Minnesota Medicine

Published monthly by the Minnesota Medical Association
February 2002/Volume 85

Lessons from an Epidemic

In Pox Americana, historian Elizabeth Fenn details how smallpox infected the politics and culture of 18th century America, as well as its people. 

By Charles R. Meyer, M.D.

In 1978, on September 11 in Birmingham, England, Janet Parker died of smallpox, which she apparently had contracted from a smallpox laboratory housed below her flat. She was the last recorded fatality from smallpox in the world. In 1979, the World Health Organization declared the disease smallpox erased from the face of the earth, though the smallpox virus, variola, still existed in laboratories in Russia and the United States. The American supply of variola cultures was scheduled for destruction until that decision was reversed on April 22, 1999, likely in response to reports of a huge bioweapons project in the former Soviet Union and uncertainty about the whereabouts of possible errant Russian smallpox cultures. 

After routine smallpox immunization was halted in the early 1970s, smallpox dropped from American consciousness until another September 11.

Following the World Trade Center and Pentagon terrorism attacks and the ensuing flurry of anthrax cases, doctors reached for their textbooks to refresh their textbook-only knowledge of smallpox, and public health officials dusted off bioterrorism protocols suddenly made relevant. Since even the previously immunized likely had lost their immunity, a worrisome question arose: What would an epidemic of smallpox act like if unleashed in a population with few immune individuals? Elizabeth Fenn’s book Pox Americana: The Great Smallpox Epidemic of 1775-82 provides some historical clues.

Though not the first attack of smallpox in the New World, the epidemic that Fenn describes was unprecedented in its scope and lethality. Stretching from the entire East Coast into Mexico and the American Southwest and up to Hudson Bay and the Pacific Northwest, smallpox claimed more than 130,000 North American lives from 1775 to 1782, preferentially targeting nonimmune groups such as American Indians and slaves. As it swept across America, it was a microscopic character in major dramas of American history, stopping entire armies, cowing intrepid explorers, and decimating American Indian populations. 

During the American Revolution, war fueled smallpox, and the disease burned through armies. Mobile armies with infected soldiers carried the virus to new territory in New England and tidewater Virginia. Close-quartered troops were tinder for rapid spread of the infection. Smallpox killed legions of soldiers that the enemy’s muskets missed, contributing to the defeat of the Continental army at Quebec City. There, mostly-immune British troops repelled the colonist forces that were crippled by sick and dying soldiers from the hinterlands of the colonies, where smallpox was sporadic. Fearing smallpox, potential recruits avoided enlistment, and the militia abandoned the defense of Charleston. Presented with this subversive force, George Washington employed not only traditional quarantine measures but also the controversial technique of inoculation, a pre-Jenner induction of immunity used for 200 years in which live variola virus was applied to a small incision in a patient’s hand. After a short incubation, the inoculated patient usually developed a mild case of smallpox. Although inoculation was popular, with inoculation hospitals springing up throughout colonial America, it ignited medical objections because of its inherent risks and religious opposition because of its perceived “distrust of God’s overruling care.” Yet Washington ordered inoculations for his troops, and Fenn suggests that “Washington’s unheralded and little-recognized resolution to inoculate the Continental forces must surely rank among his most important decisions of the war.” 

Carried by American Indian traders and warriors, variola swept through tribes in Canada’s Hudson Bay region, the American Southwest, and the Western plains. It altered the balance of power between tribes and white settlers and became what Fenn dubs “an unwitting instrument of empire.”

Hauntingly, contemporary themes emerge in Fenn’s account. Fear of British “bioterrorism” surfaced during the siege of Boston in 1775, and in 1781 the leaders of the Continental army accused Britain’s Gen. Cornwallis of using smallpox as a weapon when he released into society 30,000 smallpox-infected slaves who had been fighting with the British. A unique suggestion for “weaponizing” smallpox was offered by British officer Robert Donkin: “Dip arrows in matter of smallpox and twang them at the American rebels, in order to inoculate them; this would sooner disband these stubborn, ignorant, enthusiastic savages than any other compulsive measures. Such is their dread and fear of that disorder!”

Certainly, an outbreak of smallpox in the 21st century would not mimic the 18th century epidemic that Fenn analyzes. Modern antibiotics, sophisticated medical care, and the promised availability of smallpox vaccine would limit the lethality and scope. But, like the colonists, slaves, and American Indians, we are a society with minimal immunity to smallpox and even less firsthand experience. Unknown and exotic, and a bit shadowy and menacing, smallpox is currently the stuff of novels and histories, and its reintroduction into our world would foster some of the same terror that Fenn describes in Revolutionary America. I hope that we’ll be ready, if necessary, and not echo the frustration of John Adams when he said, “The small Pox! The small Pox! What shall we do with it?” 

Charles Meyer is editor-in-chief of Minnesota Medicine.