How The 'Pox' Epidemic Changed Vaccination Rules

Pox: An American History
Pox: An American History
By Michael Willrich
Hardcover, 400 pages
Penguin Press
List Price: $27.95

Read An Excerpt

Historian Michael Willrich was planning to write a book about civil liberties in the aftermath of Sept. 11 when he stumbled across an article from The New York Times archives. It was about a 1901 smallpox vaccination raid in New York — when 250 men arrived at a Little Italy tenement house in the middle of the night and set about vaccinating everyone they could find.

"There were scenes of policemen holding down men in their night robes while vaccinators began their work on their arms," Willrich tells Fresh Air's Terry Gross. "Inspectors were going room to room looking for children with smallpox. And when they found them, they were literally tearing babes from their mothers' arms to take them to the city pesthouse [which housed smallpox victims.]"

The vaccination raid was not an isolated incident. As the smallpox epidemic swept across the country, New York and Boston policemen conducted several raids and health officials across the country ordered mandatory vaccinations in schools, factories and on railroads. In Pox: An American History, Willrich details how the smallpox epidemic of 1898-1904 had far-reaching implications for public health officials — as well as Americans concerned about their own civil liberties.

"110 years ago, vaccination was compelled by the state," he says. "But there no effort taken by the government to ensure that vaccines on the market were safe and effective. We live in a very different environment today where there are extensive regulations governing the entire vaccine industry."

At the turn of the 20th century, explains Willrich, there were little to no regulations governing the pharmaceutical industry. Many people were forced to receive the vaccine — most of the time against their will.

"There was one episode in Middlesboro, Ky., where the police and a group of vaccinators went into this African-American section of town, rounded up people outside this home, handcuffed the men and women and vaccinated them at gunpoint," says Willrich. "It's a shocking scene and very much at odds with our daily-held notions of American liberty."

People infected with small pox would also be quarantined against their will in large isolation hospitals called pest houses.

"People would literally dragged there against their will," he says. "Some of the most poignant scenes are when mothers are fighting with health officials to keep their children in their own homes rather than have them be taken off to a pesthouse. People at the time rightly associated pest houses with death. That's where someone was taken to die."

Michael Willrich is an associate professor of history at Brandeis University. He is also the author of City of Courts and contributes regularly to The Washington Monthly and City Paper. i i

hide captionMichael Willrich is an associate professor of history at Brandeis University. He is also the author of City of Courts and contributes regularly to The Washington Monthly and City Paper.

Dari Michele/Penguin Press
Michael Willrich is an associate professor of history at Brandeis University. He is also the author of City of Courts and contributes regularly to The Washington Monthly and City Paper.

Michael Willrich is an associate professor of history at Brandeis University. He is also the author of City of Courts and contributes regularly to The Washington Monthly and City Paper.

Dari Michele/Penguin Press

Resistance To Vaccinations

From the very start of the organized vaccination campaign against smallpox, there was public resistance, says Willrich. The battle between the government and the vocal anti-vaccinators came to a head in a landmark 1902 Supreme Court decision, where the Supreme Court upheld the right of a state to order a vaccination for its population during an epidemic to protect the people from a devastating disease.

"But at the same time, the Court recognized certain limitations on that power — that this power of health policing was no absolute and was not total and there was a sphere of individual liberty that needed to be recognized," says Willrich. "Measures like this needed to be reasonable and someone who could make a legitimate claim that a vaccine posed a particular risk to them because of their family history or medical history [would not have to be vaccinated.]"

In addition, the Supreme Judicial Court of Massachusetts stipulated that a state couldn't forcibly vaccinate its population.

"[They said,] 'Of course, it would be unconstitutional and go beyond the pale for health officials to forcibly vaccinate anyone because that's not within their power,'" says Willrich. "And I think that's really a shoutout to the Boston health authorities who were employing forcible vaccination all the time in the poorest neighborhoods in the city."

Because so many refused to get vaccinated, there were isolated incidents of smallpox outbreaks in the United States until 1949, says Willrich. It wasn't until 1972 that the U.S. government decided to stop mandatory vaccination against smallpox, in part because the disease had been largely eradicated.

The Current Anti-Vaccine Controversy

In 1998, the British medical journal The Lancet published a report by Dr. Andrew Wakefield that suggested that there might be a link between autism and the measles, mumps and rubella (MMR) vaccine.

"This paper was thoroughly discredited and debunked but the idea that vaccines might somehow be the cause of autism stuck," says Willrich. "And so, according to some of the most recent studies, something like one-fifth of all American parents believe that vaccines cause autism. This is simply not true. But it's a powerful association in the public mind."

Wakefield is no longer allowed to practice medicine in England and The Lancet withdrew the study in 2010. In January, 2011, the British Medical Journal said that the study wasn't just wrong — it was "a deliberate fraud" that altered key facts to support the link between vaccinations and autism.

Even though the study was discredited, many people continue to believe the link between vaccinations and autism, says Willrich.

"[In 2003,] according to the CDC, there was something like 22 percent of American parents of young children were refusing one or more vaccines for their children," he says. "Five years later, that percentage had nearly doubled to about 40 percent of all Americans. So the vaccine controversy today is one of the most important public health crises we face in America."

And, he says, public health officials can and should do more to inform the public that the American Academy of Pediatrics, the American Medical Association and the CDC all believe that vaccines are safe.

"I think this is the time for doubling their efforts to spread the good word about vaccines and also have a candid public discussion about the risks and benefits," he says. "There's no more opportune moment than the present to launch a new publicity campaign around vaccines. ... Viruses spread in human populations from person to person and if you have a vast majority of a community vaccinated against that virus, the virus will simply never have a toehold in that community."

Excerpt: 'Pox: An American History'

Pox: An American History
Pox: An American History
By Michael Willrich
Hardcover, 400 pages
Penguin Press
List Price: $27.95

New York, 1900

Manhattan's West Sixty-ninth Street no longer runs from West End Avenue to the old New York Central Railroad tracks at the Hudson River's edge. In the space now occupied by aging high-rise condominium towers and their long shadows, there once stood a low-slung street of tenements and houses. At the turn of the twentieth century, it was said to be the most thickly populated block in the most thickly populated city in the United States of America. Someone called it "All Nations Block," and, being a pretty fair description of the place, for a while the name stuck.

A brisk walk from the fashionable hotels of Central Park West, All Nations Block was a rough world of day laborers, bricklayers, blacksmiths, stonemasons, elevator runners, waiters, janitors, domestic servants, bootblacks, tailors, seamstresses, the odd barber or grocer, and, far outnumbering them all, children. Each morning, the children streamed east to Public School No. 94 at Amsterdam Avenue or to the crowded kindergarten run by the Riverside Association at 259 West Sixty-ninth Street. That same foot-worn building housed the charitable association's public baths; in any given week, four hundred men or more paid a nickel for a towel, a piece of soap, and a shower that had to last. The tenement dwellers of All Nations Block did not choose their neighbors. It was the kind of place where an itinerant black minstrel actor, feeling feverish and far from his southern home, could find a bed for a few nights, in a great warren of rooms whose other occupants were Italian, Irish, Jewish, German, Swedish, Austrian, African American, or simply, so they said, "white."

The men of the West Sixty-eighth Street police station knew the block and its ways well. The policemen came when the neighbors brawled, when jewelry went missing in an apartment by the park, or when the Irish boys of the All Nations Gang got too rough with the Chinese laundryman on West End Avenue. The police came once again on the night of November 28. A forlorn and drunken stonemason named Michael Healy, imagining himself to be under attack in his room ("They're after me," he had shouted, "See those black men!"), had hurled himself through a fourth-floor window and fell, in a cascade of glass, to, or rather through, the ground below. The Irishman made a two-by-two-foot hole in the surface, breaking through to some long-forgotten trench near the building's cellar. A neighborhood boy ran to the Church of the Blessed Sacrament on West Seventieth Street and summoned a priest. When the priest arrived, he crawled right through the hole and into the trench, which was already crowded with police, an ambulance surgeon, and Healy's broken but still breathing body. Before this subterranean congregation, the priest administered last rites. That was the way things went on All Nations Block. It was the night before Thanksgiving, the first of the new century.

* * *

New Yorkers of a certain age would remember that Thanksgiving as the day the smallpox struck the West Side. The outbreak had in fact started quietly a few days earlier, on All Nations Block. The city health officers found the children first: twelve-year-old Madeline Lyon, on Tuesday, and on Wednesday, a child just across the street, identified only as a "white boy four years old." For the health officers to diagnose the cases with any confidence, the children must have been suffering for days, with raging fevers, headaches, severe back pain, and, likely, vomiting, followed by the distinctive eruption of pocks on their faces and bodies. Once the rash appeared and the lesions began their two-week metamorphosis, from flat red spots to hard, shotlike bumps to fat pustules to scabs, the patients were highly contagious. The health officers removed the children, stripped their rooms of bedding and clothing, and disinfected the premises.

The health department followed the same procedure with the five other cases that were reported elsewhere in Manhattan within hours of the Lyon case. One was a white domestic servant named Mary Holmes, who worked in an affluent apartment house on West Seventy-sixth Street. The other four were black, evidently from the neighborhood of the West Forties. They were Adeffa Warren, Lizzie Hooker, Susan Crowley, and Crowley's newborn daughter — these last two had been removed in haste from the maternity ward at Bellevue Hospital. Through interviews, health officers had established that the four black patients had come into contact with an unnamed infected "negress," who remained at large. How any of these patients might have been connected to the children on West Sixty-ninth Street, about a mile and a half uptown, remained uncertain. But the authorities were working on the assumption that the outbreak started on All Nations Block.

The officers of the internationally renowned New York City Health Department, medical men given broad powers to police and protect the public health in one of the world's most powerful centers of capital, were not easily shaken by the odd case of smallpox among the wage earners. Now and then an infected passenger got past the U.S. government medical inspectors at Ellis Island or crossed into the city on one of its many railroad tracks, waterways, roads, footpaths, or bridges. Most New Yorkers had undergone vaccination for smallpox at one time or another — on board a steamship crossing the Atlantic, in the public schools, in the workplaces, in the city jails and asylums, or, if they possessed the means, in their own homes under the steady hand of a trusted family physician. When an isolated case of smallpox triggered a broader outbreak, the health officials took it as an unmistakable sign that the population's level of immunity had begun to taper off, as it did every five to ten years. The time had come to sound the call for a general vaccination. "We are not afraid of smallpox," said Dr. F. H. Dillingham of the health department, when the news broke that smallpox had reappeared on Manhattan. "With the present facilities of this department we can stamp out any disease."

On Thanksgiving Day, as the Columbia University football team took the field against the Carlisle Indian School and three thousand homeless people lined up for a hot dinner at the Five Points House of Industry, a vaccination squad from the health department's Bureau of Contagious Diseases moved into West Sixty-ninth Street. The four doctors began a quiet canvass of All Nations Block, starting with the immediate neighbors of the infected children. Health department protocol called for a thorough investigation of each case, in order to trace its origin, followed by the immediate vaccination of all possible contacts. In a place as densely inhabited as All Nations Block, everyone would have to bare their arms for the vaccine.

With a willing patient, the vaccination "operation," as doctors called it, lasted just a minute or two. The doctor took hold of the patient's arm, scoring the skin with a needle or lancet. He then dabbed on the vaccine, either by taking a few droplets of liquid "lymph" from a glass tube or using a small ivory "point" coated with dry vaccine. Either way, the vaccine contained live cowpox or vaccinia virus that not long before had oozed from a sore on the underside of an infected calf in a health department stable. In the coming days, the virus would produce a blister-like vesicle at the vaccination site. In due course, the lesion would heal, leaving a permanent scar: the distinctive vaccination cicatrix. If all went well, the patient would then enjoy immunity from smallpox for five to seven years, sometimes longer. And, of course, as long as a person was immune, she could not pass along smallpox to others.

The health department's plan was to secure All Nations Block first and then follow the same procedure on the surrounding streets. In the coming days, health officers and police would maintain a quarantine on the block and enforce vaccination in the neighborhood schools. The health department would use all the available methods to fight the disease: total isolation of patients, quarantine of their living environment, vaccination of anyone exposed to the disease, disinfection of closed spaces and personal belongings, and close surveillance of the infected district and its residents.

It was a sensible protocol, born of medical science and the city's long experience with the deadliest contagious disease the world had ever known. Historically, smallpox killed 25 to 30 percent of all those whom it infected; most survivors were permanently disfigured with the dreaded pitted scars. Decades after the scientific revolution known as the germ theory of disease, biologists and doctors were still searching in their laboratories for the specific pathogen that caused smallpox. But they felt confident they had a strong understanding of the microbe's behavior: its pathological course in the human body, its epidemiological effects in a population, and the immunological power of vaccination to prevent the virus from attacking an individual or proliferating across an entire community. According to the state-of-the-art scientific knowledge, the "infecting germs" of smallpox spread unseen from one nonimmune person to another, communicated in a cough, a brush of bodies, or across the folds and surfaces of everyday things: an article of clothing, a Pullman porter's whisk broom, a piece of mail, a newspaper, a library book, a bit of currency, a shared cigarette. Because smallpox had an incubation period of ten to fourteen days, during which the infected person presented no noticeable symptoms, health officers strived to retrace the circuits of human contact in order to identify probable carriers and contain the outbreak.

The vaccination corps had not been on the block long before the doctors realized the need for reinforcements, men armed with more than vaccine. As the physicians moved from door to door, rapping loudly and calling for the occupants to come out and be vaccinated, many residents refused to cooperate. The doctors tried to explain the danger, which could not have been easy given the many tongues spoken on the block. But many people would not submit to having their own or their children's arms scraped by the vaccinators without, according to The New York Times, "loud wails and even positive resistance." Receiving word of the worsening situation on All Nations Block, the commander of the West Sixty-eighth Street station dispatched a detail of six policemen to assist the doctors in "enforcing the vaccination."

Well into the cool autumn night, All Nations Block echoed with the rapping of nightsticks on doors, the shouting and pleas of the residents within, and, through it all, the rattle of the horse-drawn ambulance wagons as they moved to and from the infected district. By midnight, the vaccination corps had discovered another twenty-two cases on the block, many of them little children, all of them, in the health officers' view, requiring immediate isolation. The ambulance wagons carried the patients five miles over rough city roads to the Willard Parker Hospital, the health department's contagious diseases facility at the foot of East Sixteenth Street on the East River, where the doctors gave them a fuller examination. From there they were ferried off Manhattan and many more miles upriver to the city smallpox hospital, the "pesthouse" on North Brother Island, a nineteen-acre wooded island situated between Rikers Island and the Bronx mainland. Pesthouses, public hospitals used to isolate poor people suffering from infectious diseases, were the most dreaded of American institutions. The trip to North Brother Island was a grim journey into unknown territory. No known cure for smallpox existed. The pesthouse doctors could do little more than treat the patients' symptoms. It was up to the virus, and to each patient's own resources, to determine who among the infected would die in the seclusion of North Brother Island.

Author's footnotes have been omitted.

Excerpted from An American History by Michael Willrich. Reprinted by arrangement of The Penguin Press, a member of Penguin Group (USA), Inc. Copyright (c) 2011 by Michael Willrich.

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