Controversies in Science and Technology: From Maize to Menopause

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

19 Public Resistance or Cooperation? A Tale of Smallpox in Two Cities Judith Walzer Leavitt 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, more recently , severe acute respiratory syndrome (SARS), monkey pox, Lyme disease , and West Nile virus. The potential for bioterrorists to use 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 at what happened when epidemics commonly attacked U.S. 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, a look back can teach us a lot. In this chapter, I concentrate on smallpox to 311 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. The encounter with new European diseases often destroyed or decimated Native American communities, and the European settlers themselves periodically fell victim to this horrible disease.1 Although vaccination provided a reliable preventative by the end of the eighteenth century, epidemics persisted throughout the nineteenth century and the first half of the twentieth century . The history of smallpox in the United States can be instructive in trying to understand why a disease with a clear preventative 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 U.S. cities are particularly relevant to our situation at the beginning of the twenty-first century. One occurred in Milwaukee, Wisconsin, which experienced a major smallpox outbreak in 1894 that led to a complete breakdown in civic order. In a context of political wrangling and medical dissension, the public resisted the health department mainstays of vaccination and isolation, which led to almost a month of rioting in the city streets, while smallpox spread widely and killed many who were exposed only because of the social disorder. The second smallpox example is the one that threatened New York City in 1947, and it illustrates the opposite response, civic order and citizen cooperation . New Yorkers 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 fiftythree 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? Smallpox in Milwaukee, 1894 Smallpox hit every ward in Milwaukee in June 1894, just months after the appointment of a new health commissioner, Walter Kempster, a British-born nationally recognized public health authority (Leavitt 1996). Immediately after taking office, Kempster tried to reorganize the health department, hire new people on the basis of merit rather than political patronage , even applicants from his own political party. With his natural al312 l e av i t t lies, medical and political, angry with him, Kempster faced a challenging situation under the best of circumstances. Then, smallpox arrived and chaos erupted. As the health commissioner noted in the middle of the epidemic, “The alarm caused by a few cases of smallpox has served to unbalance the equanimity of the entire community” (Milwaukee Health Department Annual Report 1895, 20). The health department response to the outbreak was the same as it had been during previous outbreaks. The agency started a vaccination campaign, opened the isolation hospital, and isolated some of the sick in their own homes, with...