PROLOGUE
Manhattan’s West Sixty-ninth Street no longer runs from West End Avenue to the old New York Central Railroad tracks at the Hudson River’s edge. In the space now occupied by aging high-rise condominium towers and their long shadows, there once stood a low-slung street of tenements and houses. At the turn of the twentieth century, it was said to be the most thickly populated block in the most thickly populated city in the United States of America. Someone called it “All Nations Block,” and, being a pretty fair description of the place, for a while the name stuck.
A brisk walk from the fashionable hotels of Central Park West, All Nations Block was a rough world of day laborers, bricklayers, blacksmiths, stonemasons, elevator runners, waiters, janitors, domestic servants, bootblacks, tailors, seamstresses, the odd barber or grocer, and, far outnumbering them all, children. Each morning, the children streamed east to Public School No. 94 at Amsterdam Avenue or to the crowded kindergarten run by the Riverside Association at 259 West Sixty-ninth Street. That same foot-worn building housed the charitable association’s public baths; in any given week, four hundred men or more paid a nickel for a towel, a piece of soap, and a shower that had to last. The tenement dwellers of All Nations Block did not choose their neighbors. It was the kind of place where an itinerant black minstrel actor, feeling feverish and far from his southern home, could find a bed for a few nights, in a great warren of rooms whose other occupants were Italian, Irish, Jewish, German, Swedish, Austrian, African American, or simply, so they said, “white.”1
The men of the West Sixty-eighth Street police station knew the block and its ways well. The policemen came when the neighbors brawled, when jewelry went missing in an apartment by the park, or when the Irish boys of the All Nations Gang got too rough with the Chinese laundryman on West End Avenue. The police came once again on the night of November 28. A forlorn and drunken stonemason named Michael Healy, imagining himself to be under attack in his room (“They’re after me,” he had shouted, “See those black men!”), had hurled himself through a fourth-floor window and fell, in a cascade of glass, to, or rather through, the ground below. The Irishman made a two-by-two-foot hole in the surface, breaking through to some long-forgotten trench near the building’s cellar. A neighborhood boy ran to the Church of the Blessed Sacrament on West Seventieth Street and summoned a priest. When the priest arrived, he crawled right through the hole and into the trench, which was already crowded with police, an ambulance surgeon, and Healy’s broken but still breathing body. Before this subterranean congregation, the priest administered last rites. That was the way things went on All Nations Block. It was the night before Thanksgiving, the first of the new century.2
New Yorkers of a certain age would remember that Thanksgiving as the day the smallpox struck the West Side. The outbreak had in fact started quietly a few days earlier, on All Nations Block. The city health officers found the children first: twelve-year-old Madeline Lyon, on Tuesday, and on Wednesday, a child just across the street, identified only as a “white boy four years old.” For the health officers to diagnose the cases with any confidence, the children must have been suffering for days, with raging fevers, headaches, severe back pain, and, likely, vomiting, followed by the distinctive eruption of pocks on their faces and bodies. Once the rash appeared and the lesions began their two-week metamorphosis, from flat red spots to hard, shotlike bumps to fat pustules to scabs, the patients were highly contagious. The health officers removed the children, stripped their rooms of bedding and clothing, and disinfected the premises.3
The health department followed the same procedure with the five other cases that were reported elsewhere in Manhattan within hours of the Lyon case. One was a white domestic servant named Mary Holmes, who worked in an affluent apartment house on West Seventy-sixth Street. The other four were black, evidently from the neighborhood of the West Forties. They were Adeffa Warren, Lizzie Hooker, Susan Crowley, and Crowley’s newborn daughter—these last two had been removed in haste from the maternity ward at Bellevue Hospital. Through interviews, health officers had established that the four black patients had come into contact with an unnamed infected “negress,” who remained at large. How any of these patients might have been connected to the children on West Sixty-ninth Street, about a mile and a half uptown, remained uncertain. But the authorities were working on the assumption that the outbreak started on All Nations Block.4
The officers of the internationally renowned New York City Health Department, medical men given broad powers to police and protect the public health in one of the world’s most powerful centers of capital, were not easily shaken by the odd case of smallpox among the wage earners. Now and then an infected passenger got past the U.S. government medical inspectors at Ellis Island or crossed into the city on one of its many railroad tracks, waterways, roads, footpaths, or bridges. Most New Yorkers had undergone vaccination for smallpox at one time or another—on board a steamship crossing the Atlantic, in the public schools, in the workplaces, in the city jails and asylums, or, if they possessed the means, in their own homes under the steady hand of a trusted family physician. When an isolated case of smallpox triggered a broader outbreak, the health officials took it as an unmistakable sign that the population’s level of immunity had begun to taper off, as it did every five to ten years. The time had come to sound the call for a general vaccination. “We are not afraid of smallpox,” said Dr. F. H. Dillingham of the health department, when the news broke that smallpox had reappeared on Manhattan. “With the present facilities of this department we can stamp out any disease.”5
On Thanksgiving Day, as the Columbia University football team took the field against the Carlisle Indian School and three thousand homeless people lined up for a hot dinner at the Five Points House of Industry, a vaccination squad from the health department’s Bureau of Contagious Diseases moved into West Sixty-ninth Street. The four doctors began a quiet canvass of All Nations Block, starting with the immediate neighbors of the infected children. Health department protocol called for a thorough investigation of each case, in order to trace its origin, followed by the immediate vaccination of all possible contacts. In a place as densely inhabited as All Nations Block, everyone would have to bare their arms for the vaccine.6
With a willing patient, the vaccination “operation,” as doctors called it, lasted just a minute or two. The doctor took hold of the patient’s arm, scoring the skin with a needle or lancet. He then dabbed on the vaccine, either by taking a few droplets of liquid “lymph” from a glass tube or using a small ivory “point” coated with dry vaccine. Either way, the vaccine contained live cowpox or vaccinia virus that not long before had oozed from a sore on the underside of an infected calf in a health department stable. In the coming days, the virus would produce a blisterlike vesicle at the vaccination site. In due course, the lesion would heal, leaving a permanent scar: the distinctive vaccination cicatrix. If all went well, the patient would then enjoy immunity from smallpox for five to seven years, sometimes longer. And, of course, as long as a person was immune, she could not pass along smallpox to others.7
The health department’s plan was to secure All Nations Block first and then follow the same procedure on the surrounding streets. In the coming days, health officers and police would maintain a quarantine on the block and enforce vaccination in the neighborhood schools. The health department would use all the available methods to fight the disease: total isolation of patients, quarantine of their living environment, vaccination of anyone exposed to the disease, disinfection of closed spaces and personal belongings, and close surveillance of the infected district and its residents.8
It was a sensible protocol, born of medical science and the city’s long experience with the deadliest contagious disease the world had ever known. Historically, smallpox killed 25 to 30 percent of all those whom it infected; most survivors were permanently disfigured with the dreaded pitted scars. Decades after the scientific revolution known as the germ theory of disease, biologists and doctors were still searching in their laboratories for the specific pathogen that caused smallpox. But they felt confident they had a strong understanding of the microbe’s 'font-size:10.0pt;font-family:"Times New Roman",serif;color:blue'>9
The vaccination corps had not been on the block long before the doctors realized the need for reinforcements, men armed with more than vaccine. As the physicians moved from door to door, rapping loudly and calling for the occupants to come out and be vaccinated, many residents refused to cooperate. The doctors tried to explain the danger, which could not have been easy given the many tongues spoken on the block. But many people would not submit to having their own or their children’s arms scraped by the vaccinators without, according to The New York Times, “loud wails and even positive resistance.” Receiving word of the worsening situation on All Nations Block, the commander of the West Sixty-eighth Street station dispatched a detail of six policemen to assist the doctors in “enforcing the vaccination.”10
Well into the cool autumn night, All Nations Block echoed with the rapping of nightsticks on doors, the shouting and pleas of the residents within, and, through it all, the rattle of the horse-drawn ambulance wagons as they moved to and from the infected district. By midnight, the vaccination corps had discovered another twenty-two cases on the block, many of them little children, all of them, in the health officers’ view, requiring immediate isolation. The ambulance wagons carried the patients five miles over rough city roads to the Willard Parker Hospital, the health department’s contagious diseases facility at the foot of East Sixteenth Street on the East River, where the doctors gave them a more full examination. From there they were ferried off Manhattan and many more miles upriver to the city smallpox hospital, the “pesthouse” on North Brother Island, a nineteenacre wooded island situated between Rikers Island and the Bronx mainland. Pesthouses, public hospitals used to isolate poor people suffering from infectious diseases, were the most dreaded of American institutions. The trip to North Brother Island was a grim journey into unknown territory. No known cure for smallpox existed. The pesthouse doctors could do little more than treat the patients’ symptoms. It was up to the virus, and to each patient’s own resources, to determine who among the infected would die in the seclusion of North Brother Island.
The germ theory taught that contagious diseases such as smallpox did not arise spontaneously; they did not spring to life in vaporous miasmas from stagnant water or decomposing filth, as physicians and sanitarians had previously assumed. Doctors now understood smallpox to be caused by invisible life forms—“germs”—that could only survive and proliferate by infecting human carriers. There seemed to be no animal or insect vector for smallpox: no species of mosquito, rodent, or bird that carried the disease from person to person, place to place. If smallpox suddenly appeared in a previously healthy community, there were only two possible explanations: either viral material from a recent case had survived for a time in clothing or bedding or, more likely, someone had brought the pox into the community. On this point medical science reinforced the common reflex of human communities everywhere to blame sudden misfortune on their most marginal inhabitants, outsiders and “others.”11
“What a potent factor in maintaining the prevalence of small-pox is that unemployed and largely unemployable degenerate, the habitual vagrant or tramp,” observed a writer in the London-based Lancet, the preeminent English-language medical journal. “The fact that this parasite upon the charity and good nature of the community is in his turn a vehicle for the spread of other parasites, both animal and vegetable, is common knowledge but practically no compulsory steps have been taken to curtail seriously the vagrant’s movements or to promote his elementary cleanliness.”12
Suspicion fell immediately upon one of the infected patients en route to North Brother Island, the black minstrel actor who had just arrived on All Nations Block. A member of the traveling Wright Troupe, the man (whose name is lost to the historical record) had come north only a short time before and had taken a room in one of the houses where the sick children were later discovered. The rumor quickly spread that “this negro” had carried the germs in his body from Pittsburgh and, living in a house filled with playful innocents, infected at least one of them. That child, the theory went, infected classmates in the swimming bath of the Riverside Kindergarten. The theory had an easy plausibility; the white doctors of the health department, no less than the residents of All Nations Block, lived in an American culture of race that scorned black bodies as vessels of moral and physical danger. But perhaps there was more to the theory than a reflexive racism. Smallpox had been epidemic for several years in the American South, where it had spread first and most widely among black laborers in the coal mines, railroad camps, tobacco plantations, and crowded cabin settlements of the rising New South. Given the long incubation period of the disease, it might have been expected that an African American traveler would eventually bring the southern smallpox to New York. On two separate occasions during the preceding three years, smallpox epidemics had struck upstate communities. Each time the New York State Health Department had attributed the outbreaks to a traveling negro minstrel show.13
As the city health department grew concerned about the seemingly connected center of contagion, in the neighborhoods of the West Forties near Eighth Avenue, rumors circulated about a second suspect. He, too, was black. Albert Sanders, twenty-two, had suffered through nearly the full course of smallpox without medical attention before he was discovered; no patient found so far had been infected longer than he was. During this time Sanders had managed to mingle with many people. Unlike the minstrel man, Sanders had been in town for a while, and his name had appeared in the papers before. In the brutal West Side race riot of August 15, 1900, as hundreds of whites taunted and beat blacks in the African American neighborhoods along Eighth Avenue, Sanders had been listed among the injured, suffering from scalp wounds and cuts. Evidently the experience had not inspired in him a trust of whites, doctors included.14
Once two dozen cases of smallpox had turned up on the West Side, the question of the outbreak’s precise origin became almost moot. Whoever had started it—the minstrel man of All Nations Block, the unnamed “negress,” Albert Sanders, or someone else—the outbreak would now be difficult to contain.
By December 6, one week after Thanksgiving, the New York papers were calling the outbreak a full-blown smallpox epidemic, the worst in Manhattan since 1892. Three of the patients on North Brother Island had already succumbed to the disease: the servant Mary Holmes; twenty-year-old Elizabeth Oliver; and the Crowley infant, whose mother, it seemed, had not had the heart to name her. The pesthouse now held forty-four smallpox patients, with more arriving almost every day. All hopes of keeping the outbreak quarantined in a small area of the city had vanished when five-year-old Sadie Hemple, until recently a resident of West Sixty-ninth Street and pupil at the Riverside Kindergarten, turned up across the river in Hoboken with a case of smallpox. The virus had incubated in her body while she and her parents moved to their new home, a five-story tenement house where some twenty other children lived. The Hoboken authorities removed Sadie to their own pesthouse, in a place called Snake Hill. New York officials had to concede that the West Side outbreak had “overleaped the bounds” of All Nations Block.15
The health department’s vaccination corps was now scraping the arms of the poor at the rate of fifteen hundred per day. Resistance to vaccination had abated in some of the infected areas—where the people were, in the words of one city vaccinator, “well scared up.” More than five hundred poor people called each day for free vaccinations at the board of health’s headquarters on West Fifty-sixth Street, most of them mothers with little children in tow. But with each new outbreak in another of the island’s crowded tenement districts, the vaccination corps met fresh resistance. Over time, the corps would ever more closely resemble a military outfit. Across the city, private physicians and druggists bought up “hitherto unheard of quantities” of the health department’s vaccine stock. At factories, department stores, and offices, employers told their employees to get vaccinated or not bother showing up. On Wall Street, the managers of the New York Stock Exchange set up their own on-site vaccination station. All employees had to submit to the procedure before they could take their positions in the great scrum of the trading floor.16
Among the many political effects of the widening epidemic in New York City was an earnest moral discourse, as the city’s chattering classes mulled the significance of the event. The ancient and filthy scourge of smallpox had struck at the very heart—and, it seemed to many, the very moment—of modern American civilization.
The New York Times, the moderately progressive voice of elite opinion, published a series of editorials in which it called the epidemic “a matter of grave public concern.” The editors cautioned their affluent readers against indifference; the outbreak was no longer safely confined to “the congested tenements of one locality.” “Public conveyances and places of public assembly bring all classes together to such an extent that only the recluse can feel quite safe,” the Times advised, “and not even the recluse if ministered to by servants who visit friends in the infected districts.”17
Such a recognition of the inescapable interdependence of modern urban life stood as the grand unifying theme of the many disparate progressive reform campaigns of the turn of the century: movements for safer working conditions, social insurance for wage earners and their families, better housing for the poor, new programs to rehabilitate criminals, and innumerable measures to protect the public health. The same ethical and political logic, which held individual liberty subordinate to the collective interests of society, underlay the Times’s call for universal vaccination: “This is not only a wise measure of personal precaution, but it is a public duty which every citizen owes to those with whom he comes in daily contact.” The Times was prepared to take this logic to its furthest conclusion and endorse the most punitive measures for vaccination in the “great and crowded city.” But the editors expected that such measures would prove unnecessary. The “anti-vaccination heresies” that had spread so perniciously in England and other foreign countries in recent years would find few followers in the United States, the Times insisted. “Here a saving common sense has prevailed in all classes of the population, and smallpox works serious ravages only in remote corners inhabited by out-and-out savages.” A progressive appeal to social interdependence, civic obligation, and enlightened common sense did not, in this instance, imply tolerance, empathy, or solidarity. Or good taste: three people had recently died in the city, ravaged by smallpox. Were they “savages”? 18
These were, of course, the overheated ruminations of editorial writers. The Times’s editors got the high moral tone of the moment just right, and the facts of the historical events unfolding around them all wrong.
In December 1900, the United States was in the throes of an extraordinary five-year wave of smallpox epidemics. It was the worst visitation of smallpox in a generation or more, and the last Americans would experience on a continental scale, as a national event. From Alabama to Alaska, no state or territory was untouched. Smallpox made its way across an increasingly interconnected American landscape: from southern tobacco plantations to western mining camps to immigrant tenement districts in aging east coast cities; from the nation’s capital in Washington to Filipino and Puerto Rican villages on the farthest edges of the new American empire. The epidemics did not confine themselves to a few “remote corners” of the country. Many major American cities experienced deadly epidemics. New Orleans reported nearly 1,500 cases and 450 deaths in 1900. In Philadelphia, smallpox infected 2,500 people and killed nearly 400. Boston recorded 1,600 cases and 270 deaths. And by the time the smallpox epidemic that started on All Nations Block was through with New York City in 1902, the health department had recorded 2,100 cases, and 730 men, women, and children lay dead.19
No reliable figures exist to quantify the overall damage done by small-pox to American lives, commerce, and property during these epidemic years. The U.S. Public Health and Marine-Hospital Service, the federal disease-control agency, conceded that its smallpox statistics were woefully incomplete. The federal officials dutifully published the data they received from state and local health boards, but in many states those agencies were just coming into their own. Many smallpox-infected communities lacked the will or the wherewithal to accurately report cases of infectious disease.
Still, the admittedly spotty statistics of the federal health service suggest the broad chronological arc of the epidemics. At the beginning of 1898, smallpox was largely absent in the United States, apart from a few trouble spots, mostly in the South, including Birmingham, Alabama, and a hard-bitten Appalachian coal town called Middlesboro, Kentucky. As Surgeon General Walter Wyman of the Public Health and Marine-Hospital Service recalled, “[I]t was during the winter of 1898–99 that the disease began to assume great proportions.” In 1899, the service reported more than 12,000 cases, from all over the South, followed by 15,000 cases, now in the mid-western states, too, in 1900. In 1901, the number of new cases surged to nearly 39,000. According to the Medical News, by then the distribution of smallpox in the United States had become “alarmingly general.” In 1902—the year Wyman would remember as “the high-water mark” of the epidemics—the service counted 59,000 new cases. The agency tallied another 42,590 new cases in 1903. By the end of that year, the surgeon general assured the nation that “the disease has spent its force and will now continue to decrease until it practically disappears.” In fact, smallpox did taper off dramatically in 1904, but the disease did not disappear. Smallpox would continue to trouble American communities until the last reported U.S. case occurred in 1949. All told, during the five-year wave of epidemics around the turn of the century, the federal service counted 164,283 American cases of smallpox. The actual number of cases may have exceeded five times that figure.20
But for American public health officials, the truly stunning statistic from those epidemics was the body count. It was shockingly low. According to the federal health service reports, only 5,627 people died. Again, the mortality figure was impressionistic at best; the Census Bureau independently reported nearly 4,000 smallpox fatalities in 1900 alone (more than five times the health service’s figure for that year). Still, all agreed that the death toll was astonishingly, inexplicably, blessedly small. If smallpox had measured up to its historical virulence, the epidemics of 1898–1903 would have killed at least 50,000 Americans .21
Although in some places smallpox proved as destructive as ever, in the vast majority of American epidemics after 1898, the disease seemed to have lost its lethal force. Vaccinal protection could not explain the phenomenon: when the smallpox came, most Americans had not been vaccinated in years. It seemed a new “mild type” of smallpox had appeared on the epidemiological landscape, the likes of which the “civilized” nations of Europe, England, and the United States had never seen. No one could say how long the new pox would remain mild. Many medical authorities expected the disease to revert to classic, malignant smallpox at any moment. For American health officials, the low mortality rate posed the greatest medical mystery—and the toughest political challenge—of the turn-of-the-century smallpox epidemics.22
The sudden appearance of a new mild form of smallpox altered the political calculus of compulsory vaccination—a measure that had been none too popular in late nineteenth-century America. To this day, medical experts consider smallpox vaccine, which contains a bovine virus called vaccinia, “the least safe vaccine available.” Serious complications, including postvaccinial encephalitis and death, are rare: scientists expect one million vaccinations to cause three to five serious reactions. But milder reactions—rashes, fatigue, headache, fever, painfully tender arms—are common. In 1900, vaccination carried significantly greater dangers. The government compelled vaccination, but did little to ensure that American vaccine makers produced safe, effective vaccine. Newspaper stories, medical texts, and popular rumors linked vaccination to syphilis, tetanus, and the ubiquitous “sore arms” that caused countless American breadwinners to lose days or even weeks of work. Because the new pox killed less than 1 percent of the people whom it infected, many laypeople and even doctors refused to believe it was smallpox at all. In the absence of a recognizably horrific case of smallpox, many failed to see the benefit of vaccination. Many saw vaccination as the greater risk to life and limb. And their resistance to compulsory vaccination would help persuade the federal government to impose new regulatory controls on the American vaccine industry.23
But reasonable health concerns do not alone explain the widespread opposition to compulsory vaccination at the turn of the twentieth century. Antivaccinationism was an international phenomenon, but everywhere it reflected the social divisions and political tensions of its time and place. The roots of American antivaccination sentiment ran deep and wide. Race stymied smallpox control, as white taxpayers, particularly in the South, balked at paying for vaccine to protect blacks; meanwhile, African Americans rightly mistrusted government vaccinators whose chief aim was to protect the white community. Christian Scientists viewed compulsory vaccination as a violation of religious freedom. Physicians who practiced popular forms of alternative medicine decried government vaccination orders as yet another example of creeping “state medicine.” Parents resented school vaccination mandates for encroaching on their domestic authority and for violating their children’s innocent bodies. Antivaccination propagandists traced compulsory vaccination to a corrupt conspiracy between health officials, lawmakers, and vaccine manufacturers. On the broadest level, though, the vaccination question revealed a sharp uneasiness toward the authority of medicine and the power of the state at the height of the Progressive Era, a period of time when both institutions were reaching more ambitiously than ever before into American life.24
Contrary to the Times’s assertion, then, an unquestioning submission to vaccination was anything but the “common sense” of the American people during these smallpox outbreaks—even in the many places where local and state governments made such submission compulsory by law. Ordinary Americans responded to government vaccination orders in a variety of ways, ranging from ready compliance to violent riots. They organized antivaccination societies, conducted legislative campaigns (some of them successful) to repeal state vaccination laws, and flooded the courts with lawsuits challenging compulsory vaccination as a violation of their constitutional rights. More often, people resisted public health authority in more private, mundane ways: by concealing sick family members at home, forging vaccination certificates, or simply dodging their legal duty to be vaccinated. In the aftermath of this nationwide fight against smallpox, the United States would remain, in the words of one of the nation’s preeminent public health experts, “the least vaccinated of any civilized country.”25
The aim of this book is to explain why this was so. To trace the origins and broader significance of smallpox and the “vaccination question” in Progressive Era America, I have found it necessary to stray far from the familiar narrative conventions of the epidemic tale. This is not a story of rising body counts and medical heroics—though the changing lethal power of the smallpox virus, the emergence of the modern vaccine industry, and the strenuous work of public health officials are all central to this narrative. Nor is the story told in these pages a comforting tale of human solidarity springing up in unexpected places: the tragic disaster that forces the people of a community to overcome their differences and work together to survive and rebuild. The smallpox outbreaks of the turn of the century did occasion such moments, and they are remembered here. But the history of these American epidemics is, inescapably, a history of violence, social conflict, and political contention. And that made all the difference .26
America’s turn-of-the-century war against smallpox sparked one of the most important civil liberties struggles of the twentieth century. To readers versed in the scholarly literature about American civil liberties, this claim may sound curious (or even spurious). According to the conventional text-book narrative, the modern era of civil liberties properly begins with the famous free speech cases of the post–World War I era, when the U.S. Supreme Court established new First Amendment protections for political dissent. But contemporaries of the period, including no less a giant of the American legal realm than Justice Oliver Wendell Holmes, Jr., of the United States Supreme Court, recognized that the celebrated free speech battles reprised constitutional questions that the vaccination struggle had raised for Americans two decades earlier. As Justice Holmes wrote in a 1918 letter to Judge Learned Hand, “Free speech stands no differently than freedom from vaccination.”27
In a burst of litigation arising from the smallpox epidemics, the critics of compulsion had carried the vaccination question all the way to the U.S. Supreme Court in 1905. They raised a broad set of questions about the nature of institutional power and the bounds of personal liberty in a modern urban-industrial nation. Their demands went far beyond the right to speak out against the government. The critics of compulsory vaccination insisted that the liberty protected by the Constitution also encompassed the right of a free people to take care of their own bodies and children according to their own medical beliefs and consciences. It was a bold but deeply problematic claim. And it brought the opponents of compulsory vaccination into direct conflict with the agents of an emerging interventionist state, whose progressive purpose was to use the best scientific knowledge available to regulate the economy and the population in the interests of the social welfare.28
This, then, is the story of a largely forgotten American smallpox epidemic that killed relatively few people but left a surprisingly deep impression on society, government, and the law. The story begins where the epidemics did, in the fields and work camps of the New South.