Content Objectives
Immunity
The human immune system is remarkable. The immune system fights pathogens and protects the human body against invaders. There are two types of immune systems: innate and adaptive. The innate system uses skin and mucous membranes as the first line of defense. The skin and mucous membranes are designed to keep invaders from entering the body. Once the body is penetrated, the second line of defense, special cells and enzymes, are deployed. Phagocytes are special cells that act as scavengers, for this reason they are also called scavenger cells. Phagocytes seek out invaders, surround them, and digest them. There are other cells that produce a substance that kills pathogens, but they also kill tissue and immune system cells. All the dead material creates a yellow substance called pus, which played an important role in protecting people from smallpox.
Some proteins with enzymatic activity have several jobs in the immune system. They mark pathogens as a target, so the phagocytes can recognize the enemy. Some proteins also destroy the viral envelope or cells infected by a virus.1 There are also natural killer cells that find cells infected by a virus and abnormal cells that turn into tumor cells. Natural killer cells kill these foreign or misfunctioning cells using cytotoxins. Together the innate immune system is the one with which humans are born.
There is also the adaptive immune system, which is more “specialized.” The adaptive immune system can “remember” pathogens and launch a targeted attack. The adaptive immune system is made up of T cells, B cells, and antibodies. T cells have three main roles. They are messengers that alert other immune cells or T helper cells. T cells detect cells infected with a pathogen and tumor cells. Some T helper cells remember pathogens for the future. B cells have antibodies on their surface, and they attach to molecules. When an antibody sticks to a molecule, the molecule is then called the antigen. The B cells then recognize this binding event and replicate. These B cells remain in the body after the infection has been destroyed as “memory B cells,” and can fight off the same type of bacteria more quickly if it invades again. Antibodies are in the bloodstream, and they attack pathogens and other harmful substances. Antibodies attach to the pathogens and substances which signals a response of the immune system. Antibodies are composed of B cells and can produce antigens. The innate and adaptive immune system work together to protect humans.
Smallpox
Smallpox is an infectious disease in humans caused by the Variola virus which is a member of the genus Orthopoxvirus. There are two forms: Variola major and Variola minor. The former is more common and severe; the latter is milder. Smallpox is spread from person-to-person through close contact or contact with contaminated objects called fomites. The incubation period for smallpox is longer than most pathogens and it can take one to three weeks for the first symptom to appear. Smallpox presents with flu-like symptoms, a fever, and a rash over the face, chest, arms and legs that develops into pustules. It is contagious until the last scab falls off a body. Smallpox leaves scars and may cause blindness. While there is no therapeutic cure for smallpox, vaccinations developed to treat smallpox are very effective. Smallpox infection was eradicated from the world in 1977. There are two known places in the world where smallpox is stored: the CDC in Atlanta and the State Research Center of Virology and Biotechnology VECTOR in Russia (previously the Soviet Union).
Inoculation/variolation
Inoculation is the process to generate adaptive immunity and is also called variolation. The process involved taking a small amount of pus from a pustule, or lesion, on a patient suffering with smallpox. A small incision was made in a non-immune person’s arm or leg, then the pus was introduced.
Variolation was widely used throughout Asia in the sixth century A.D.2 The practice of variolation spread to Europe from Constantinople where it was quite popular. Two Greek physicians, Emmanual Timoni and John Pylarini, worked in Constantinople and studied the process extensively before publishing a report, The Philosophical Transactions of the Royal Society of 1716. The report described how to perform the procedure by making a small incision, putting drops of pus in the incision, and covering it with a dressing. The patient was to refrain from touching it and getting it damp. Patients were put on a diet and kept in bed. Pustules would appear and the patient would be monitored for 40 days. Since the amount of viral matter introduced was small and usually from a patient with a light case, the resulting case would be milder than a naturally occurring case.3 The process was promoted by Lady Mary Wortley Montague, who was the wife of the British Ambassador to Turkey. She had witnessed the success of variolation in Turkey. When she returned to England in 1718, she was determined to make the procedure popular. Once she convinced King George I to inoculate his two grandchildren, the procedure was generally accepted in England. The process was still being used in parts of Africa in 1951.4
The American Method
The origin of the American method of inoculations has been contested. The American method was distinct from previous methods because it used mercury during the preparation and process of inoculation. Since ancient times, mercury had been used to treat great pox, or syphilis. The idea to use mercury in the inoculation process came from a Dutch physician named Hermann Boerhaave. Both Dr. George Muirson of Long Island and Dr. Adam Thomson of Philadelphia claimed to have invented the American method. In 1731, Muirson used the method on himself, taking “fourty grains of calomel,” a mercury chloride mineral, to prepare his body for the procedure. Muirson did not publish his work, but he did share it locally. Ezra Stiles, a minister and the seventh president of Yale College, called Muirson, “the First Practitioner in the World of Mercurial Inoculation.”5 This claim was disputed by the people of Philadelphia. They believed Thomson deserved the credit. Thomson created his preparatory method with mercury in Maryland in 1738. He moved to Philadelphia in 1748 and expanded his inoculation practice. In 1750, he delivered a speech about the method. Soon after the presentation, Benjamin Franklin published Thomson’s method.6 Despite the controversy around the origin of the American method, it was widely used in the colonies.
John Adams, who was inoculated in 1764, described the American method as grueling. It began with a diet including milk and mercury that lasted a week. In letters to his wife, Abigail, John described going through the preparation with his brother. He described how they were both sick and that he had loose teeth which were signs of mercurial poisoning.7 After the preparation, Adams was ready for the inoculation. The process involved making an incision, putting pus from a smallpox pustule into the incision, covering it and waiting for the person to develop a case of smallpox. The cases of smallpox were typically milder than a naturally occurring case, but the process could also result in a full infection and cause death and spread smallpox. Abigail Adams and her four children were inoculated in July 1776. In her letters to John, she did not mention any preparation with mercury or a milk diet.8
Robert Sutton entered the inoculation business in 1756 in England. His business was quite small until his children joined the business in the early 1760’s. The Sutton family (Robert and his six sons) advertised Suttonian Inoculations as an improved method of inoculation.9 This method did not require the diet regimen and did not use as deep an incision. The pus was not from a sufferer of natural smallpox, but from a previously inoculated person.10 The Suttonian method was promoted as milder. The method was not published until 1796, but others trained in the method did not keep it a secret.
However, the uniqueness of the technique was challenged by Thomas Ruston, a college student in America. He graduated from the College of New Jersey (Princeton) in 1762. Ruston later went to medical school in Scotland and became the head surgeon in several hospitals in Britain. He began to question the Suttonian method and was convinced it was the same as the method his fellow Americans had developed. He devised a plan to perform chemical analysis on the medicine used by the Suttons. Ruston discovered that the medicine was almost identical to the mercury-based ones used by American inoculators.11 The Sutton family was driven by greed. The Suttonian method seemed to survive the controversy and continue to thrive.12
Despite the controversy surrounding the Suttonian method, Daniel Sutton made some remarkable discoveries about smallpox through his observations and experiments. Sutton observed that more pocks formed when area of skin was heated. This observation supported having patients out in cold air. One day he performed about 700 inoculations. He observed that inoculations performed in the morning fared better than those performed in the afternoon. The afternoon inoculees had about five times as many pock marks. This was likely attributed to the heat. Sutton also noticed the formation of a pustule on the seventh day was a likely indicator of the outcome. A fully-formed pustule with a dome-like top meant a mild case, while a flat pustule likely brought a high fever, back pain, and convulsions. Sutton also was able to determine if a person had prior exposure to smallpox based on the immune reaction at the site of inoculation. Immediate swelling and an itchy red ring would appear if the person already had smallpox. Today, we know this as an immune response of antibodies. In 1796, Daniel Sutton published his autobiography, The Inoculator, which included his observations and instructions. From 1763-1766, he single-handedly inoculated 22,000 people and only three died. He may have been more well-known and less controversial if he had published his work earlier.13
Edward Jenner’s vaccination
Edward Jenner, an English physician, visited a farm and had a conversation with a pretty milkmaid. Milkmaids often had pretty faces free of pock marks. Jenner asked her if she had been inoculated. She shared that she had not, and she continued to tell him that, “I cannot take [get] smallpox, for I have had cowpox.”14 After learning that milkmaids were not catching smallpox, Jenner theorized that somehow cowpox protected them from smallpox. Jenner convinced some milkmaids to let him inoculate them with smallpox. They did not develop symptoms. Jenner wanted to be sure, so he inoculated them again. Once again, they did not develop smallpox.15 On May 14, 1796, Jenner experimented by injecting a young boy named James Phipps with cowpox, since cowpox was less fatal than smallpox. A few months later he injected him with smallpox, and James did not contract the disease. Vaccination was an improvement since the patients did not become infected with smallpox.16
Smallpox in the 13 Colonies
When European settlers arrived in the New World, they brought diseases with them. The Native Americans had no prior exposure to the diseases (cattle were not present in the Americas), therefore they had no adaptive or acquired immunity to them. Thus, providing millions of vulnerable victims to Variola. Between 1600-1700, 75% of Native Americans in Virginia died, including members of the Powhatan, Mattaponi, Pamunkey, and Chickahominy.17
The smallpox epidemic that swept across the North American continent transgressed races, classes, and geographic areas. It is estimated that more than one hundred thousand people died in the epidemic that raged from 1775-1782.18 The smallpox epidemic in North America was different from the epidemic that swept through Europe, where there were crowded cities, transportation, and frequent communication between regions. North America had neither the population density nor the transportation to sustain a continuous outbreak. Instead, smallpox came in waves, often with years between outbreaks while a new vulnerable population amassed.19 Smallpox was endemic throughout English cities and towns, and in rural areas smallpox seemed to cycle through about every five years.20 In the colonies, those who previously lived in Europe tended to have some immunity to smallpox. Throughout American history smallpox would impact people’s freedom differently depending on the politics of the time.
Boston
Boston was the epicenter for smallpox during the colonial era. Prior to the Revolutionary War, there were a series of smallpox epidemics in Boston, a bustling city with a dense population and a port that brought many ships that carried people, supplies, and disease. During one of the outbreaks, Minister Cotton Mather asked an enslaved African named Onesimus if he had smallpox. Onesimus shared with Mather that he had a surgery which protected him against smallpox. Mather probed further and Onesimus described the process which was the practice of the Gurumantese tribes in Africa.21 Onesimus had a scar from the procedure and several other enslaved Africans validated Onesimus’s story. Still, Onesimus’s account was largely dismissed. Similar stories from Europe and Asia spread to doctors in Boston about the process of inoculation, or variolation. Zabdiel Boylston was a prominent surgeon in Boston. He performed the first surgery in the American colonies in 1710 and a second one in 1718.22 Mather convinced Boylston to try inoculation. On June 26, 1721, he inoculated his young son and two of his enslaved Africans. Boylston continued to inoculate people in Boston throughout the 1721 epidemic. In 1724 he served as a fellow to the Royal Society in London. He published his Historical Account of the Small-Pox in New England. He never mentioned the role Onesimus played.23 When smallpox returned to Boston in 1730, Boylston once again showed the effectiveness on inoculation. “About 400 people were inoculated with 12 deaths compared to 3,600 infected with natural smallpox and nearly 500 deaths.”24 Despite much success, there was much skepticism largely due to religious beliefs. Initially it was considered, “A distrust of God’s overruling care to inoculate.”25
In Boston, the two major protection strategies were quarantine and inoculation. As early as 1647, Puritans would implement quarantines when ships arrived from Barbados. In 1731, the Massachusetts General Court passed a new law that forbade people from concealing the smallpox.26 A red flag would be flown outside a household with smallpox and a fence was erected around the house. Quarantine offered protection once a person knew that they had smallpox.
Inoculation offered advantages in preventing or stopping an outbreak, but the benefits came with more risk. The inoculation process was difficult to go through and could result in death. Another concern was that it would spread smallpox, since following inoculation, the patient was infected with the disease and contagious for several weeks. Inoculation was a money-making procedure for the inoculators and primarily provided protection for the wealthy. However, during outbreaks, smallpox would become a community concern. In Boston, once 20 households had smallpox, a general inoculation would take place. Once the selectmen or elected officials declared the general inoculation, anyone who was not immune and didn’t want to inoculate had three days to leave the city. Inoculations were provided to anyone who came to Boston, regardless of their residency.27 During the 1764 epidemic the selectmen provided free inoculations for those unable to afford it.28 They also reimbursed the patients for free. The idea of free medical care for the poor showed that all people deserved the freedom, or right, to their health and was the beginning of public health.
Individuals’ rights to their health are essentially the pursuit of happiness as described by Thomas Jefferson in the Declaration of Independence. Most people would agree that it is difficult to pursue happiness if you do not have good health. During the Revolutionary War, many British and other European soldiers had adaptive immunity since they lived with cows, and many were exposed to cowpox. Many were also immune since smallpox was endemic in Europe. On the other hand, North America lacked the population density and transportation networks to sustain smallpox. There would be an outbreak and then the susceptible population had to build up again before another outbreak would occur. Boston became a model for handling smallpox outbreaks by rallying together for the collective good, just as it would do during the Revolutionary War.
Norfolk Riots - Virginia
The Norfolk riots took place in Norfolk, Virginia, a fast-growing port city, between 1767 and 1768. The riots were complicated with many actors, so here is a brief overview of some key events. The rioters were not opposed to inoculation, but to those who would risk the safety of the community for their own protection.29 In 1767, the Virginia General Assembly passed a law requiring ships carrying convicts and indentured servants to quarantine upon arrival. The law did not mention enslaved people. The law would be repealed in 1768, demonstrating Virginia’s nonchalant approach to public health. In 1736, Norfolk was granted a charter to incorporate as a borough, making it an autonomous urban port city with certain powers to govern within city limits. As a port city, Norfolk was vulnerable to smallpox outbreaks. When outbreaks occurred, the city was using a church and some of its buildings as the pest house. A pest house was the building used to quarantine contagious people. City officials decided to use public land for a new pest house and government officials to oversee it.
The riots arose while tensions were high, as Great Britain had recently passed the Stamp and Sugar Acts. In June 1767, Dr. John Dalgleish had performed a private, elective inoculation without permission. The situation came to light when the inoculee showed up at the pest house. It was believed that Dalgleish intended to perform more secretive inoculations. In February 1768, Dalgleish attempted to rent a house near the city to use as an inoculation hospital without permission. Again, controversy ensued. The owner decided not to rent the house to Dalgleish.
The residents of Norfolk generally supported inoculation but felt the procedure should be supported by the government and not done recklessly. One letter to the Virginia Gazette expressed support when inoculation was “to serve the community” and not profit seeking.30 Later, Dr. Archibald Campbell hired Dalgleish to inoculate his family. The inoculations were to take place at Tanner’s Creek, a house owned by Campbell, outside Norfolk. The poor people in the neighborhood were afraid, but there was no law in Virginia prohibiting inoculation. There was a standoff with locals, and a failed attempt the next day to compromise. The people against the inoculations argued that they could not afford it, and allowing the wealthy to inoculate put them in harm’s way. They supported the fairness of a general inoculation. The other side argued that general inoculation was too expensive.31
The dispute escalated. In June 1768 when Campbell inoculated 28 people, a large crowd of 200 people gathered to protest and vandalize his home.32 Campbell made an agreement to move the inoculees to the pest house, so they were marched five miles during the night. Several weeks later, when the inoculees were released from the pest house, an article appeared in the paper that described the nighttime march during a storm.33 The letter was disputed as inaccurate. The Virginia Gazette published other letters on August 25, that appealed to the wealthy. The concern was raised that they received the same treatment as the Black people during their stay at the public pest house. They would be separated from the Black people at Tanner’s Creek during a private inoculation. On August 27, Tanner’s Creek was burned down.34 No one was ever arrested for the arson. Multiple lawsuits arose and Attorney Thomas Jefferson, who was 24 at the time defended the inoculators until he left the law business.35
More turmoil and lawsuits occurred. On October 9, 1769, one case was decided favorably for the inoculators, as there was no law in Virginia that prohibited inoculation. In November 1769, the Virginia General Assembly passed an act that forbade inoculation not deemed necessary by the government. Violators would face a $1,000 fine per inoculation. The law recognized the hardship some faced to pay for an inoculation and allowed any city or borough to levy taxes to offset the cost of inoculation36 In the spring of 1770, another one of the lawsuits was decided. Jefferson led the defense of James Parker, an inoculator and the prosecution team for the rioters. The ruling was that all parties had some responsibility. A few people were levied a fine that was never collected. Parker felt the case would have been treated differently in Great Britain. He believed a man in England would be allowed to be inoculated in his own home.37
While there were differing opinions around inoculation, the majority in Norfolk believed that liberty meant safety for all through a communal effort of interdependence, not independence.38 Virginia’s inoculation law was effective under normal circumstances, but it would prove largely ineffective when the colony was overwhelmed with marching armies or thousands of enslaved people seeking freedom.39 Unfortunately, the health of the enslaved people was largely ignored. Neither private inoculations nor public health policies offered protection for this most vulnerable population.40 This oversight would have huge implications throughout Virginia’s history.
Smallpox and the Revolutionary War
Smallpox was an invisible enemy during the war. The tiny pathogen would alter military strategies and kill more people than “musket balls or cannon blasts.”41 Since smallpox was not endemic in North America, the Patriot army was at a disadvantage with large numbers of susceptible troops. In the spring of 1775, smallpox was again raging in Boston. In a town meeting at Faneuil Hall, a decision was made to place a hospital ship “some distance from wharf” instead of voting for a general inoculation. The people of Boston had no way to know that this would be the last meeting before the American Revolution broke out at Lexington and Concord on April 19, 1775, and the smallpox pandemic in North America would begin.42 Prior to George Washington’s arrival in Cambridge, Massachusetts as Commander in Chief of the Continental Army, Dr. Artemus Ward, general and commander in chief of the Massachusetts militia, established several hospitals. Some were set up specifically to quarantine and care for soldiers suffering from smallpox.
Washington brought little practical experience with smallpox when he arrived in Massachusetts. Washington supported the idea of isolation and quarantine but was skeptical of so many hospitals. Dr. Ward wanted someone appointed to inspect soldiers for any sign of illness. This strategy would not be effective since smallpox takes 10-14 days before a victim shows symptoms. Washington wanted his soldiers to be more careful with their cleanliness but had little understanding of how smallpox spread and how to contain it in an urban environment.43 Unfortunately, utilizing these prevention strategies, Washington’s army acted like a mobile city spreading smallpox wherever it went. What was Washington to do? Smallpox was a great threat in his crowded camps, but inoculation could leave his army incapacitated, make them vulnerable to an attack, or spread the contagion if one inoculee returned to camp too soon. Washington felt inoculation was too dangerous.
In October, British General Gage had his troops inoculated. Washington believed this was to spread smallpox. Washington wrote to John Hancock, “that the British army was inoculating its soldiers as ‘a weapon of Defence they Ars using against us’ but did not consider having his own soldiers inoculated in response.”44 Conspiracy theories and the idea of germ warfare seemed to percolate throughout the war on both sides. While Washington was concerned about Gage’s behavior and intent, he soon learned that the governor, John Murray, Lord Dunmore in Virginia has issued a proclamation in 1775 declaring freedom for, “All indented Servts & Slaves,” who would take up arms for the British. Within a month, the number of Dunmore’s troops had doubled from 300 to 600 men. This concerned the elite Patriots such as Washington who owned a plantation and enslaved Africans. Lund Washington, George’s cousin, reported, “There is not a man of them, but would leave us, if they believe’d they could make there Escape.” He continued, “Liberty is sweet.”45 The exact number of enslaved Africans who joined Dunmore’s Ethiopian Regiment, as it would come to be called, are estimated to be between 800 and 1,000. Others never made it to Dunmore for a variety of reasons. Dunmore based his army in Norfolk, Virginia. Patriots in Virginia viewed this as the start of a slave rebellion.46 The siege of Boston would end, and smallpox would return forcing another general inoculation in the spring of 1776.
In July of 1776, the Second Continental Congress met to draft the Declaration of Independence, though independence was not the only topic discussed. Smallpox was on the minds of the delegates. The failed campaign in Quebec was fresh on their minds and they believed smallpox inoculation and self-inoculation were responsible for the outbreak. Despite, the opportunity, Congress chose to neither recommend inoculation to the army nor to America. On July 3, 1776, the day the final version of the Declaration of Independence was revised, John Adams wrote to his wife Abigail. He said, “Yesterday the greatest Question was decided, which ever was debated in America, and a greater perhaps, never was or will be decided among men.”47 The “Question” that was decided was whether the colonies should declare independence from Great Britain. The colonies voted unanimously to declare independence. The greater one was, “The small Pox! The small Pox! What shall we do with it?”48 Adams wrote about another important decision that took place on July 9 in a letter to Abigail. The Massachusetts General Court passed legislation to permit inoculation hospitals to open in every county. When the data was compiled, the numbers show that of 304 natural cases with 29 deaths and a 10% mortality rate. There were 4,988 inoculations with 28 deaths and slightly higher than 0.5% mortality rate.49 The general inoculation that took place in Boston would prove to be the most successful large-scale immunization effort of the 18th century.50
The handling of the smallpox outbreaks in Quebec was the antithesis of Boston. Author Elizabeth Fenn estimated about 538 American deaths occurred due to smallpox while in Quebec from late 1775-1776.51 As news of the failed Quebec campaign spread, the enlistments in the Patriot army declined. Soldiers were deserting the army for fear of contracting smallpox. There was also great pressure from states in New England for the commanding officers to change their policies on inoculation. According to Fenn, “It would take increasing pressure from ordinary Americans, colonial governments, the medical community, and ultimately a momentous change of opinion from General George Washington to provide broad support for Americans’ Health in the face of crisis.”52
Figure 1: This watercolor from the American was of Independence was painted by Jean Baptiste Antoine de Verger. Credit: World Digital Library
The British had a small army and a need for more soldiers, so they turned to the enslaved population during the southern campaign (see Figure 1). The recruitment of enslaved Africans was haphazard as individual commanders did so based on the local situation. Enslaved Africans in the Revolutionary era had little acquired immunity since they were isolated on plantations usually some distance from urban areas. So, when enslaved Africans joined military forces, smallpox outbreaks usually followed. Infectious disease affected not only Britain’s policy toward enslaved Africans service, but also the enslaved chances of freedom.53 Governor Dunmore had issued the proclamation freeing the enslaved who would bear arms for the British. Thousands of runaways joined Dunmore’s army on the banks of the James River. Soon, there was a smallpox epidemic affecting the runaways. Dunmore decided to move his troops onto hundreds of ships, or a “flotilla”. The “flotilla” was described as a floating town with thousands of soldiers crowded onto ships. The tight living quarters would prove to be a huge mistake.54 When smallpox broke out on the ships in 1776, Dunmore established a small camp at Tucker’s Point, near Portsmouth, Virginia. Soon after the camp establishment, surgeons recommended inoculation, but the location made the camp vulnerable to an attack. Dunmore decided to move the ships to Gwynn’s Island on the Chesapeake Bay. The troops would be inoculated there.55 The situation worsened when typhus struck. Black soldiers seemed to suffer more, and segregated quarters likely isolated the sickness among the Black soldiers.56 When a Patriot militia reached Gwynn’s Island, a Patriot officer described the scene as, “The deplorable condition of the miserable wretches left behind is beyond description… It is suppose they buried 500 Negroes while on the island, which was only seven weeks.”57 After 1776, Blacks in the British army were no longer inoculated, and many were left without care. In 1776, the Ethiopian Regiment sailed to Staten Island, N.Y., leaving Virginia, carrying smallpox with them.58 As the war progressed, the British established a policy against harboring African Americans. In 1777, the British decided they would no longer accept Blacks into the army. The Black men and their families were neglected by the British.59 Ironically, the promise of “freedom” from Dunmore and the British was short-lived and provided little protection against smallpox.
George Washington
In 1776 Washington implemented a no-inoculation policy. He declared, “any officer in the Continental Army, who shall suffer him-self to be inoculated, will be cashiered and turned out of the army, and have his name published in the News papers throughout the Continent, as an Enemy and Traitor to his Country.” Washington was not alone to feel that inoculation spread smallpox and could be weaponized by the enemy. Despite the efforts of vigilance and isolation, Washington’s army was continually plagued with smallpox. The risk of smallpox was volatile especially as new troops were constantly joining the ranks. The threat of smallpox was impacting recruitment. In 1777, Washington finally conceded and issued an inoculation order. In Pox Americana, Fenn describes how Washington considered inoculation as getting smallpox, which is true, but it was typically a milder case. Once his wife, Martha, underwent the inoculation process in Philadelphia with ease, his mindset began to shift. Fenn notes the evidence of the change is that Washington used the word “innoculation” in his writing for the first time, instead of saying “take the smallpox.”60
Figure 2: Washington Crossing the Delaware (1851). Metropolitan Museum of Art, New York City.
Washington shifted and began to use inoculation and quarantine to protect his soldiers. Washington ended up with one of the best inoculators in North America, Dr. John Cochran, as his chief medical advisor. Washington defeated the Hessian troops at Trenton and had another victorious battle at Princeton. Cochran crossed the Delaware River with Washington on Christmas (see Figure 2). Washington’s army wintered in Morristown, New Jersey, and on February 6, 1777, Washington declared, “no precaution can prevent it from running through the whole of our Army, I have determined that the troops shall be inoculated.”61 Since it was nearly impossible to keep the inoculated soldiers away, Washington and his medical advisors offered free inoculations to civilians who opened their homes and churches as inoculation hospitals.62
By 1777, the Patriot army would inoculate Black and White soldiers. In the beginning, troops would continue to spread smallpox. Through experience, the process became refined. At one point, troops would inoculate while marching, but then the procedure was to inoculate while mustering. The newly-inoculated troops would join the rest of the soldiers once they were no longer contagious. Washington learned that the soldiers that came from the more rural areas and the south were more vulnerable due to a lack of exposure to the deadly disease. For this reason, Washington learned to have new recruits from North Carolina and Virginia stop in Philadelphia to get inoculated before reporting to duty. The Continental Army kept the inoculation a secret by establishing inoculation centers in significant towns that were along important roadways, but far enough away from the British.63 Washington ordered Connecticut’s Governor Trumbull and the General Assembly to permit inoculation hospitals. Surprisingly, Trumbull, a staunch adversary finally relented, thus permitting inoculations for the first time since 1761. George Washington not only became a champion for inoculation but also demonstrated that he would be a leader for the people.
Yorktown
The Battle of Yorktown was the last major battle of the American Revolutionary War. British General Charles Cornwallis would surrender to General George Washington on October 19, 1781. Smallpox would once again impact the war and freedom-seeking African Americans. After Dunmore’s failure, the British no longer viewed enslaved Africans as assets, instead they were a liability. During the southern campaign in the Carolinas, the British implemented quarantines in the cruelest way. Boston King, an enslaved South Carolinian, described the practice he experienced, “All the Blacks affected with that disease were ordered to be carried a mile from the camp… We lay sometimes a whole day without any thing to eat or drink.”64 As Cornwallis marched from the Carolinas through Virginia, self-emancipated Africans joined hoping for liberty.65 Cornwallis’s army may have had as many as 5,000 Blacks.66 Cornwallis used the Africans mainly as laborers. As the British struggled to feed their soldiers, they found themselves unable to care for the Black loyalists in the British camps. The Patriot army on land and their French allies at sea were closing in on Cornwallis and his British army. With the British surrender, most of the enslaved Africans who survived smallpox and the Battle of Yorktown, were sent back to their owners. Thomas Jefferson estimated that about 27,000 enslaved Africans from Virginia lost their lives in 1781. Once again, the British promise of freedom for enslaved Africans was fleeting. Smallpox played a big role in the outcome of the Battle of Yorktown and the American Revolution.
The Early 19th Century
Benjamin Waterhouse, an American physician, became a medical professor at Harvard in 1783. Waterhouse advocated for the use of the cowpox vaccination instead of variolation. Waterhouse received a vial of the cowpox from Edward Jenner and in 1800, he administered the first smallpox vaccine in America to his son.67 A few years later, Waterhouse sent Thomas Jefferson his pamphlet A Prospect of Eliminating Smallpox, to which Jefferson responded favorably. Jefferson became a proponent advocating for vaccination. Waterhouse sent some vaccine to Thomas Jefferson. Jefferson sent some vaccine with Meriwether Lewis and William Clark on their journey to explore the Louisiana Territory.68 On February 27, 1813, James Madison, the fourth president, signed legislation the “Act to encourage Vaccination.”69 In 1822, a mistake was made where a vaccine contained smallpox instead of cowpox, which resulted in some deaths as well as distrust.70 Subsequently, Madison’s legislation was repealed in 1822. The fallout continued, and by 1840 smallpox epidemics and deaths were on the rise.71
Civil War and Reconstruction
Abraham Lincoln was elected president of the United States in 1860. South Carolina and other southern states seceded from the United States. On April 12, 1861, the American Civil War began with the South firing on Fort Sumter in South Carolina. The Civil War would last from 1861-1865. Vaccination was used by the North and South to ward of smallpox. There were problems with the vaccines. Without central oversight, the effectiveness was inconsistent. At times the vaccine was inactive, weakened, or contaminated, so smallpox outbreaks continued throughout the war.72 According to Author Michael Oldstone, “Of over 600,000 Union and Confederate soldiers, estimates were that 29,000 developed smallpox and over 10,000 died of the disease.”73
Lincoln issued the Emancipation Proclamation in 1863 freeing the enslaved Africans. During the war, the Union required smallpox vaccinations in 1864, but many freedmen opposed the “mandatory” vaccination. Some disapproved of the intrusion into health matters and some thought the procedure was harmful.74
During the Civil War, most of the fighting took place between the two capitals, Washington, D.C. and Richmond. The South, and Virginia in particular, were in ruins and had to be rebuilt, so Congress passed legislation to reconstruct the South. There were millions of freed Africans in need of food, clothing, education, and medical care, so the government set up the Freedmen’s Bureau, which was to assist the newly-freed Africans. Smallpox had spread from Washington, D.C. into the Upper South in 1867-68. The newly-freed Africans were a vulnerable population since many had no prior exposure and had not been inoculated or vaccinated. The migratory patterns of formerly-enslaved Africans aided the spread, in much the same way that a marching army or transportation had previously enhanced the spread of diseases. In the South, the smallpox epidemic was concealed, so it would not hinder the effort to rebuild.
People blamed the outbreak on the former enslaved Africans for refusing to take the mandatory vaccination.75 There was resistance, arrests, and corrupt behavior throughout the South while attempting to force vaccinations on the freedmen. Freedmen’s hospitals were ill-equipped to handle the outbreak, despite all the knowledge and protocols that had been established during the Revolutionary War. Protocols were not followed, and resources were not provided to the Freedmen’s hospitals. Not surprisingly, the narrative surrounding smallpox would shift and the disease would be one caused by filth and immoral behavior. During the height of the epidemic, from the winter of 1865 to the spring of 1866, “the New York Times and Nation, stated that the health of the ‘South was good.’”76
Ironically, a cholera outbreak in 1866 led to a state of emergency in the South. The cholera outbreak was a threat to all people, since infectious diseases do not discriminate. However, most of White people had immunity to smallpox through exposure; either natural or medicinal means leaving the freedmen as the susceptible population. Since cholera seemed to be posing the threat to white people, Officials implemented protocols and sent resources to stop the spread of cholera. It seems the narrative was intentionally created to justify the “selective amnesia” about how to handle a smallpox epidemic that affected freedmen. By 1869, it is estimated that 49,000 freedpeople were infected with smallpox throughout the postwar South.77
Present Day
There are many connections and similarities between the smallpox epidemics that ravaged North America and the COVID-19 pandemic in 2020. During both, people had to quarantine to stop the spread. Vaccination clinics popped up, as did inoculation “hospitals”. With both, there was fear of the disease and skepticism for the preventive treatment (inoculation and vaccination). Despite the passage of about 250 years, freedom of one’s health and the disproportional impact on marginalized populations still exists today. With the recent resurgence of measles, people are once again grappling with the decision of whether to vaccinate or not. People value their freedom, and the decisions that they make regarding their body and their health.
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