Book Review

Dirt and Disease: Polio before FDR

N Engl J Med 1993; 328:670March 4, 1993

Article

Dirt and Disease: Polio before FDR
By Naomi Rogers. 258 pp., illustrated. New Brunswick, N.J., Rutgers University Press, 1992. $39 (cloth); $15 (paper). ISBN: 0-1835-1786-9

Dirt and Disease is a medical and social history of polio-myelitis in the United States in the early 20th century. Polio cases began to increase in Western Europe and the United States around the turn of the century and reached a terrifying peak in 1916, when a major epidemic hit the mid-Atlantic states. The author, a historian at the University of Alabama, uses the 1916 epidemic as the focal point for an intelligent, well-written account of the medical theories, public health strategies, and social prejudices of the period.

Rogers' book provides an insightful look at how physicians and public health officials tried to use the still relatively new sciences of bacteriology and epidemiology to find the cause of the mysterious spread of the disease. Polio did not fit the dominant paradigm, which attributed the persistence of infectious diseases to the unsanitary practices of the poor, especially immigrants; it attacked rural and urban, immigrant and native-born children in a seemingly random pattern. That poor children might have acquired a greater immunity to the disease, which middle-class suburban children might lack precisely because of higher levels of cleanliness, did not occur to the scientists of the day. They tried instead to find some direct etiologic link -- for example, flies, or what one contemporary called “germs with legs” -- between the sick children of the city and the suburbs.

In tracing the scientific efforts to control the polio epidemic, Rogers clearly shows how difficult it was to integrate the new insights of laboratory science with clinical and epidemiologic information. Demonstrating how the polio virus was transmitted, developing easy diagnostic tests, providing effective treatments, and developing an antipolio serum all proved to be beyond the skills of early-20th-century researchers. The polio epidemic clearly showed the limitations of the experimental method at a time when both physicians and the public were being urged to embrace the authority of science.

In the face of such uncertainty, public health authorities had to control the epidemic as best they could. They turned to the new discipline of epidemiology for clues about how the disease spread. Rogers describes three models of polio transmission, based on urban congestion, insect vectors, and direct contagion by asymptomatic carriers, that were used to make sense of the epidemic. The persistence of the 19th-century equation between dirt and disease, Rogers concludes, led epidemiologists “to ignore correlations that did not seem to make sense.” “They expected polio cases to appear in working-class families who were recent immigrants, living in overcrowded, filthy conditions. The cases scattered among other members of the community were seen as anomalous.” The only way to explain the latter cases was to hypothesize contact with food, milk, or insects tainted by infected immigrants. Thus, public health authorities responded to the threat of polio by emphasizing domestic cleanliness, control of insects, and quarantine of victims.

In the 1920s and 1930s, in large part because of one “celebrity victim” of polio, Franklin Delano Roosevelt, the image of polio as a disease of dirt and poverty began to change. New research on the polio virus in the 1930s and 1940s began to unravel the complexities of its transmission, and safe vaccines against the disease were developed in the 1950s. At that point, the story of polio became one of scientific triumph. Rogers concludes her book by emphasizing that social assumptions can pattern scientific thinking about disease, particularly infectious disease: “We may no longer share pre-Rooseveltian assumptions about the carriers and victims of epidemic polio, but this story should caution us to persist in questioning the assumptions that underlie our definitions of disease today.”

Dirt and Disease is a well-written, persuasively argued work of history. Rogers treats technical matters in a clear and comprehensible way, and she has a good eye for the telling anecdote. Although she portrays the limits of early-20th-century attempts to explain and control polio, she is not harsh in her criticisms, nor does she apply the standards of the present. This is a book that will appeal to anyone interested in the history of infectious disease and its control.

Nancy J. Tomes
State University of New York, Stony Brook, NY 11794