December 14, 2018
Nurses and patients in a late 19th century military hospital

Life Before Vaccines: My Story

by Margot Smith, DrPH

Medical science has profoundly changed our lives. I am sure that I would not have survived to this old age without antibiotics and advances in epidemiology and surgery. I was a child in the 1930s. We lived in a flat across the street from my grammar school playground and I had friends in the neighborhood. It was a time when parents simply said “Go out and play” and we did. Our games were hopscotch, kick the can, jacks, tag, jump rope, handball, and hide and seek. We cruised on roller skates and bikes, and built club houses out of boxes in vacant lots. We were supposed to come home at twilight, before dark. The milkman, bakery truck, and iceman delivered to our doors. We felt safe in our neighborhoods.

But my parents were fearful of epidemics. At school in first through 8th grades, I had classmates who suffered from scarlet fever, mumps, measles, German measles, chicken pox, and whooping cough. I had rubella and had to stay in bed for several days in a darkened room; they thought light was bad for sick children’s eyes. Several of these diseases required the family to put a quarantine sign on their door; their children missed a lot of school.

As an adult, I knew survivors—men who could not father children because they had mumps as a child, a woman with a flail arm from polio, people with chicken pox scars, those deafened because of measles, a man who spent 3 years in a tuberculosis sanitarium and a woman whose child was mentally disabled because she had German measles during her pregnancy. I have friends who had polio then who now have post-polio syndrome—that is, muscle weakness, fatigue, and pain, for which there is no known cure. They experienced their illnesses before vaccines and antibiotics.

Understanding disease

In the 1930s germ theory was less than 100 years old. Although people from Biblical times knew that diseases were contagious, no one knew exactly how they were spread. In 1854 there was the famous moment when John Snow stopped an epidemic of waterborne cholera in London by removing certain water pump handles. In the 1860s, Louis Pasteur and Robert Koch found that diseases were caused by germs—this led to both a new world of medical exploration and to new fears as to how epidemics originated. We were supposed to wash our hands after we handled money because it was contaminated with germs when touched by other people.

All had heard of Typhoid Mary, the infamous cook in 1900 New York who was a typhoid carrier and infected her employers. She was finally quarantined and incarcerated. The well-known author Helen Keller was blind and deaf because of fever as a child; she was taught to communicate through sign language and later speech by her teacher, Anne Sullivan. A movie, The Miracle Worker, was made in 1960 about her life.

The discovery of germs led to the birth of the Public Health movement and laws and practices designed to control the spread of disease. At that time, the main way epidemics were prevented was by quarantine, the isolation of the ill. When I was a child, patients and entire families could be quarantined. Quarantine was first used in Italy in the 14th century for ships crews coming from places with plague epidemics; later, in the 19th century, it was used to limit the spread of plague, cholera, yellow fever, and smallpox. Today, there are still laws for quarantining people and animals arriving on ships and planes.

These are guidelines for how long diseases are contagious and possibly how long quarantines were needed:

  • Poliomyelitis: 40 days
  • Diphtheria: Onset of sore throat for up to 4 weeks
  • Measles: 4 days before rash until 4 days after rash appears
  • Rubella (German measles): 7 days before rash until 5 days after rash appears
  • Chicken pox: 2 days before rash until all sores have crusts (6–7 days)
  • Scarlet fever: 21 days from the onset of the disease (in the absence of complications, 15 days)
  • Mumps: 5 days before swelling until swelling gone (7 days)
  • Whooping cough (pertussis): Onset of runny nose until 21 days after symptoms.
  • Typhus: 12 days after the fall of temperature

The first vaccine

People long knew that exposure to certain diseases made them immune; one could get certain illnesses only once. This was known about smallpox, which killed about 30 percent of those who caught it and often left facial scars on survivors.

In Asia, India, and Turkey, it was known that inoculation with smallpox scabs could lead to a mild disease that made one immune. Lady Mary Montagu, the wife of England’s ambassador to Turkey, was the first to bring the practice into Europe. In 1715, she was disfigured as a result of smallpox. After learning about inoculation in Turkey, she was determined to protect her six-year-old son from the disease through inoculation. “The smallpox, so fatal, and so general amongst us, is [in Turkey] entirely harmless by the invention of [inoculation],” Montagu wrote to a friend. “There is a set of old women who make it their business to perform the operation every autumn…The old woman comes with a nut-shell full of the matter of the best sort of smallpox, and asks what veins you please to have opened…”

In the 1790s, Edward Jenner, a country physician in England, noticed that the faces of milkmaids, the young women who milked cows, were rarely scarred with smallpox. He found that their exposure to cowpox, an infection of cows, protected them. This led to the development of cowpox vaccination as smallpox prevention—the word vaccine is derived from the Latin, Variolae vaccinae (smallpox of the cow).

Immunization to smallpox was important in the Revolutionary War. George Washington in 1790 ordered mandatory inoculation for troops who hadn’t survived smallpox before. However, inoculation with this live virus was dangerous: It killed about 2 to 3 percent of those injected with even small amounts. Today, vaccines are developed from dead or weakened bacteria or virus.

My childhood vaccination for smallpox left a scar on my upper arm, a rarity now. In the "History of Medicine in California" mural at the University of California Medical School in San Francisco, artist Bernard Zakheim shows James Ohio Pattie in 1829 vaccinating the California Alcalde (governor) with cowpox during a smallpox epidemic; vaccination was a novelty at that time and place. Massachusetts was the first state in the U.S. to require smallpox vaccination in 1902.

Now that smallpox has been eradicated, smallpox vaccinations are no longer required. The last U.S. wild smallpox case occurred in 1949 and, after extensive vaccination campaigns, the last case of smallpox in the world occurred in 1977.

Our Disease-Fighting Heroes

As kids we loved movies that idolized those who fought disease. Here's a sampling of the films that inspired many of us to go into the health care field.

Vaccines for common childhood diseases

Polio: For my parents, polio was a major fear. In summer, public swimming pools were closed because of polio, which thrived in summer months. The consequences of polio were serious: Children lost the ability to walk, to breathe, to use a limb. Hospitals had wards full of patients living out their lives in iron lungs.

Our president, Franklin Roosevelt, was a victim of polio. He found relief from his symptoms with trips to Warm Springs, Arkansas. Later, in the 1940s, polio patients were treated with exercise in warm pools, a method discovered by the Australian nurse Sister Kenney. She invented the concept, physical therapy. Many cities built warm pools where children and adults with polio could find exercise. In 1938, the March of Dimes was founded to fund the effort to find a vaccine. In 1960, 2,525 cases of paralysis due to polio were reported. In 1955, Jonas Salk developed the first polio vaccine, and it came into use that year. The oral polio vaccine was developed by Albert Sabin and came into commercial use in 1961.

In 1963, I gave my children an oral vaccine developed by Albert Sabin in a sugar cube and was grateful that I did not need to fear this dreadful disease. In 1965 there were only 61 cases in the U.S. By 1994, polio was declared eliminated from the Americas. In 2002, it was eliminated from Europe. Today, only Pakistan and Afghanistan continue to have polio cases.

Diphtheria: In my childhood, I was not aware of anyone having diphtheria. However, my mother was from Eastern Europe (Chernowitz, Ukraine), born in 1893 and the youngest of 11 children. She knew only eight of her siblings as her parents lost three sons to diphtheria in one week, years before she was born. At that time, 40 percent of children who caught diphtheria died. The British royal family suffered from diphtheria epidemics during the late nineteenth century. Four members of the royal family died in the 1870s. Thanks to the discovery of germs as a cause of disease, diphtheria bacteria were observed by Theodor Klebs in 1883 and cultivated by Friedrich Löffler in 1884. The first successful vaccine for diphtheria was in 1923.

Vaccination for diphtheria became wildly popular in the U.S. after an outbreak in Alaska resulted in the famous Great Race of Mercy from the town of Nenana to Nome by dog sled. Balto, the lead sled dog on the final stretch into Nome, has a statue in New York City’s Central Park. The relay took five and a half days and was successful in delivering the diphtheria vaccine that saved Nome and its surrounding communities from the epidemic. The race received coverage in newspapers around the country.

The Race of Mercy news generated a vaccination campaign in the U.S. that dramatically reduced the incidence of the disease. In the 1920s, there were 200,000 cases of diphtheria a year in the U.S. and 15,000 deaths; there were no deaths in the U.S. in 2015. We children did not experience diphtheria because we were vaccinated. However, today there are reports that Indonesia, Pakistan and other countries with refugees still have outbreaks and deaths.

Measles: Measles were another real danger for us children. In 1912, U.S. healthcare providers and laboratories were required to notify the health departments of measles cases. In the first ten years of reporting, there were about 6,000 measles-related deaths each year and 48,000 infected people were hospitalized. Complications from measles include difficulty breathing, ear infections and loss of hearing, seizures, hepatitis, and eye infections, as well as potentially fatal complications including and neural and heart problems and pneumonia.

Before 1963, when a vaccine became available, nearly all children got measles by the time they were 15 years of age. I never caught measles and was glad to vaccinate my children. We feared measles, whooping cough, rubella, mumps, and scarlet fever—they might be fatal, or make us very ill and keep us out of school for weeks. Some parents arranged to expose their children to measles and chickenpox. These diseases were far more dangerous in adults.

A prevention timeline

The success of small pox vaccination and the identification of specific germs led to a search for vaccines for other diseases. In my lifetime, these vaccines now protect my children and grandchildren from devastating diseases:

  • 1923: diphtheria
  • 1924: tetanus
  • 1940: pertussis (whooping cough)
  • 1961: poliomyelitis (polio)
  • 1963: measles
  • 1967: mumps
  • 1969: rubella (German measles)
  • 1994: hepatitis B
  • 1995: varicella (chickenpox)

We no longer fear epidemics and deaths from these childhood dangers because vaccination prevents them and we have antibiotics to treat them. Because so many people are vaccinated, these diseases are no longer commonplace. Although not all children are vaccinated, these diseases are under control. Epidemiologists call this the "herd effect"—protection from infectious diseases that happens when most of a population is immune and thereby protects those who are not immune. I for one am grateful that these deadly illnesses are no longer prevalent.

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