Pox: An American History, by Michael Willrich (New York: Penguin Press, 2011, ISBN 9781594202865) 400 pp. Cloth, $27.95.
During the first years of the twentieth century, smallpox, that most feared of scourges, became known as the “fool killer.” One simply had no excuse for catching it anymore. Any physician worth his salt knew the clinical progression of the disease and the efficacy of vaccination in warding against it. But if the history of vaccination teaches us anything, it’s that some people, fools or otherwise, require more than an expert’s say-so.
At that time, people actually had good reasons to avoid public health officials’ vaccination lancets. The smallpox vaccine was notorious for causing “sore arm,” which could debilitate a worker for a full week. In an era with only inchoate social safety nets and job security, such a loss in pay didn’t always seem worth it. Moreover, many average Americans doubted the science behind vaccination, with germ theory only having recently emerged in the preceding decades. And there was grounds for suspicion about the safety of vaccines themselves, following a few highly publicized reports of doses being tainted with tetanus or syphilis by unregulated and unscrupulous manufacturers.
In his exhaustively researched Pox: An American History, Brandeis University historian Michael Willrich tells of the last wave of smallpox epidemics to sweep through the United States, between 1898 and 1903, and of medical experts’ struggles to defuse them. This was the start of the Progressive era, when critical reforms in workers’ rights and the rights of women and children were changing the face of society. Willrich also describes the time as including “the advent of the modern expert, when university-trained professionals in medicine, the sciences, and law acquired a new authority in American life.”
Willrich richly describes the struggles these experts and a nascent public health force faced with stymieing what should have been a highly preventable disease. When Dr. Charles P. Wertenbaker of the elite corps of Marine-Hospital Service’s traveling surgeons was dispatched to Middleboro, Kentucky, he arrived to find a smallpox epidemic that had been allowed to run amok due to petty squabbling between municipal and county officials over who would fund the effort to fight it. Add in a population of marauding day laborers inherently skeptical of vaccination, and one witnesses how a cut-and-dry public health case can turn soggy. Officials often carried out compulsory vaccination campaigns with the local police force in tow. Opposition was met with fines and arrests; on some rare occasions, vaccinations were even administered at gunpoint.
Willrich argues convincingly that the federal government’s push for universal vaccination during the Progressive era was a defining, vanguard moment for much of what now comprises the modern, centralized American bureaucracy. Of Wertenbaker he writes that, “for a growing number of people across America and many other parts of the world, a medical man in a navy suit was the first representative of the U.S. government they ever encountered.”
Something Wertenbaker and his colleagues encountered in return were indignant and sometimes cunning saboteurs. Beyond the millions of minority and poor working-class individuals who were simply skeptical or inconvenienced by vaccination were those in the educated middle class who further encouraged those groups to resist it: the activist antivaccination movement. Seizing on themes of the day, such as antimonopoly sentiment, child protection, and originalist notions of individual liberty in the new context of urban-industrial society, the antivaccinationists launched a movement that continues today. In fact, some of their talking points are still in use. An apparent favorite asserts: “Compulsory vaccination ranks with human slavery and religious persecution as one of the most flagrant outrages upon the rights of the human race.”
The antivaccinationists’ medical arguments that smallpox could be avoided with simple sanitation carried no water, and they were met with vituperation from public health officials, the likes of which make even today’s most heated debates appear civil. According to one New York doctor, “To call [the antivaccinationist] an ass is to disparage donkeys in general.” The chairman of the Boston Board of Health, Dr. Samuel H. Durgin, went so far as to offer any “leading members of the antivaccinationists” the “opportunity to show the people their sincerity in what they profess” by willingly exposing themselves to smallpox, sans vaccination. (One unorthodox, crankish physician, Dr. Immanuel Pfeiffer, actually took Durgin up on the offer, only to disappear and later be found convalescing from a full-blown case of smallpox. He was discovered in the care of a fully vaccinated household.)
Despite the more obvious cases of chicanery, Willrich warns against painting this crowd merely as outré cranks of an antediluvian outlook. Though they were wrong on the facts, their efforts fortuitously led to what he argues were the first successes in civil liberties law, which were taken up in earnest a decade later during the World War I government crackdowns on dissent and later still during the civil rights movement. When the antivaccinationists managed to take their case all the way to the Supreme Court, in Jacobson v. Massachusetts, they lost their argument that compulsory vaccination was unconstitutional. But the ruling did uphold (to a degree) their arguments for due process (the state could not vaccinate at gunpoint); equal protection (the state could not single out one immigrant group to vaccinate); and harm avoidance (someone with documented, legitimate health issues who could suffer adverse effects to vaccination must be exempted).
All told, Willrich’s history is dense and edifying. His previous award-winning book, City of Courts: Socializing Justice in Progressive Chicago, cogently explored the Dostoyevskian question of whether crime is rooted in the individual or in the larger society itself. In exploring the precarious dichotomy between public health and the rights of the individual during the Progressive era, Pox maintains his previously set standard.
However, although one mustn’t blame an author for not achieving that which he did not attempt, I wish that Willrich had done a tad more to situate his subject in the larger context of antivaccination movements in Western society, especially given the current antivaccinationist incarnation that insinuates a link between vaccines and autism spectrum disorders. The legitimacy of some aversions to vaccination in the smallpox era are simply lacking in the rhetoric today (though there are of course striking analogues as well, such as the consistent falsity of the public’s intuitive toxicology). Again and again, independent authorities from the Vaccine Court to the Center for Disease Control to countless peer-reviewed medical journals have put to rest the canard that Andrew Wakefield’s “elaborate fraud” brought into the mainstream in recent years past. But it still persists. The major measles outbreak that struck France between January and March of this year was, according to the United Nations’ health agency, a direct result of vaccine abstinence.
Nevertheless, though the author does not explicitly extrapolate his findings to the current imbroglio, Pox has embedded insights into the abiding human embrace of bunk, especially as it relates to public health. Willrich writes that public health officials came to “[realize] that a community’s understanding of disease depended on something more personal than a
public health circular or a family doctor’s advice. Medical beliefs rested upon the shared experience and memory. On this score, smallpox posed a special problem. Outside the urban centers and port cities . . . most communities had not seen smallpox in a generation.”
The same can be said of countless diseases today. For most, the utter maliciousness of diphtheria is a moot if not entirely unknown factor in considering health risks; fewer and fewer people know what it’s like to fear polio; and as for smallpox, the last two known samples may soon finally be destroyed. But just because a danger has passed from memory does not mean it isn’t dangerous. This is one reason the public so consistently misjudges risks and why an understanding of heuristics (mental tricks whereby the mind aligns its thoughts with what one wants to believe) is so vital to public health policy. A public whose reasoning is blighted by countless cognitive biases, sensationalist media, and a web culture that facilitates social information amplification and group polarization like never before cannot always be trusted to make health decisions on its own.
Another excellent new book on the subject gives the real-life account of what happens when individuals take public health concerns into their own hands. In The Panic Virus: A True Story of Medicine, Science, and Fear, journalist Seth Mnookin tells the tragic story of unvaccinated Gabrielle (Brie) Romaguera, who at four weeks old caught pertussis (whooping cough). After undergoing risky surgeries and being sustained by numerous machines, Brie eventually died. As Mnookin writes, her infection in 2003 coincided perfectly with the latest resurgence of vaccination fears.
Pox is a history of compulsory vaccination efforts in Progressive America. But it is also an encapsulated history of modern industrial-urban society itself. Admittedly, one can allegorize that latter narrative in countless ways, but not least among ready options would be to say that it is a tragedy of paradox: as our freedom has allowed for collective progress, that progress has created an exponentially more complex, wrangling society, wherein we are obliged to submit to new forms of power, authority, and expertise. This reliance on expertise is often painted in a bad light—and sometimes for good reason, as the financial crisis of 2008 showed—but there are plenty of countervailing lessons to warn against throwing the modern “expert” out with the bathwater.