Public Resistance or Cooperation? A Tale of Smallpox in Two Cities

AS WE THINK ABOUT how to respond to current threats of bioterrorism and new emerging diseases, one major consideration must be the importance of gaining the trust and cooperation of the public. Public apprehension increases with each new disease since HIV/AIDS in the 1980s and SARS, Monkey Pox, Lyme Disease, and West Nile Virus more recently. The potential for bioterrorist use of Anthrax and other weaponizable biological threats makes the public much more edgy. In the face of decreasing trust in the ability of the public sector to be honest about any health problem that might emerge and to address it swiftly and effectively—distrust in government has been growing since the Vietnam War and Watergate—the potential for civic panic and social disorder in the face of a real public health emergency such as a reappearance of smallpox is significant. It behooves us to prepare ahead of time to try to avert such trauma to our cities and towns. Looking back historically to the eras when epidemics commonly attacked American cities can provide some insight into strategies that might be worth adapting to today’s situation and can also provide information about some things to avoid. While history cannot provide simple answers to our own debates, and actions cannot be merely transferred from the past to the present, there is a lot we can learn by looking back. In this article, I concentrate on smallpox to make the bigger point about the importance of public health preparedness. Historically, smallpox ravaged North American communities from the seventeenth century well into the twentieth century. Encounters with the new European disease often destroyed or decimated Native American communities, and the European settlers themselves periodically fell victim to this horrible disease.1 Even though vaccination provided a reliable preventive by the end of the eighteenth century, epidemics persisted throughout the nineteenth and first half of the twentieth century. The history of smallpox in America can be instructive in trying to understand why a disease with a clear preventive was not in fact prevented, and in casting light on what factors are most important to success in public health campaigns against infectious diseases. Two outbreaks of smallpox in two different American cities are particularly relevant to our situation at the beginning of the twenty-first century, and they are the focus here. One occurred in Milwaukee, Wisconsin, which experienced a major smallpox outbreak in 1894 that led to a complete breakdown in civic order. The health department mainstays of vaccination and isolation were resisted by the public in a context of political wrangling and medical dissension, and resulted in almost a month of rioting in the city streets, during which time smallpox spread widely and killed many who were exposed only because of the social disorder. The second smallpox outbreak is the one that threatened New York City in 1947, and it illustrates the opposite response, civic order and citizen cooperation. In New York in 1947, people stood in line for hours, full days, even came back the next day in some cases, waiting to get their vaccinations, and there was no sign of the kind of disturbances that characterized Milwaukee 53 years earlier. Smallpox did not gain a foothold in the city. How can we explain these diametrically different public responses and what can we learn from them?