June 7, 2011 12:04:00 PM
The generations that had had smallpox vaccination scars upon their arms are dying off. That scar might have served as something like a passport to get them into a new country, or it might have allowed them to enter school. The scars aren''t seen now because inoculation with smallpox vaccine is no longer necessary; humanity may be rightly proud that it has eliminated what once had been a deadly scourge. The battle was not easily won, and in the U.S., it was fought not just against the virus, but against those who for often understandable reasons felt that it was not the government''s business to stick germs into them.
It was the epidemic of 1898 to 1903 that defined the government''s role, and this is the subject of "Pox: An American History" (The Penguin Press) by professor of history Michael Willrich. There is plenty of medical history here, as doctors and civic health care officers confront a fearful plague, but more importantly, there are accounts of the thousands of Americans who were against vaccination and the effect their efforts had upon the laws and attitudes that still affect us. Willrich''s detailed and meticulous history confines itself to the events of more than a hundred years ago (although a short epilogue catches us up to the current times) and is valuable for the insight it gives on the necessity and the limitations of governmental and police power instituted for the general medical betterment of society, issues which we are still arguing about today.
Smallpox had been a plague for humans for thousands of years before the outbreaks described here. It had fearful symptoms of high fever, severe pain and spots all over the skin that turned into pustules and into scabs over a couple of weeks during which the disease was extremely contagious. It was thought that the shed scabs were responsible for spreading the disease, but respiratory transmission was the usual way the disease spread. It was observed that those who got the disease and recovered never had to worry about getting it again; deliberately inducing a mild infection by having a patient inhale dried scabs worked, but was dangerous. In the 18th century, Edward Jenner observed that milkmaids didn''t get the disease, and this was because they had the much milder cowpox which gave them resistance. Skeptics jeered that cowpox vaccines, grown from cows, would induce bovine traits into those inoculated, but governments were soon encouraging people to get inoculations.
The outbreak that began in various American communities in 1898 brought back memories of previous rounds of the virulent form of the disease, but was relatively mild. One of the difficulties medical workers faced is that different strains posed different dangers, but they worried that even the mild versions might transmute into the deadly ones at any point. Something like 5,000 Americans were to die in these episodes and countless others survived but were permanently disfigured. The initial response to the disease was from local and state governments, and they did a spotty job.
Many local officials, when smallpox came into their communities, were unable or unwilling to step in to do anything. Paying for the vaccine and sending officials out to administer it was costly, and sometimes nothing was done simply because of cost. Sometimes the officials were reluctant to step in to stop a virus that they saw as afflicting "dark people" while bypassing whites. As in most such matters, it was not race itself that made a difference, but the close quarters, low sanitation and poor nutrition of the impoverished that was to blame. The virus itself made no racial distinctions. Part of the problem also was that doctors didn''t understand respiratory transmission, and thought that filthy living conditions were to blame, so that they thus put their efforts into enforced sanitation rather than vaccination.
Community vaccination programs were slapdash and poorly targeted, and were the bane of Walter Wyman, the head of the Marine-Hospital Service during the years of the epidemic. The organization was the precursor to the US Public Health Service, taking care mostly of the health of sailors and immigrants, but communities faced with bungled attempts to contain a horrifying disease sought the service''s help. The feds had had experience with smallpox before; a chapter here deals with what had been learned about fighting the disease in Puerto Rico and the Philippines, where American soldiers were stationed following the Spanish-American War. The Marine-Hospital Service would dispatch doctors to afflicted towns to vaccinate those who didn''t have the pox and to quarantine the sick. The problem was that not every citizen wished to cooperate with these plans, and this is where Willrich''s book is the most interesting. The doctors and their staffs were given broad powers, and had authority to make people take their vaccines and to stay in the pesthouses. For the progressive federal government of the time, the solution to the smallpox epidemic was not hard to find; universal vaccination was for the good of the communities and their citizens, and far outweighed any objections individuals or minority groups could make against it. This simple idea, scientifically sound, collided with fundamental personal, religious, and medical rights held by millions of people. The vaccine worked, but those opposed to it rightly objected that it also killed people, not just by giving them a stronger case than expected, but also by introducing other germs, like tetanus or syphilis. Manual laborers especially objected to the possibility that the vaccine could cause excruciating arm soreness leading to termination from work.
There was resistance, some of it organized. People hid from the doctors with their needles, burned down the pesthouses supposed to quarantine the sick, and kept sick relatives at home instead of turning them in. People faked vaccination certificates, and might find a doctor that could supply one for a fee, so that the scar was held to be the only proof. But then people circulated new ways to simulate a scar from the vaccine without actually risking any vaccine. Eventually, the federal government realized that mandatory vaccination had to be linked to certification that the vaccines were safe. President Roosevelt in 1902 signed the Biologics Control Act to regulate such products; it set the stage for today''s Food and Drug Administration. This did not, of course, satisfy the religious objectors to the vaccine, or the organized anti-vaccinators. Some of those opposing vaccination were simply the lunatic fringe, and others were idealists with at least some facts within their arguments. Americans being the way they are, there was plenty of litigation, winding up in a 1905 Supreme Court decision in "Jacobson v. Massachusetts" in which the court countenanced compulsory vaccination but also specified that there must be standards to balance governmental power and individual rights.
It is hard not to draw parallels with today''s anti-vaccination efforts. The great difference is that the smallpox vaccine, effective as it was in eliminating the disease worldwide, was the inoculation most prone to side effects and death. Those who objected to compulsory vaccination back then knew how to game the media, and they had their media stars who insisted that vaccination weakened constitutions. Currently, many Americans resist vaccination of their children for measles, mumps, and rubella because of bogus reports that vaccination is associated with autism; the debunking of such reports is not likely to quiet today''s anti-vaccination brigades. In a time when we are still trying to draw such lines, and trying to figure out how much the government should be involved in health care overall, Willrich''s study is a useful examination of the first federal forays into medical strategies for the good of the public, sometimes against the public will.
Rob Hardy is a local psychiatrist who reviews books for a hobby. His e-mail address is firstname.lastname@example.org.
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