Pox: An American History Part 2

America's turn-of-the-century war on smallpox did not kill humankind's ancient foe. But it did mark the beginning of the end for the disease in the United States. The deadly New York smallpox epidemic that started in All Nations Block on Thanksgiving Day 1900, setting Alonzo Blauvelt's vaccination corps into motion in the tenements and factories, was to be the city's last. Boston, too, had seen its final smallpox epidemic during the deadly 19013 visitation that sealed the city's reputation as a "hotbed of the anti-vaccine heresy." Over the next twenty-nine years, the city reported a hundred-odd cases, just four of them fatal, and then the pox vanished for good. The story was much the same in Philadelphia, Cleveland, Seattle, and other places where smallpox had raged during the first years of the century.1 By World War I, a rough pattern had taken hold. Outbreaks of malignant variola major became rare events, aggressively stamped out by America's increasingly well-organized health departments through a combination of ma.s.s vaccination and swift isolation of patients. Having learned something on the vaccination battlegrounds of the turn of the century, public health professionals self-consciously eschewed compulsion and force for public education and the promotion of the idea that every citizen had a positive right to good health. As C.-E. A. Winslow of the Yale School of Medicine observed, "Public health conceived in these terms will be something vastly different from the exercise of the purely police power which has been its princ.i.p.al manifestation in the past." Of course, every profession seeks to elevate itself by disclaiming the backwardness of its predecessors. And the new public health, far from a retreat, implied a much more ambitious program for governing everyday life in America. But over time, ordinary Americans did more fully accommodate themselves to the call for ma.s.s vaccination when the deadlier form of smallpox invaded their communities. When variola major reappeared in Detroit in 1924, causing 163 deaths, a half-million residents submitted to vaccination in a single month.2 But the new mild type of the disease remained far more difficult to control. Variola minor became the dominant form of smallpox in the United States. Between 1921 and 1930, the United States reported nearly 400,000 cases of smallpox, with a case-fatality rate of less than 1 percent. During the next decade, 108,000 cases were reported, with a case-fatality rate of just .38 percent. As smallpox continued to lose its lethal force, Americans remained ambivalent-or apathetic-about smallpox vaccination. Health departments relied on school mandates and voluntary action to maintain vaccination levels. But by the 1930s, only nine states had compulsory vaccination laws on the books, and four states had laws banning compulsion. During the 1930s, public health experts voiced the old refrain that "the United States lags behind other civilized countries in vaccination protection." And they were right. With 5,000 to 50,000 cases still occurring each year, health officials estimated that only one in two Americans had ever been vaccinated.3 The antivaccination movement had continued to challenge the authority of American public health officials. As the Birmingham, Alabamabased Southern Medical Journal lamented in 1921, "All the fools are not dead yet." Since the Supreme Court's ruling in Jacobson v. Ma.s.sachusetts, antivaccinationists had relentlessly railed against school vaccination requirements. They would continue to do so even after the Court, in a 1922 opinion written by Justice Louis D. Brandeis, dismissed a const.i.tutional challenge to a local school vaccination mandate, stating that the Jacobson ruling had effectively decided the question.4 Time and again, however, when malignant variola major reared its head, the American people bared their arms. As a.s.sistant Surgeon General R. C. Williams of the U.S. Public Health Service commented in 1946, "When you get a scare, everyone within 100 miles gets vaccinated."5 In 1947, when a traveler on a bus from Mexico City carried smallpox to Manhattan, more than six million New Yorkers lined up in a single month to get vaccinated. In dramatic contrast to the 19012 epidemics in the city, the New York City Health Department did not resort to compulsion and force, instead reaching out to the public through the radio and newspapers, while using the full agencies of the local government to trace cases and contacts. In the end, the city suffered only twelve cases and just two deaths.6 By the time of the New York outbreak, smallpox had grown scarce in the United States. America's last confirmed outbreak struck Hidalgo County, in the lower Rio Grande Valley of Texas, in 1949.7 At the time, few American states mandated smallpox vaccination. Beginning in the late 1930s, nine states and the Territory of Alaska enacted the first laws mandating immunization for another deadly childhood disease-diphtheria. The discovery of the polio vaccine and the ensuing national vaccination campaign during the 1950s changed everything, turning compulsory immunization from a political liability into a popular cause. Between 1958 and 1965, all fifty states enacted new legislation requiring schoolchildren to undergo vaccination for smallpox and other diseases. By 1969, twelve states had mandated a full slate of childhood immunization shots that included smallpox, measles, polio, diphtheria, pertussis, and teta.n.u.s. And more states were jumping on board each year. A new era of compulsory immunization had begun.8 With no reported cases of smallpox in the United States in more than twenty years, the annual tally of six to eight deaths from complications of vaccination became increasingly unacceptable. In 1971, the United States Public Health Service, the agency that seventy years earlier had sent C.P. Wertenbaker across the South to help communities fight smallpox, recommended that routine childhood vaccinations against smallpox be discontinued. Within three years, every American state had repealed its smallpox vaccination mandate for schoolchildren.9 As of 1967, smallpox still killed 2 million people every year across the globe. The World Health Organization-leading an unprecedented international campaign-launched an offensive to wipe smallpox from the planet. In an exceptional example of Cold Warera cooperation, the eradication campaign was heavily funded by the United States with the Soviet Union providing enormous quant.i.ties of vaccine. The geographical canvas for this ma.s.sive effort spanned dozens of developing countries in Asia, Africa, and Latin America. Two inventions proved crucial: the introduction of freeze-dried vaccine (which retained its efficacy for months at high heat) and the manufacture of the bifurcated needle, a cheap forked tool that enabled health workers to get four times as many vaccinations from a single unit of vaccine.10 The eradicators developed a strategy, known as "ring vaccination" or "surveillance-containment," that resembled a modern, high-tech version of the methods employed by Manhattan's turn-of-the-century vaccination corps. As each new outbreak of smallpox was reported, a vaccination team descended on the scene, vaccinating everyone they could find in the immediate vicinity and placing the area under close surveillance until the outbreak had subsided. Taking the fight to smallpox, rather than striving for universal vaccination, the surveillance-containment strategy enabled the eradicators to cut short the transmission of smallpox, even in countries that had poorly vaccinated populations. The eradicators had to work around civil wars and surmount cultural barriers; in rural Afghanistan, for example, vaccinators ran up against purdah traditions that limited their access to women and children.11 When containment teams met outright resistance, they responded with verbal pressure, legal coercion, and, in extreme cases, forcible vaccination. One senior WHO epidemiologist, a physician from the American Centers for Disease Control and Prevention (CDC) named Dr. Stanley Music, recalled how his team's initial efforts to carry out the containment policy in rural Bangladesh "resembled an almost military style attack on infected villages.... In the hit-and-run excitement of such a campaign, women and children were often pulled out from under beds, from behind doors, from within latrines, etc. People were chased and, when caught, vaccinated." Dr. Music explained the thinking of the vaccinators. "We considered the villagers to have an understandable though irrational fear of vaccination," he said. "We just couldn't let people get smallpox and die needlessly. We went from door to door and vaccinated. When they ran, we chased. When they locked their doors, we broke down their doors and vaccinated them." The strategy proved highly effective at containing smallpox. But it came at a high price. As one historian of the South Asia eradication program delicately observed, "coercion can leave behind a residue of resentment that sours public att.i.tudes toward the next vaccination campaign."12 As reported smallpox cases dwindled, teams conducted "scar surveys" of high-risk areas, inspecting people for vaccination scars or facial pockmarks, just as U.S. military surgeons had done when the Army moved across Luzon during the Philippine-American War. The last naturally occurring case of variola major occurred in a young girl in Bangladesh in late 1975. The final case of variola minor was reported in a hospital cook in Merca, a port town in southern Somalia, on October 31, 1977. On May 8, 1980, the World Health a.s.sembly declared, "[T]he world and all its peoples have won freedom from smallpox, which was a most devastating disease sweeping in epidemic form through many countries since earliest time, leaving death, blindness and disfigurement in its wake." The a.s.sembly recommended that countries across the world discontinue smallpox vaccination.13 The smallpox eradication program severed smallpox from its human host-a monumental achievement. Alas, the campaign did not annihilate the variola virus. As immunization levels around the world fell after 1980, the virus took on a new and ominous existence in the laboratory.

The WHO had authorized two laboratories to keep frozen stocks of variola-the CDC in Atlanta and the Research Inst.i.tute for Viral Protections in Moscow. By the time the Soviet Union collapsed in 1990, British and American intelligence agencies had believed for some time that the USSR had been developing weapons-grade variola. Those fears were confirmed in the mid-1990s. Civil defense agencies prepared for the worst. Long-standing concerns about the proliferation of weaponized smallpox virus intensified after the terrorist attacks of September 11, 2001, soon followed by the anthrax murders.14 On December 13, 2002, President George W. Bush announced his administration's plan to protect the nation from a smallpox attack. The plan, which many in the scientific community had opposed, involved compulsory vaccination of a half-million U.S. military personnel, followed by a voluntary campaign of a roughly equal number of frontline hospital workers and members of public health departments-the most likely health workers to come into contact with the virus during an outbreak. After that, the plan called for the voluntary vaccination of some 10 million firefighters, police, and other "first responders." The military vaccination campaign went smoothly enough. But the civilian campaign quickly collapsed. Only 38,000 health workers agreed to be vaccinated, and many American hospitals refused to partic.i.p.ate at all.15 The complex concerns elicited by the civilian program would have been familiar to the many Americans who refused vaccination at the turn of the twentieth century. Many of the health workers believed they had a specific medical condition that made smallpox vaccination particularly hazardous for them. (In fact, experts believe as many as one in five Americans today may have contraindications to smallpox vaccination, including immune systems weakened by HIV.) Others worried about the common side effects of smallpox vaccine-still known as "the most dangerous vaccine." Many felt the risk of a bioterrorist attack was too low to make getting vaccinated a good bet. (The invasion of Iraq had revealed that Saddam Hussein held no secret stockpile of variola.) Another key factor was the lack of a federal program, in the first stages of the vaccination campaign, to compensate people for death, injury, or lost work due to the vaccination. In the end, the failed civilian program reported nearly nine hundred adverse reactions to vaccine, including one death. The military program reported seventy-five cases of heart inflammation and one death.16 It was a revealing episode. In the absence of a palpable threat of an outbreak, few twenty-first-century Americans would step forward and get vaccinated against smallpox. Clearly, ignorance had little to do with it. Presumably, the 400,000 health workers who declined to roll up their sleeves were exceptionally well-informed about the risks. Even the relatively small risks of the vaccine were deemed unacceptable as long as the threat of a smallpox attack seemed remote.

Even as smallpox itself disappeared from America and the world in the final decades of the twentieth century, vaccines themselves proliferated. Thanks in large part to the polio success story, so did vaccine laws. By the century's end, all fifty states mandated that children receive immunization shots to protect them against seven different diseases. The number continues to grow. State-mandated vaccination is far more extensive than it was a century ago. But most states now provide precisely the sort of exemptions that the turn-of-the-century antivaccinationists in Europe and the United States had demanded. The people may now ask to be exempted for medical and religious reasons, or even, in some states, for conscientious objections to vaccination.17 For all of this, public distrust of vaccines is on the rise, caused in part by the unprecedented complexity of the childhood immunization landscape and fueled by the explosive communicative power of the Internet. No longer do rumors of sore arms and lost limbs circulate via word of mouth across communities of workers; a bottomless archive of information and misinformation about vaccines is just a few keystrokes away. According to the CDC's National Immunization Survey, in 2008 nearly 40 percent of American parents of young children refused or delayed giving them at least one routine shot-up from 22 percent in 2003. One quarter of American parents believe vaccines cause autism, though there is no scientific evidence to support that belief and at least a dozen major scientific studies have concluded there is no connection. In March 2010, the federal "vaccine court" ruled that the theory that a mercury-containing preservative long used in vaccines caused autism was "scientifically unsupportable." But no one now expects a single court ruling to silence the vaccination controversy.18 The vaccination question a century ago was in important respects markedly different from the current debate. Then the controversy centered on a single vaccine used to fight one horrific infectious disease. Today, healthy children under six routinely receive nearly a dozen separate vaccines, some mandated by state law, all recommended by the CDC, that offer protection against viruses ranging from varicella (chicken pox) to the human papillomavirus. Each of these vaccines raises its own particular issues of safety, parental authority, or even, in the case of the HPV vaccine, s.e.xual mores. Trying to check actual epidemics of smallpox, turn-of-the-century health officials likened their power to the military defense of the nation. Today's vaccination skirmishes are by comparison a peacetime struggle, mostly fought out in the absence of visible diseases-an absence made possible, in large part, by vaccines. The vaccine politics of the present moment reflect twenty-first-century Americans' still evolving conceptions of the family, their affective ties to particular local and virtual communities, and their complex views of a modern administrative and welfare state that was still in its infancy a century ago. Antivaccination arguments today often convey an attenuated sense of social responsibility that is all too pervasive in contemporary American culture. Our politics of health must be understood in its own historical context.19 Even so, the long-gone epidemics that swept across the United States over a century ago hold important lessons for us. In our post-9/11 moment, civil libertarians have dusted off the Jacobson decision, finding in that complex opinion a set of useful standards for balancing governmental power and individual rights during a health emergency. The experience of those historical epidemics also underscores the abiding importance of public education and political candor in matters affecting personal health. People care deeply about their bodies. To ask them to accept the risk of bodily harm for the sake of others is at times essential. But the decision to make that request of the people has the greatest prospect of success when it is made with the care and public deliberation worthy of a democratic society.

In a broader sense, the history of America's turn-of-the-century fight against smallpox cautions us against making reflexive judgments about the innumerable people, the world over, who greet scientific innovation and expert authority with skepticism, resentment, or steadfast resistance. To dismiss so many people as merely ignorant and irrational is worse than intolerant. At a time when the ability of democratic nations to promote the security and health of their citizens depends ever more on science, it is the purest folly. It tells us little about the root causes of ambivalence toward medical science or how to bridge the gap between popular beliefs and the imperatives of preventive medicine. Scientific innovations that in hindsight seem manifestly rational, benign, and inevitable often appear far more problematic to people on the ground. Unthinking scientific triumphalism is no sounder an approach than antiscientific denialism to the social conflict and political contention that are likely to continue to haunt the human quest to make ours a healthier world.

Acknowledgments.

Generous fellowships and grants underwrote this project. The Radcliffe Inst.i.tute for Advanced Study at Harvard gave me a full year to do the initial research and furnished a marvelous setting in which to do it. I am immensely grateful to Radcliffe, to the brilliantly diverting Fellows Cla.s.s of 20045, and especially to Drew Faust and Judy Vichniac for the gift of that year. I am also deeply grateful to the American Council of Learned Societies for the Charles E. Ryskamp Fellowship (named for a warm and generous scholar no longer with us), which bought me a full year of writing time and other support. Brandeis University provided a semester of leave time on each end of this project, as well as smaller grants to cover costs, for all of which I give thanks.

I owe a special debt to four exemplary historians who wrote in support of my fellowship applications: my mentor Kathy Conzen, Tom Haskell, Jackie Jones, and Laura Kalman. I hope this book repays your confidence in some small way.

Along the way, I presented pieces from the project to workshops and audiences at the American Society for Legal History, Boston College, Boston University, Brandeis University, Canisius College, Cleveland State University, Harvard University, Johns Hopkins University, New York University, Stanford University, the University of Minnesota, the University of Nevada, Las Vegas, the University of Pennsylvania, the University of WisconsinMilwaukee, the University of Virginia, and Yale University. I want to thank my many hosts for their hospitality and the members of those audiences for their challenging comments. Ironically, a bout with the H1N1 flu virus (before I had a chance to get vaccinated) forced me to cancel a presentation at the University of Michigan, but I am grateful to Tom Green, Bill Novak, and their legal history students for sending me such crisp comments on my paper. A line here and there in this book first appeared in my article "'The Least Vaccinated of Any Civilized Country': Personal Liberty and Public Health in the Progressive Era," Journal of Policy History, 20 (2008): 7693; I wish to thank the journal for permission to use that material here.

I also want to thank Ann Mary Olson, who provided excellent research a.s.sistance during my year at Radcliffe; and Fred Turner, who did some helpful digging for me in the Spooner Papers.

A great many friends and colleagues read pieces of this project along the way or heard me out as I worked through my ideas in conversation. For their insights, research leads, and camaraderie, I particularly want to thank Brian Balogh, Norma Basch, Mary Bilder, Henry Bolter, Chris Capozolla, Andrew Cohen, Tino Cuellar, Jane Dailey, Matt Daniels, Michele Dauber, Peter Garlock, Patsy Gerstner, Julian Go, Bob Gordon, Sally Gordon, Hank Greely, Rob Heinrich, Daniel Hulsebosch, Robert Johnston, Michael Katz, David Kennedy, Daniel Kosoy, Dan Kryder, Gerry Leonard, Jill Lepore, Kenneth Levin, Charlie Lord, Rob McGreevey, Harry Marks, Bill Novak, Robert Orsi, David Rabban, Heather Richardson, Elizabeth Sanders, Dennis Scannell, Mark Schmeller, Bruce Schulman, Daniel Sherman, Lindsay Silver Cohen, Ross Silverman, Jonathan Stapley, Tom Sugrue, David Tanenhaus, Geoff Tegnell, Chris Tomlins, Barbara Welke, John Witt, Rich Young, and Julian Zelizer.

I am proud to be a founding member of a Boston area writing group that over the past six or seven years has included the likes of Steve Biehl, Jona Hansen, Jane Kamensky, Stephen Mihm, Mark Peterson, John Plotz, Seth Rockman, Jennifer Roberts, Dan Scharfstein, and Conevery Valencius. Many thanks to you all for your sharp comments, good company, and the example of your fine prose.

Brandeis University has been my inst.i.tutional home throughout this project. It is in many ways a remarkable place, and I feel blessed to have such outstanding students and engaging colleagues. In particular, I want to thank Dean Adam Jaffe and Provost Marty Krauss for their continuing support and all of my colleagues in the History Department for their warm collegiality and intellectual engagement. I have learned a good deal from Rudy Binion, Greg Freeze, Paul Jankowski, Bill Kapelle, Alice Kelikian, Govind Sreenivasan, and Ibrahim Sundiata. I especially want to thank a small group of colleagues with whom I have worked especially closely over the past decade in the American History Graduate Program: Silvia Arrom, Brian Donahue, David Engerman, David Hackett Fischer, Mark Hulliung, Jane Kamensky, and my much missed colleague, Jackie Jones. I owe a special thanks to Jane Kamensky, who has been a constant source of ideas, moral support, and excellent humor.

I am especially grateful to a few individuals who read a draft of the ma.n.u.script late in the game and who provided thoughtful, expert comments: Art Bookstein (my father-in-law and a voracious reader of nonfiction), Jon Cohen (a close friend from our City Paper days and a first-rate science writer), David Igler (one of my oldest friends and a stellar historian), Charles E. Rosenberg (the dean of medical historians), and Conevery Valencius (who possesses an unusually deep knowledge of the medical beliefs of rural nineteenth-century Americans). D. A. Henderson, a man whom I have never met (but about whom I have read a great deal due to his leadership of the World Health Organization's smallpox eradication program), generously read the ma.n.u.script and provided expert comments. Like most people today, I have never seen a case of smallpox, and it was both intimidating and rewarding to be able to share this project with a scientist who knows the disease and its ways so well.

Laura Stickney at the Penguin Press has been an ideal editor for this book. As fluent as she is smart, she has edited with a sharp eye and a light hand. I am also grateful to my outstanding agent, Geri Thoma, for her unflagging support and for helping me find my way in the world of trade publishing.

I owe everything to my family.

Art and Lynne Bookstein have given me steady, unconditional support since I married their beautiful daughter fifteen years ago. Many thanks to Dari Pillsbury, who is a great friend and our in-house photographer extraordinaire.

Through their steadfast love, encouragement, and the example of their own lives and work, my parents, Mason Willrich and the late Patricia Rowe Willrich, nurtured my pa.s.sions for reading, writing, and teaching, and I thank them both for everything. I also wish to thank Wendy Webster Willrich for her support. I am deeply grateful to my siblings and their wonderful partners-Chris and Susan, Stephen and Kelly, and Kate and Erik-for challenging me and supporting me through the years. You're an amazing family, and I am lucky to have you. I'll see you soon on Stinson Beach.

I have saved my greatest debts for last, knowing words will never be enough. Max and Emily, I am so proud of you both. Thank you for your constant reminders of the things that really matter. I love you. And Wendy Jayne Willrich, you know I couldn't have done it without you. You know the tune: "I'm giving you a longing look...." With respect, grat.i.tude, and the deepest love, I dedicate this book to you.

Wellesley, Ma.s.sachusetts.

Notes.

ABBREVIATIONS USED IN NOTES.

Archival Collections.

Published Government Doc.u.ments.

Frequently Cited Journals.

Frequently Cited Newspapers.

PROLOGUE.

1 U.S. Census Bureau, Twelfth Census of the United States (1900), Schedule 1-Population, Manhattan, New York, New York, District 461. Note: all enumeration district-level census data cited in the notes to follow was retrieved using the U.S. Federal Census Collection in the online database Ancestry Library Edition, ancestry.com (Provo, UT). "Smallpox on West Side," NYT, Nov. 30, 1900, 2. Robert W. DeForest and Lawrence Veiller, eds., The Tenement House Problem: Including the Report of the New York State Tenement House Commission of 1900 (New York: MacMillan, 1903), 53.

2 "Jumped Through a Window," NYT, Nov. 29, 1900, 4. "West Side Robberies," NYT, Nov. 29, 1900, 5. "Chinaman Whips a Gang," NYT, Dec. 6, 1900, 2.

3 "Smallpox in Manhattan," NYT, Nov. 28, 1900, 3. "Chemists Report on Water," NYT, Nov. 29, 1900, 5. For a concise contemporary description of the pathology of smallpox, see U.S. Treasury Department, Public Health and Marine-Hospital Service, Handbook for the Ship's Medicine Chest, by George W. Stoner, M.D., 2d ed. (Washington: Government Printing Office, 1904), 2124.

4 "Smallpox in Manhattan."

5 Ibid. On the New York City Health Department, see John Duffy, A History of Public Health in New York City, 18661966 (New York: Russell Sage Foundation, 1974); Evelynn Maxine Hammonds, Childhood's Deadly Scourge: The Campaign to Control Diphtheria in New York City, 18801930 (Baltimore: The Johns Hopkins University Press, 1999).

6 "Smallpox on West Side." "Columbia Beat Indians," NYT, Nov. 30, 1900, 8. "Thanksgiving Day Cheer," NYT, Nov. 30, 1900, 3.

7 D. H. Bergey, The Principles of Hygiene: A Practical Manual for Students, Physicians, and Health-Officers (Philadelphia: W. B Saunders, 1904), 374. George Henry Fox, A Practical Treatise on Smallpox (Philadelphia: J. B. Lippincott Company, 1902), 2631. Dr. Fox was the consulting dermatologist to the New York City Health Department.

8 "Smallpox on West Side." "Fighting the Smallpox," NYT, Dec. 1, 1900, 16.

9 William Welch and Jay F. Schamberg, Acute Contagious Diseases (Philadelphia: Lea Brothers & Co., 1905), 160. For the state-of-the-art scientific knowledge about smallpox, as it existed in the United States circa 1900, see Surgeon General Walter Wyman's "Precis Upon the Diagnosis and Treatment of Smallpox," PHR, 14 (Jan. 6, 1899), 3749. The authoritative modern treatise on the subject is F. Fenner et al., Smallpox and Its Eradication (Geneva: World Health Organization, 1988). See also Ian Glynn and Jenifer Glynn, The Life and Death of Smallpox (New York: Cambridge University Press, 2004); D. A. Henderson, Smallpox: The Death of a Disease (Amherst, NY: Prometheus Books, 2009), esp. 34.

10 "Fighting the Smallpox."

11 On the germ theory and its reception in the United States, see Nancy Tomes, The Gospel of Germs: Men, Women, and the Microbe in American Life (Cambridge, MA: Harvard University Press, 1998).

12 "The Spread of Small-pox by Tramps," Lancet, Feb. 13, 1904, 44647. See also "Smallpox and Tramps," JAMA, 22 (1894): 635.

13 "Smallpox on West Side." "Fighting the Smallpox." "Smallpox up the State," NYT, Jan. 4, 1901, 3. "New York," PHR, 16 (Feb. 8, 1901): 23839. See W. Michael Byrd and Linda A. Cayton, An American Health Dilemma: A Medical History of African Americans and the Problem of Race, 2 vols. (New York: Routledge, 2000, 2002).

14 "Fighting the Smallpox." "Race Riot on West Side," NYT, Aug. 16, 1900, 1.

15 "Forty Smallpox Cases," NYT, Dec. 5, 1900, 5; "Smallpox Case in Hoboken," NYT, Dec. 3, 1900, 5. "The Smallpox Epidemic," NYT, Dec. 4, 1900, 8.

16 "Fighting the Smallpox." "Two New Smallpox Cases," NYT, Dec. 7, 1900, 2. "Smallpox Still Spreading," NYT, Dec. 15, 1900, 6.

17 "Smallpox Epidemic."

18 "Smallpox Epidemic." "Topics of the Times," NYT, Dec. 12, 1900, 8. See Michael Willrich, City of Courts: Socializing Justice in Progressive Era Chicago (New York: Cambridge University Press, 2003).

19 n.o.bOH 190001, 23. PBOH 1902, 38. Michael R. Albert et al., "The Last Smallpox Epidemic in Boston and the Vaccination Controversy, 19011903," NEJM, 344 (1901), 375. NYCBOH 1901, 79, 56. NYCBOH 1902, 89. NYCBOH 1903, 8, 238. See James Nevins Hyde, "The Late Epidemic of Smallpox in the United States," PSM, 59 (Oct. 1901): 55767; and Charles Fletcher Scott, "The Fight Against Smallpox," Ainslee's Magazine, July 1902, 54045.

20 USSGPHMHS 1898, 598. USSGPHMHS 1901, 15. USSGPHMHS 1903, 72. USSGPHMHS 1904, 19. The Service fiscal year ran from July 1 to June 30. On underreporting, see USSGPHMHS 1899, 75556; USSGPHMHS 1910, 189. "Echoes and News," MN, Sept. 21, 1901, 470. "The number of cases notified each year represents at most 20% of those that actually occurred; many patients did not see a physician and many others who did were not reported as having smallpox." Fenner et al., Smallpox and Its Eradication, 329. From my own research, I judge Fenner's 20 percent figure to be very conservative.

21 USSGPHMHS 1903, 72. USCB 1900, Vol. 4-Vital Statistics Part II, Statistics of Death, 228.

22 Welch and Schamberg, Acute Contagious Diseases, 2078. Charles V. Chapin, "Variation in Type of Infectious Disease as Shown by the History of Smallpox in the United States, 18951912," Journal of Infectious Diseases, 13 (1913), 194.

23 Pamela Sankar et al., "Public Mistrust: The Unrecognized Risk of the CDC Smallpox Vaccination Program," American Journal of Bioethics, 3 (2003), esp. W22. Edward A. Belongia and Allison Naleway, "Smallpox Vaccine: The Good, the Bad, and the Ugly," Clinical Medicine and Research, 1 (2003): 8792. Vincent A. Fulginiti et al., "Smallpox Vaccination: A Review, Part II. Adverse Effects," Clinical Infectious Diseases, 37 (2003): 25171. Welch and Schamberg, Acute Contagious Diseases, 5883.

24 The literature on American antivaccinationism is growing, and it is no longer easy to dismiss the movement, as John Duffy once did, as "filled with cranks, extremists, and charlatans." History of Public Health in New York City, 152. See, esp., James Colgrove, "'Science in a Democracy': The Contested Status of Vaccination in the Progressive Era and the 1920s," Isis, 96 (2005): 16791; idem, State of Immunity: The Politics of Vaccination in Twentieth-Century America (Berkeley: University of California Press, 2006); Nadav Davidovitch, "Negotiating Dissent: Homeopathy and Antivaccinationism at the Turn of the Twentieth Century," in The Politics of Healing: Histories of Alternative Medicine in Twentieth-Century North America, ed. Robert D. Johnston (New York: Routledge, 2004), 1128; Robert D. Johnston, The Radical Middle Cla.s.s: Populist Democracy and the Question of Capitalism in Progressive Era Portland, Oregon (Princeton: Princeton University Press, 2003), 177220; idem, "Contemporary Anti-Vaccination Movements in Historical Perspective," in Johnston, ed., Politics of Healing, 25986. Martin Kaufman, "The American AntiVaccinationists and Their Arguments," BHM, 50 (1976): 55368; Judith Walzer Leavitt, The Healthiest City: Milwaukee and the Politics of Health Reform (Princeton: Princeton University Press, 1982), 76121. On England, see Nadja Durbach, Bodily Matters: The Anti-Vaccination Movement in England, 18531907 (Durham: Duke University Press Books, 2005). For an overview, see Arthur Allen, Vaccine: The Controversial Story of Medicine's Greatest Lifesaver (New York: W. W. Norton, 2007).

25 Chapin, "Variation in Type," 194.

26 "The Vaccination Question and the Purity of Vaccine," Therapeutic Gazette, 26 (1902): 9899.

27 For an excellent revision of the conventional periodization of free speech, see David M. Rabban, Free Speech in Its Forgotten Years (New York: Cambridge University Press, 1997). Holmes to Hand, June 24, 1918, in Gerald Gunther, "Learned Hand and the Origins of Modern First Amendment Doctrine: Some Fragments of History," Stanford Law Review, 27 (1975), Appendix, 757.

28 Michael Willrich, "'The Least Vaccinated of Any Civilized Country': Personal Liberty and Public Health in the Progressive Era," Journal of Policy History, 20 (2008): 7693.

ONE: BEGINNINGS.

1 Henry F. Long, "Smallpox in Iredell County," NCBOH 189798, 208.

2 U.S. Census Bureau, Twelfth Census of the United States (1900): Schedule No. 1-Population, Iredell County, North Carolina. "Dr. John F. Long Dead," CO, Apr. 29, 1899, 4. Federal Writers' Project, North Carolina: A Guide to the Old North State (Chapel Hill: University of North Carolina Press, 1939), 7178, 4017. Hugh Talmage Lefler and Albert Ray Newsome, North Carolina: The History of a Southern State (Chapel Hill: University of North Carolina Press, 1954), 48183.

3 Long, "Smallpox in Iredell County," 214. My account of Harvey Perkins's case also draws upon "From Bulletin, February 1898," in NCBOH 189798, 8285; C. P. Wertenbaker, "Smallpox at Statesville, N.C.," PHR, 13 (Jun. 24, 1898), 63435; and "Harvey Perkins Dead," CO, Feb. 22, 1898, 6.

4 Long, "Smallpox in Iredell County," 208.

5 USSGPHMHS 1898, 627, 59899. "Warning Against Smallpox," Mar. 25, 1898, in KBOH 189899, 23. C.P. Wertenbaker, "Investigation of Smallpox at Columbia and Sumter, S.C.," PHR, 13 (May 13, 1898), 470. See "From Bulletin, February 1898," in NCBOH 189798, 82; "Smallpox in the United States as Reported to the Supervising Surgeon-General United States Marine-Hospital Service, December 29, 1896, to December 31, 1897," PHR, 12 (Dec. 31, 1897), 142122; C.P. Wertenbaker, "Smallpox at Middleborough, Ky.," PHR, 13 (Mar. 25, 1898), 27374. See also W. Michael Byrd and Linda A. Clayton, An American Health Dilemma, Vol. 1: A Medical History of African Americans and the Problem of Race: Beginnings to 1900 (New York: Routledge, 2000), 322414.

6 "From Bulletin, January 1898," NCBOH 189798, 80. "From Bulletin, February 1898," ibid., 84. C.P. Wertenbaker, "One Case of Smallpox in Wilmington, N.C.," PHR, 13 (Jan. 14, 1898), 25. C.P. Wertenbaker, "Investigation of Smallpox at Charlotte, N.C.," PHR, 13 (Feb. 18, 1898), 14041.

7 C.P. Wertenbaker's transmission to Mayor E. B. Springs is published in "From Bulletin, February 1898," 84.

8 Ibid., 84. "Harvey Perkins Dead."

9 "From Bulletin, February 1898," 85.

10 Long, "Smallpox in Iredell County," 210. Lewis, "Annual Report of the Secretary," 28. C.P. Wertenbaker, "Smallpox at Statesville, N.C.," 63435.

11 Long, "Smallpox in Iredell County," 216.

12 Dr. H. Y. Webb, "Smallpox in Greene County," ABOH 188384, 129.

13 At the turn of the century, public health reports in many places had yet to adopt a standardized, bureaucratic format. The biennial reports issued by the Kentucky and North Carolina boards of health, for example, as well as the weekly Public Health Reports published by the U.S. Marine-Hospital Service, consisted chiefly of letters and telegraphic transmissions from local health authorities, who leavened their smallpox dispatches with a wealth of local social and political detail. On the dramaturgic character of epidemics as social events, see Charles E. Rosenberg, "What Is an Epidemic? AIDS in Historical Perspective," in Explaining Epidemics and Other Studies in the History of Medicine (New York: Cambridge University Press, 1992), 27892.

14 KBOH 189899, 61, 81, 133, 92. PHR, 14 (Mar. 3, 1899), 278. PHR, 13 (Jul. 29, 1898), 781. "Vigorous Measures Have Been Adopted," The State (Columbia, SC), Apr. 5, 1898, 2.

15 James Nevins Hyde, "The Late Epidemic of Smallpox in the United States," PSM, 59 (Oct. 1901), 55767, esp. 557.

16 H. F. Long, "Report of the State Small-Pox Inspector," NCBOH 18991900, 29.

17 "Thou shalt not be afraid for the terror by night; nor for the arrow that flieth by day; Nor for the pestilence that walketh in darkness; nor for the destruction that wasteth at noonday."-King James Bible, Psalm 91:56. This psalm was quoted, albeit inaccurately, in the most important vaccination decision handed down by the North Carolina Supreme Court. In the majority opinion, Justice Clark insisted upon the right of the community to protect itself against "the deadly pestilence that walketh by noonday." State v. W. E. Hay, 126 N.C. 999, 1001 (1900).

18 KBOH 189697, 4647. KBOH 189899, 30.

19 Col. A. W. Shaffer, "Small-pox and Vaccination for Plain People. By One of Them," NCBOH 189798, 173.

20 F. Fenner et al., Smallpox and Its Eradication, (Geneva, 1988), 21744, esp. 210, 217. Sergei N. Shchelkunov, "How Long Ago Did Smallpox Virus Emerge?" Archives of Virology, 154 (2009): 186571. See also Ian Glynn and Jenifer Glynn, The Life and Death of Smallpox, 654, esp. 4; and Donald R. Hopkins, Princes and Peasants: Smallpox in History (Chicago: University of Chicago Press, 1983).

21 By "natural" host range, I mean outside the laboratory. See S. S. Kalter et al., "Experimental Smallpox in Chimpanzees," Bulletin of the World Health Organization, 57 (1979): 63741. For a useful overview of the virology of variola and the other orthopoxviruses, see Fenner et al., Small-pox and Its Eradication, 69119.

22 See C.-E. A. Winslow, "Communicable Diseases, Control Of," in Encyclopaedia of the Social Sciences , ed. Edwin R. Seligman (New York: MacMillan, 1937), vol. 3: 6678. The death toll figure is from Richard Preston, "The Demon in the Freezer," New Yorker, July 12, 1999, 47. See also Preston's Foreword to D. A. Henderson, Smallpox: The Death of a Disease (Amherst, NY: Prometheus Books, 2009), 12.

23 U.S. Treasury Department, Public Health and Marine-Hospital Service, Handbook for the Ship's Medicine Chest, by George W. Stoner, M.D., 2d ed., 21. See also Fenner et al., Smallpox and Its Eradication, 117.

24 Macaulay quoted in Hopkins, Princes and Peasants, 38. Glynn and Glynn, Life and Death of Small-pox , 1, 4. Fenner et al., Smallpox and Its Eradication, 169208.

25 Jennifer Lee Carrell, The Speckled Monster: A Historical Tale of Battling Smallpox (New York: Dutton, 2003). Fenner et al., Smallpox and Its Eradication, 224, 229. Henderson, Smallpox, 4043. Mary Beth Norton et al., A People and a Nation: A History of the United States, 6th ed. (Boston: Houghton Mifflin, 2001), 26. See Alfred W. Crosby, The Columbian Exchange: Biological and Cultural Consequences of 1492 (Westport, CT: Greenwood, 1972). For a compelling reconsideration of the "virgin soil" theory, see David S. Jones, "Virgin Soils Revisited," William and Mary Quarterly, 60 (2003): 70342.

26 Fenner et al., Smallpox and Its Eradication, 224.

27 "Precis upon the Diagnosis and Treatment of Smallpox," PHR, 14 (Jan. 6, 1899), 3749. Hopkins, Princes and Peasants, 13. Preston, "Demon in the Freezer," 48.

28 Fenner et al., Smallpox and Its Eradication, 71.

29 "Smallpox in the United States as Reported to the Supervising Surgeon-General United States Marine-Hospital Service, January 1 to December 30, 1898," PHR (Dec. 30, 1898), 155962.

30 "Precis." The following description of the clinical course of smallpox relies heavily on the exhaustive research compiled by a team of World Health Organization scientists in Fenner et al., Small-pox and Its Eradication, esp. chs. 1 and 3. Running more than 1,400 pages, the tome is often referred to as "The Big Red Book of Smallpox." It is by far the single most comprehensive source on the science of smallpox and vaccination. For a more concise medical discussion of the pathology of smallpox, see Hopkins, Princes and Peasants, 39. Like Frank Fenner and his coauthors, Dr. Hopkins, a physician and epidemiologist, worked in the WHO smallpox eradication program.

31 "Precis," 38.

32 "Smallpox Rumor," CO, Feb. 26, 1898, 6. Fenner et al., Smallpox and Its Eradication, 266, 45. Hopkins, Princes and Peasants, 3.

33 "Precis," 38. Fenner et al., Smallpox and Its Eradication, 5, 44, 167. See also Michael R. Albert et al., "Smallpox Manifestations and Survival during the Boston Epidemic of 1901 to 1903," AIM, 137 (Dec. 17, 2002): 9931000, esp. 993.