look at the landscape of the city at this point in time. This is not a healthy place in many respects. New York City remained a center for polio epidemics for the next four decades. And initially it was seen, as many infectious diseases were, as a disease of unsanitary living conditions and of the immigrants -- the immigrants' bad behaviors. But polio slowly became more associated with the middle classes by the 1930s, and then was considered as a danger to all. The agent, the pathogen that causes polio was identified in 1908 as a filterable virus, but the 1916 epidemic generated enormous fear in the public. Health officials had to deal with families fleeing the center of the disease, and they also had to deal with people who stayed behind. The officials tried to restrict people's movement; they tried to identify the sick; they tried to placard people's houses where the sick were. They also tried to calm public fears, though they weren't quite successful with that. And in New York City, as people, many people, just, again, tried to leave, you know, it's like, time to leave, take the kids, get out of the city. To identify those free of the disease, the city's health commissioner introduced a system of health certificates, in part because neighboring towns were restricting entry to people from New York City who didn't have a certificate certifying that their children were free of the disease. These certificates gave communities outside New York City one way to assess whether a child was free of infection. By the end of the epidemic -- that is, it went into the early fall -- 68,000 certificates had been issued. Even so, New York children were frequently refused entrance to neighboring towns, are threatened with quarantines that lasted as long as four weeks. In a few cases, like the city of Paterson, New Jersey, they said until further notice, no nonresidents will be allowed to enter the city. And a city on Long Island just put big red signs up on the main road entering the town that all children who lived outside of the town would not be allowed to enter it. Placards identifying housing where there were many cases of the disease were placed outside tenement buildings, but these placards were never placed outside of middle-class homes, because it was at -- In one sense, the health officials believed that the disease was less dangerous in middle-class communities than it was in the immigrant communities, so you see constantly the ways in which the fear of the immigrant classes and their threats to the city get pretty wrapped up in public health policies, even after the introduction of bacteriology and more scientific-based public health. The other thing that happened to poor parents is they were faced with the prospect of their children being removed from their homes and taken to the contagious disease hospital if health officials felt that they couldn't provide adequate care for the children inside of their homes. All manners of public gatherings were cancelled during the epidemic. Theaters... The health commission instructed all motion picture theaters to bar entry to children under 16. And even though the theater owners protested and said they were losing money, the city maintained the closure of the theaters. Playgrounds were closed. Sand piles were disinfected. Children's reading rooms in public libraries were closed. And parents were also urged to guard the behavior of their children. One official told parents to avoid caressing or kissing children, to forbid children from buying fruit or other exposed foods from street vendors, and to keep them from exchanging toys, marbles, candy, or chewing gum with other children. Now, despite the dominance of the new public health, the department ended up blaming the epidemic on the irresponsible sanitary behavior of immigrants. But this began to wear thin, because this kind of explanation couldn't explain the appearance of the disease in middle-class homes. And eventually, epidemiological research would show that children in more affluent homes were in fact more at risk to polio than poor children. Poor children, in fact, were more exposed to the virus when they were very young, because the virus was very prevalent in New York City. So they were exposed at a very young age and tended to have a mild reaction, in many cases. Middle-class kids were not exposed to the virus. They're kept inside much more, shielded from contact with other children much more as infants, and so they weren't exposed at the same early period, and when they were finally exposed, the virus had more severe effects. So as historian Naomi Rogers has noted, the 1916 polio epidemic and the campaign to contain it, we have to understand this in the context of its time. These health officials, as someone mentioned earlier, were part of a progressive reform movement, and they tried to use legislative power -- that is, the laws on the books that public health officials could invoke -- in the time of outbreaks of disease. They also tried to use moral persuasion to address these kinds of outbreaks and to deal with a whole host of urban problems. But one of the things that I think is an aspect of these kinds of reformers in situations like this is that they believe that the city was both an incredible place to be, but it was also a very threatening place to be. It was dirty; it sort of had a kind of immoral cast to it. And these things had to be contained, controlled, and regulated in order for the city to be a healthy place for either the poor or the middle class to live. 5 And these reformers believed that regulation wasn't enough. The behavior of individuals had to be altered, and that -whether that behavior could be changed through education, that was the best way, so to educate people about what to do in the face of these kinds of infectious disease outbreaks, including putting screens on their windows when it was widely believed that polio was being transmitted to humans via flies, and that meant that everybody had to defer to scientific authority. If the experts said it was time to get your window screen, you had to get your window screen, or else you were going to be stigmatized as someone who was threatening everybody else's health. In a sense, through this education campaign and deference to the authority of scientific experts, these reformers really hoped to transform the family, home, community, and ultimately the American society as a whole. And to achieve their goal, health officials really exalted the role of medical science and supported the use of government power. Now, in this case, exalting the role of medical science in the case of polio in 1916 turned out not to be such a great idea, because the medical, the scientific knowledge about polio was very 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. compassion in the initial days. Once children became infected with AIDS, you know, I think you sort of see change in people's willingness to think about ways we might contain the epidemic that were not so harsh. After the discovery of the vaccine for polio, along with the development of other vaccines, the memories of fear and stigma associated with outbreaks of these diseases tended to fade from public view, and a kind of complacency set in. People thought, well, we've conquered all the great infectious diseases of the 19th century: tuberculosis -- we know how to deal with that; syphilis, gonorrhea, typhoid, typhus, yellow fever, malaria, polio, diphtheria, all the great killers -- we had really effective means of controlling them. And people thought we were now entering the golden age when we would be free of infectious diseases. And then the 1980s came, and AIDS came, and people said, "Uh-oh." Our complacency was truly shattered. The control of infectious diseases, I want to end by saying, is one of the great triumphs of public health and scientific research in this century. But I think the major point to take away is that with every success came very real challenges to the values that Americans hold dear. Thank you. 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 [was] thought of to be a disease of gay men, of drug addicts, of people engaging in various sexual, sexually deviant behavior. The response did not evoke a great deal of 6