Hookworm and its impact on public health reform in the twentieth century.

        The cycle of the hookworm parasite began with an unsuspecting person stepping on ground infested with hookworm larva from an infected human’s feces.  This usually took place in poorly built outhouses in the rural South where walking barefoot was the norm.  Stepping barefoot on infested fecal matter in a dilapidated outhouse was the most common way hookworm was spread and impossible to avoid until adequate sanitary facilities were constructed.  Early reports on hookworm attributed the Southerner’s disposition for walking barefoot as a joyful habit, one that was undertaken voluntarily.  Perhaps the more likely scenario was that poor rural Southerners could not afford appropriate footwear and due to the South’s warm climate could get by without shoes.  The South’s poor spent what money they had on things that were crucial to survival, shoes not being one of them.  Once a barefooted Southerner stepped on hookworm infected ground, the hookworm entered its victim’s body through the tender skin between the toes, causing an irritation popularly dubbed “ground itch” or “dew poison.” In the bloodstream the hookworm parasite worked its way to the lungs and made its way up the bronchial passages into the throat.  At this point, the hookworm’s host would cough up the hookworm and inadvertently swallow some parasites, passing them into the gastrointestinal tract.   The hookworm parasite would then fasten onto the lining of the upper part of the small intestine and began feasting on the host’s blood. Securely lodged in the bowels and supplied with a limitless source of food, the female adult hookworm would lay approximately 10,000 eggs a day directly into the gastrointestinal tract.  The hookworm eggs would pass out of the host’s body in the feces, where they would wait to be stepped on and start the cycle all over again.  Unlike other parasites, hookworm eggs display an unusual tenacity during all stages of its life cycle.  Under optimal conditions, hookworm larva can live in soil for months without finding a host.   The South’s ideal climate and soil conditions combined with the lack of adequate sanitary facilities explain why hookworm easily became and remained such a widespread regional epidemic.  Poor sanitary conditions and the spread of the hookworm parasite went on unimpeded in the South until the Italian physician Camillo Bozzolo found the first cure used in the United States for hookworm disease.

        Bozzolo discovered that a dose of thymol followed by an Epsom salt chaser on an empty stomach would first jolt the worms loose from the intestinal wall and then forcibly expel them from the system.  The average thymol dose was from two to ten grains, or about one to two grams.  It was customary to give the drug in two or three doses, giving each dose one or two hours apart in order to prolong the presence of thymol in the upper bowel.  Once thymol was administered, the patient was told to remain in bed and abstain from food or drink until one or two free bowel movements had occurred.  In order for a patient to be completely cured, four to eight thymol treatments at weekly intervals were usually necessary. For nearly thirty-five years thymol remained the standard treatment for hookworm until replaced by other drugs in the 1930’s.  However, the thymol cure was only the first step taken to combat the proliferation of hookworm.  Prevention of an individual becoming infected again proved much more difficult than administering the thymol cure.  A cured indidvual could easily contract hookworm again because of the problematic habit of walking barefoot in infested outhouses.  Southerners therefore had to be informed about the importance of footwear when outside and also provided with sanitary outhouses that would not serve as a vector for spreading hookworm. This would not prove to be an easy task.  A survey made in the southern United States in the early part of the twentieth century showed that about sixty-eight percent of rural homes in the South were not equipped with outhouses of any kind.  One organization created to provide the South with outhouses and establish regulated state public health agencies was the Rockefeller Sanitary Commission for the Eradication of Hookworm.

Heralded as “the greatest galvanizing event in the history of the rural reform movement of the early twentieth century,” the Rockefeller Sanitary Commission for the Eradication of Hookworm was organized on October 26, 1909 as a result of a gift of one million dollars from John D. Rockefeller.  Rockefeller hoped that a five-year campaign against the disease would lead to the adoption of well-considered plans for a cooperative movement of the medical profession and other agencies.  The Commission funded programs to provide an accessible cure for hookworm as well as medical education reform. The Commission’s medical chair Charles Stiles toured and surveyed the South and Midwest, documenting hookworm statistics to persuade the Commission to fund the implementation of effective state public health programs.  Stiles estimated that there were two million cases of hookworm in the South around the turn of the twentieth century and used his staggering statistics to lobby for government intervention in exterminating hookworm.  With the consent of the Commission, Stiles organized a board of distinguished and influential Southern men to begin the eradication of hookworm. However, the Commission’s most important contribution to the South was not the eradication of hookworm, but the network of state and local public health agencies it left in its wake.  

Before the Commission intervened, state public health systems were understaffed, legally powerless, and without adequate funds.  The first Commission funded attempt by a Southern state health agency to control hookworm disease was undertaken in 1910 in Richmond, Virginia.  Once the health agency was implemented, Virginia experienced a dramatic change in the prevalence of hookworm infestation.  In April 1910, an average of 82.6 percent of children were found infested in Virginia’s schools.  Ten years later in the summer of 1921 the population of hookworm sufferers dropped to 2.2 percent!  Previous to Commission funded local health agencies, the South’s public health efforts had been centered on larger towns and cites while health protection for people living in rural country districts remained neglected.   Due to the Commission, state health programs for rural counties in the United States rapidly appeared.  In 1916 fourteen full time county public health programs existed in the United States, by 1926 there were three hundred and forty-one.  The Commission’s funding of state health programs made the physical welfare of people in rural as well as urban areas become recognized as much of a part of Southern governments as police or school systems.

After the Commission dissolved to form the Rockefeller Foundation in 1915, state public health systems and public opinion of them were left greatly improved.  Once hookworm began to recede because of improved public health systems, school attendance rose sharply in places where hookworm had been common and then nearly eradicated.  Children cured of hookworm were twenty five percent more likely to attend school than similar children who were still infected with hookworm, leading to a more productive adulthood for the cured children.  By 1940 an adult who was hookworm free as a child earned forty-five percent more compared with an individual who had been infected with hookworm.   The eradication of hookworm enabled a more productive Southern population slowing narrowing the economic gap between the poor in the South and the poor in the North.  Perhaps the newfound economic productivity directly resulting from the eradication of hookworm is why the capitalistic Rockefellers began the Commission. Healthier workers equated to more productivity and income from factories owned by the upper class.  For whatever reasons the Commission was started it marked an important change in the United States public health system forever.

In conclusion, the hookworm epidemic opened a new chapter in public health reform and changed sanitary conditions in the South forever.  Because hookworm was generally not deadly but disabilitating, it escaped detection for centuries and would have remained a part of the South if not for Charles Stiles and the Rockefeller Sanitary Commission.  Through the Commission, hookworm acted as a catalyst for a change in public health policies in the United States by placing greater importance on prevention of a disease rather than only emphasizing a cure.  The importance placed on the prevention of hookworm lead to the construction and proper maintenance of adequate sanitary facilities throughout the South.  The Commission also enabled public health systems to become properly funded and staffed, being able to perform their job of informing the public to lessen the spread of a communicable disease such as hookworm.  The expanse of state public health programs throughout the South was the beginning for a nation wide reform in public health, predominantly due to the hookworm epidemic.