In the rear room above Caballo’s saloon in East Harlem, behind the door with the big brass padlock, three children lay sleeping one cold February night in 1901. They slept under the bed, on a piece of cloth. Molina Caballo, the eldest, was four. Huddled beside her were her baby sister, Rose, and eighteen-month-old Antoinette Alvena. Some boxes of clothing stood by the bed, like a low wall, blocking the view from the doorway.1

Out on the street two hundred and fifty men awaited the order to move. Their breath formed a bank of fog against the winter night. Half of them were doctors—vaccinators and inspectors from the New York City Department of Health. The rest were uniformed patrolmen from the East 104th Street Police Station. It was 9:30, the hour chosen by Dr. Alonzo Blauvelt to ensure that the working people of Italian Harlem would be at home in their beds. The forty-seven-year-old chief inspector of the department’s Division of Contagious Diseases had forsaken the warmth of his own bed to lead this raid in person. The vaccination corps aimed to inspect every room, yard, and body between Second Avenue and the East River, moving north from 106th Street to 115th Street. On an ordinary street map, the area didn’t look like much: a few blocks on a vast city grid. But to the Department of Health, this stretch of five- and six-story tenements, where as many as five large families crowded onto every floor, marked a trouble spot in the medical geography of Manhattan, one of the island’s most thickly populated and disease-ridden Italian “colonies.”2

Ten weeks had passed since the Thanksgiving smallpox outbreak on All Nations Block, over on the West Side. In that time, the department had reported nearly two hundred cases—not quite enough to strike terror into a city of three and a half million people, but more than enough to cause the circulation of library books to plummet, the city’s regional trade to shrink, affluent families on the Upper West Side to cast out their servants, and the health department to hire seventy-five extra vaccinators. The department’s smallpox strategy, as Blauvelt had recently explained it to The New York Times, involved isolation of all infected persons, surveillance of their family members and known contacts, and vaccination of “suspicious neighborhoods.”3

City health officials often reminded the public that the Empire State had no compulsory vaccination law. But their actions said otherwise. The department’s strategy for containing smallpox ensured that the full power of public health policing would be felt chiefly in the city’s tight spaces—the crowded places where the wage earners lived, worked, prayed, and amused themselves. In those places, made closer still by the sudden entry of a vaccination squad and its armed police entourage, the department’s authority proved hard to resist—and yet hard not to. What counts as compulsion is a question best answered by the person with her back to the wall. Even Blauvelt had said, after the December raids of the Bowery lodging houses, where his men had vaccinated 4,500 homeless people, that the sight of all those nightsticks “might have been something of a persuader.”4

The response of American public health departments to epidemic smallpox at the turn of the century revealed progressive social governance at its most powerful and problematic. New York City’s methods were exceptional only in their bureaucratic sophistication and scale. The same working principles, tactics, and values drove campaigns against smallpox in urban communities from San Francisco to Boston. The known behavior of smallpox—its tendency to spread like wildfire in crowded places—dictated a spatial response. In fact, smallpox would one day be eradicated across the world using a strategy of isolation, surveillance, and targeted vaccination not so different from that used by New York City to fight this, its last major epidemic of the disease, in 1901 and 1902. But the spatial strategy of disease control generated its own political theater of government coercion and working-class resistance.

Space, a necessary condition for the exercise of human freedom, came at a premium in the modern, urban-industrial society that the United States was so rapidly becoming. No one knew the price of space better than “the masses”: the sort who journeyed to America below the water line, in the teeming steerage compartments of steamships, and who sought work in factories and mines, shelter in tenements and lodging houses, leisure in saloons and dance halls, and an education for their children in the public schools. Fighting contagion in the name of the public health meant wielding extraordinary authority in those tight spaces. Public health was, without question, a cutting-edge, progressive enterprise—the marshaling of modern science for the betterment of society. Few stood more to gain than tenement dwellers from successful campaigns against smallpox and other plagues. But as the price for the space they occupied in the nation, such people were expected to bear a level of intrusion and coercion that American governments did not dare ask of their better-off citizens. As a consequence, smallpox control triggered some of the Progressive Era’s most dramatic conflicts between working-class people and the government. That is why Blauvelt’s medical men traveled with a police escort.

New York’s two major Italian “colonies” on the East Side—home to tens of thousands of America’s newest immigrants—were closely watched by health officials even when smallpox did not threaten. As workingmen and families from southern Italy poured through New York harbor during the 1880s and 1890s—forming one distinct enclave on the Lower East Side around Mulberry, Elizabeth, and Mott streets, and another up here along the southern edge of East Harlem—their communities had become known to health officers as danger zones. The Italians understood all too well that disease flourished in those crowded, airless, double-decker tenements. Many who had made the move north from Mulberry Bend to East Harlem had done so not just to be closer to the construction and transit companies that were building northern Manhattan but also to live in this relatively cleaner and more open section by the East River. But East Harlem, too, grew thick with people and sickness.5

In both settlements, the Italians often welcomed health officials’ efforts to improve their environment. In the summer of 1900, Blauvelt met little opposition when he rolled onto Mott Street at the head of a “disinfecting party,” equipped with two wagons carrying one hundred gallons of disinfectant. Sanitary inspectors, backed by eighty policemen, moved through hallways, rooms, and cellars, pumping spray into every nook and across every surface they suspected of harboring germs. But when health department tactics collided with cherished cultural practices or the sanctity of the family, the officers encountered strong opposition. No action occasioned greater resistance than when authorities tried to remove an Italian child infected with tuberculosis or smallpox from her mother. Such experiences had convinced charity officials and health officers that Italian tenement mothers—knowing little English and seemingly indifferent to modern hygiene—posed a special threat to their own children and to the public health. “With ignorance of that stamp,” said the crusading reformer Jacob Riis, “there is no other argument than force.”6

With the return of smallpox to New York in late 1900, the eyes of the department were trained once again on the city’s “Little Italies.” In mid-January 1901, officials discovered a case of smallpox in a Mott Street tenement. In the last few days of the month, a department raiding party removed thirty people with smallpox from Italian Harlem. Inspectors found children tucked away in cupboards. “No one knows the damage that has been done by these Italians,” said Dr. Frederick Dillingham, assistant sanitary superintendent for Manhattan. “They have gone from infected homes to work everywhere in this city; they have ridden in street cars, mingled with people, and may have spread broadcast the contagion. The most stringent measures should be taken to stamp out the spread of the disease.” Now, on the night of February 1, as Blauvelt’s men looked around at all those tenements, they had a good idea what they would find behind their brick and wooden walls.7

At Blauvelt’s command, the men moved. They followed the same method on each block. With policemen stationed on the roofs, at the front doors, and in the backyards, doctors and police entered the tenements and rapped on doors, rousing men, women, and children. Frightened and furious, the residents moved into the lighted areas, where doctors inspected their faces for pocks and their arms for the mark of vaccination. Some understood the officials’ English. They translated for the many who did not. Everyone lacking a good mark had to submit to vaccination. According to the Times, which had a reporter on the scene, many residents were “forcibly vaccinated.”8

While some fought, others fled. Quick-footed men slipped past police at stairwells, doorways, and coal scuttles, bolting into the night. Doctors and police chased a man wearing nightclothes as he leaped over back fences. Catching him, they discovered he had recently been vaccinated—he had the ripe sore on his arm to prove it. He fled because, speaking no English, he did not understand the raid’s purpose. He ran as if his life depended on it.9

The Times reporter recorded the “many dreadful scenes” that marked the progress of the vaccination corps through “the infected district.” Italian Harlem was a predominantly male world—a complex and conflicted community forged in the common experiences of separation and alienation. Separation from loved ones back in southern Italy. Alienation from New York’s Irish-dominated Catholic Church and Tammany Democratic machine. Only on these blocks did the authority of the Italian workingmen normally prevail. On a typical day, the streets were a male domain of bocce games, card playing, and conversation. Even so, mothers had a special moral authority in the tenements. In rooms where precious space was set aside for shrines to the Madonna, the bond of mother and child received the utmost respect. Now, as doctors and policemen “tore suffering little children from the arms of shrieking mothers,” the reporter watched in amazement as “embryo riots” erupted in the rooms, yards, and streets.10

Chief Inspector Blauvelt and a group of his men arrived at the three-story wood-framed building on First Avenue that housed Caballo’s saloon. They climbed the steps to the second floor. In the rear of the building, they came upon the door with the brass padlock. Tenants insisted those rooms were vacant. But Blauvelt and his men paused at the threshold. According to the Times reporter, “after a time they heard someone move within and the faint moan of a child in pain.” The men kicked down the door. Inside, they found a second locked door. They forced it open. They came upon the pile of boxes. Pulling them away, they found the children under the bed. All three, the doctors quickly determined, were sick with smallpox “in the most dangerous stage.”11

The mother of the Caballo children—who must have been in that room all along, the “someone” who moved within—struggled with the men as they carried her children and little Antoinette down the stairs to the street. The doctors tried to calm her, assuring her she could accompany her children to the isolation hospital on North Brother Island. Well-behaved mothers were sometimes allowed that privilege, especially if they were nursing infants. But when she continued her protest on the street, the physicians barred her from the ambulance wagon. Mrs. Caballo, the Times reporter wrote, “fought like a tigress on the sidewalk, and her screams aroused the neighborhood for blocks around.” At last, she was driven indoors. The ambulance rolled away.12

By the end of that long night, Blauvelt’s corps had scraped vaccine into the arms of many tenement dwellers, put watches on suspicious people, and removed nine infected children from their homes. Three-year-old Marion Scarroni was already dead when the doctors found her. None of the infected children had ever been vaccinated. In defiance of the law, their families and neighbors had secreted them away for days. Perhaps the parents believed they could best take care of their own children themselves; with smallpox, attentive care could mean the difference between survival and death. Or perhaps the parents feared, as the Times reporter supposed they must, that their little ones would “be taken away from them forever.”13

In the early hours of the morning, the men of the vaccination corps made their way through the still sleeping city to their own homes to get some rest. They would need it. The Department of Health had another raid planned for Italian Harlem the following night.

None of the children had ever been vaccinated. The scarless arms of those nine children of the Italian diaspora tell us something about their political status. Each was, in the words of the Constitution, a “natural born Citizen” of the United States. How could a child’s skin say so much? In the final years of the nineteenth century, in the midst of the greatest sustained wave of human migration the world had ever seen, a vaccination scar had become something more than a sign of immunity from smallpox. The scar had become a sort of passport—a stamp-sized tattoo of political immunity, required by U.S. law and the quarantine regulations of the nation’s major ports for entry into the American body politic. This legal requirement did not apply with equal force to all. The class-based spatial arrangements of the ocean voyage governed migrants’ treatment upon arrival; steerage passengers underwent a far more exhaustive medical inspection than did their shipmates traveling in first- and second-class cabins. This much is reasonably certain: at the turn of the century, no child en route from Italy to a place like East Harlem would have made it through the Port of New York without well-defined pockmarks (proving a previous case of smallpox) or a discernible mark of recent vaccination.14

Twenty-four million people migrated to the United States between 1880 and 1924, two thirds of them entering the country through the Port of New York. The world over, people were on the move. Within Europe, some two million people picked up and moved each year in the late nineteenth century. Others reached ports like Bremen, Naples, or Liverpool and kept going. The promise of decent jobs and a greater measure of political and religious liberty helped make the United States the foremost destination of the global transoceanic migrations of the era. Until the 1920s, U.S. immigration law—shaped by interests of humanity and political economy—left the borders open to most of the world’s peoples. Still, slowly accumulating categories of exclusion tightened the nation’s points of entry, revealing the particular contours of the immigrant nation’s rising anxiety about newcomers. Congress welcomed all but prostitutes (excluded in 1875); Chinese people, convicts, lunatics, idiots, and paupers (1882); unskilled contract laborers (1885); polygamists and “persons suffering from a loathsome or a dangerous contagious disease” (1891); and epileptics and anarchists (1903).15

Immigrants to the United States traveled alone, in families, or even as transplanted communities. Some came only as sojourners, others as the first pioneers in chains of family members intent on permanent settlement. Increasingly, they came from regions of southern and eastern Europe that prior to the 1880s had been insignificant players in the peopling of America. Italy alone contributed tens of thousands of migrants each year during the 1890s, hundreds of thousands annually after 1900. Four fifths of the Italians came from the southern peninsula and Sicily (the mezzogiorno). Compared to the familiar English, Scottish, Irish, and Germans, the “new” immigrants from Russia, the Austro-Hungarian Empire, and Italy seemed utterly foreign to many native-born Americans, who associated them with urban squalor, criminality, and, above all, disease. American state and federal governments shared that assessment, and beginning in the 1880s they built an increasingly elaborate system for the control of immigrant ships and the diseases they carried.16

Whether they began their journey by foot, wagon, or rail, immigrants from Europe or Asia got their first glimpse of America from a crowded, clamoring steamship. By 1870, steam had replaced wind as the force that powered the Atlantic crossing. During the next three decades, as the immigrant trade exploded, steamships grew larger and faster. Dozens of companies competed for immigrant fares, including Britain’s White Star and Cunard lines, France’s Companie Générale Transatlantique, Germany’s Hamburg-Amerika line, and New York–based Pacific Mail Steamship Company. Steel hulls, better boilers, and stronger engines enabled the construction of great ships weighing five thousand tons or more. Each might carry as many as three hundred passengers in their first- or second-class cabins and a thousand or more belowdecks in the steerage compartments—so named because of their location near the ships’ steering machinery.17

Companies packed steerage passengers onto tiers of narrow metal bunks that rose from dirty floors to low, sweaty ceilings. Toilet facilities were inadequate, portholes few. The lines running from southern Italy were notorious. One journalist, traveling as an immigrant from Naples in 1906, wondered how a steerage passenger was supposed to “remember that he is a human being when he must first pick the worms from his food . . . and eat in his stuffy, stinking bunk, or in the hot and fetid atmosphere of a compartment where 150 men sleep.” The introduction of third-class cabins on some lines around the turn of the century offered passengers a bit more space. But accommodations remained exceedingly tight for the vast majority making the ocean voyage to America.18

The discovery of smallpox aboard a crowded ship at sea, a common occurrence in the nineteenth century, was a harrowing event that called forth the full power of the captain. As “master of the vessel,” the captain’s legal authority over his crew and passengers was, in the words of one law scholar, “necessarily summary and virtually absolute.” The captain’s men pulled infected passengers from their bunks and isolated them in the ship’s infirmary. They fumigated compartments and personal effects. They vaccinated all aboard. Stoner’s Handbook for the Ship’s Medicine Chest instructed that the scabs from the sick passengers had to be carefully gathered up and burned, lest the infectious stuff be “conveyed not only to other parts of the ship, but to any part of the world to which the ship is bound.” U.S. quarantine regulations required that the dead be wrapped in a sheet saturated with carbolic acid or bichloride of mercury and then placed in a hermetically sealed coffin or buried at sea. Nineteenth-century practice was to throw the bodies overboard “the instant that life had ceased.” When the ship reached its destination, crew and passengers could expect to spend fourteen days in quarantine while medical officers waited to see how widely smallpox had spread among them. Exceptions were often made for travelers in first and second class.19

Even without smallpox aboard, travel in steerage was hazardous to the health. Late nineteenth-century American reformers and port officials protested the “heartless treatment” of steerage passengers on journeys that some compared to the “Middle Passage” of the bygone slave trade. Federal law levied a $10 penalty on ship companies for every passenger over eight years of age who died en route to the United States. But as two New York State commissioners of immigration lamented in 1868, the law was little enforced and did nothing for the hundreds of steerage passengers who died each year. The “interest of humanity” and “political economy,” these officials declared, required the reform of a system where “emigrants are treated more like beasts of burden than human beings.” The New York officers urged Congress to require all immigrant ships bound for America to carry a medical officer.20

By the time Congress finally enacted such a law, in 1882, the germ theory was on the rise. “Reasons of hygiene” joined the old “sentiments of charity, morality, and humanity” in congressional deliberations. Consequently, ship surgeons would do much more than care for sick passengers. They would become on-board agents of American quarantine regulations. That same year, 1882, the short-lived National Board of Health called for a new federal law to mandate “the vaccination of all immigrants not previously protected”—a policy that at that time applied only to passengers from foreign ports known to be infected with smallpox. But the board’s argument that compulsory vaccination served the national interest—by preventing the constant importation of smallpox and stopping the amassing of “large numbers of susceptibles in circumscribed localities” (cities)—failed to move Congress to adopt a uniform national policy until another decade had passed.21

Faster ships, more than sharper laws, made the Atlantic crossing safer. In 1867, the journey took fourteen days or more; by 1900, some steamships could make the trip in under six. But the passenger’s relief was the quarantine officer’s headache. Speed altered the nature of the threat from smallpox. The average incubation period for the disease was about twelve days; in the age of sail, if anyone on board was infected that fact was likely to become known well before the vessel reached port. With each new increment of speed, the likelihood increased that infected travelers would reach port without presenting symptoms. As Dr. William M. Smith, health officer of the port of New York, reported in 1888, smallpox was the most difficult “latent contagion” to check by maritime quarantines. In that year alone, Dr. Smith’s medical officers inspected some 383,000 steerage passengers. Given the rising boat speeds, any number of them might have contracted smallpox in a European village, traveled more than three thousand miles to New York, shown no symptoms at quarantine, boarded a train, and not felt the first fever until reaching the American heartland. Outbreaks in Illinois, Indiana, and Missouri were traced to recently arrived immigrants from Europe. According to Smith, this problem of latent contagion had caused “more anxious reflection” among American port health officers “than any other subject during the past nine years.” He called for a strict policy that all passengers not vaccinated within the previous eight years submit to the procedure within two days of boarding a U.S.-bound ship.22

Increasingly, immigrant-receiving ports enforced just such a rule. One English opponent of vaccination, arriving in New York aboard a White Star steamship, wrote home that “America was closed against the unvaccinated anti-vaccinator, [who] was fast falling into the condition of the American negro-slave who was hunted down everywhere by everybody.” Like New York, the port of Boston required all arriving steerage passengers to present a certificate, signed by the ship’s medical officer, stating that they were protected from smallpox due to having survived the disease or by recent vaccination. Anyone failing to meet this requirement would be vaccinated by a port physician on arrival or be detained for fourteen days on Gallop’s Island. Steamship companies posted the port’s vaccination requirements, translated in several languages, on their Boston-bound ships. For many immigrants, seeing this notice was their first encounter with American law.23

For some steerage passengers, vaccination aboard a ship at sea was just one inconvenience among many. For others, the experience was overwhelming. Steamship companies insisted they were merely providing a service, one required of them in order to do business in American ports. Passengers, they said, were at liberty to refuse the service and face the consequences. But the true test of liberty lies in its exercise. Liberal political theorists since John Locke had suggested that real human freedom and consent required physical space—“room enough”—for their exercise. Liberty needs an exit.24

Mary O’Brien was just seventeen when she boarded the Cunard Steamship Company’s Catalonia in Queenstown, Ireland. The Catalonia set sail for Boston on the Fourth of July, 1889. Mary had never been away from home, and her mother had recently died. She made the journey with her father and brother, traveling in a steerage compartment with three or four hundred strangers.25

When the Catalonia was about three days out from Boston, Mary sat with other female passengers on deck. A ship steward approached and told them to go below. Not knowing the purpose, Mary descended the staircase into steerage. At the landing, halfway down, she passed the ship’s surgeon, I. T. M. Griffin, who stood with two stewards. She continued to the bottom of the stairs. All of the ship’s female steerage passengers had been lined up at the foot of the stairs and were making their way slowly up. The male passengers were nowhere to be seen. (Mary later learned that her father and brother, along with all the rest, had been taken to another part of the ship.) As the line moved forward, Griffin inspected each woman’s arm and “proceeded to vaccinate those that had no mark.” As they passed inspection, each woman received a card from a steward—a vaccination certificate to be presented to the port physicians. Mary held back until she was the last woman on the stairs. She later recalled that she saw “no means of exit except where the surgeon stood.” She told Griffin that she knew from her mother that she had been vaccinated as a baby. He said there was no mark, and she “must be vaccinated.”26

It seemed to Mary that no time at all had passed between that utterance and the sensation of Griffin’s penknife scraping her left arm and the dabbing on of some stuff from a glass tube. By her own admission, she had not spoken out; she had not struggled. But she would later testify before a Boston jury that she had been vaccinated against her will and that the vaccine had made her sick. The judge instructed the jury that there was no evidence to support O’Brien’s claim of assault. Hearing the case on appeal in 1891, the Supreme Judicial Court of Massachusetts agreed. To reasonable men of privilege and power—on a bench that included the future Supreme Court justice Oliver Wendell Holmes, Jr.—the young Irishwoman’s legal claim may have seemed absurd. But, O’Brien’s lawyers argued, “a distinction must be drawn between mere submission and positive consent.” In the closed space below the waterline, separated from home and family, the immigrant girl had, by all appearances, passively submitted. Seeing no other exit, she held up her arm to be vaccinated. How many others felt as she did, we will never know.27

In 1891, the U.S. government took control of immigration administration. As it did, the poorer immigrants passed through an increasingly elaborate gauntlet of medical inspection at the nation’s borders. At many American ports, state quarantine officers continued to inspect immigrants, but they did so in compliance with a burgeoning national regime for the processing of aliens. Mass immigration continued unabated, but immigration policy grew increasingly fraught, a battleground for business interests and organized labor, nativists and humanitarians. Global outbreaks of cholera, small-pox, and other diseases kept hygiene central to the administrative process. In laws of 1891 and 1893, Congress assigned the U.S. Marine-Hospital Service responsibility for keeping migrants with contagious diseases from entering the country. Service officers inspected immigrants at port stations from New York Harbor to San Francisco Bay, as well as at designated crossings along the Canadian and Mexican “frontiers.” At a growing number of foreign ports, Service men attached to U.S. consulates inspected immigrant ships before departure, advising steamship companies to refuse passage to those passengers who appeared likely to be turned back for medical reasons upon reaching America.28

U.S. quarantine regulations in force by 1894 made vaccination a prerequisite to entry. Like the older state rules, the federal requirement treated steerage passengers as a class: “All passengers occupying apartments other than first or second cabin shall be vaccinated prior to entry, unless they can show that they have had smallpox, or have been recently successfully vaccinated.” Every steerage passenger bound for America received an inspection card that detailed an elaborate transatlantic process of medical inspection. Boxes on the front of the card recorded the migrant’s passage through inspection by a U.S. consular agent or Marine-Hospital Service officer at the port of departure; through quarantine at the port of entry; and by the U.S. Immigration Bureau. Another box, completed by the ship’s medical officer, called for the passenger’s number on the ship’s manifest list, where U.S. inspectors could find the detailed information on each passenger (including a medical history) required by U.S. law. The back of the card called for an official stamp or signature certifying vaccination. In seven languages, the card warned its holder, “Keep this card to avoid detention at quarantine and on railroads in the United States.”29

A ship entering New York harbor after 1891 first passed quarantine, which remained the province of New York port authorities. The port health officer and his assistants boarded, examining the ship’s manifest and its bill of health—a statement from the U.S. consulate detailing the sanitary condition of the ship and the port of embarkation. The inspectors then searched for passengers infected with any of five quarantinable diseases: smallpox, cholera, plague, typhus, or yellow fever. Smallpox was a constant concern. Unlike the mild form of the virus spreading across much of the country after 1898, the disease making the Atlantic passage was still classic deadly smallpox.30

New York quarantine officials viewed Italian immigrants as a special threat, despite the fact that Italian state medicine had long been in the vanguard of European smallpox control. The Italians had introduced bovine vaccine, and Italian law required all children to be vaccinated within six months of birth and required revaccination for entry into the schools and factory jobs. But none of the nation’s fourteen vaccine-manufacturing establishments could be found south of Rome. And in southern Italy, where most immigrants to the United States originated, vaccination was far from universal. For Dr. Alvah H. Doty, health officer of the port of New York, smallpox arriving on steamships from Naples was a “constantly recurring” problem. Without the quarantine precautions, “a horde of people would be landed on our shores to scatter smallpox broadcast over our land.” It became routine: a huge ship would steam into the harbor, quarantine inspectors would find smallpox aboard, and all of the steerage passengers would be subject to vaccination and detention on Hoffman Island.31

If the New York inspectors found no quarantinable diseases aboard, they left the ship. At that point, physicians of the Marine-Hospital Service’s Boarding Division took over. They gave passengers in the first- and second-class cabins a perfunctory inspection. Rarely was a first-class passenger singled out for closer inspection; and when this did occur, it usually happened not because the passenger looked especially unhealthy, but because some unspecified social marker made him appear out of place. As one officer of the Service explained, “If a passenger is seen in the first cabin, but his appearance stamps him as belonging in the steerage or second cabin, his examination usually follows.”32

When the steamship at last arrived at its destination, a wharf or dock in New York City, only passengers traveling in third-class or steerage were ferried to the federal government’s immigration depot at Ellis Island to run the gauntlet of medical inspectors known, in Service parlance, as “the line.” The inspection at Ellis Island began as soon as the immigrants stepped off the barge. They lined up under the watchful eyes of the medical inspectors, who scanned the crowd for any individual possessing a mental or physical defect. Carrying their baggage, the immigrants climbed the steep stairs to the Registry Room, also known as the Great Hall. Watching from the top of the stairs, Service physicians looked for signs of weakness or heavy breathing that might indicate heart trouble. As the immigrants made their way through the congested gates and cordoned-off areas of the facility, officers examined eyes and scalps, hands and throats, all the while looking for signs that the passenger was unfit to enter the American nation.33

The power to exclude migrants from the political space of the nation—ordering their return to their port of origin, at the expense of the steamship company—was the ultimate power entrusted to U.S. officials at points of entry. The exercise of this authority rested upon the medical expertise of the Marine-Hospital Service officers, who by 1903 inspected nearly 900,000 immigrants each year at thirty-two American ports and several overseas. The power to exclude was not exercised often. In an average year, U.S. officials turned back fewer than 1 percent of all arriving immigrants. But medical criteria, rather than political radicalism or poverty, became an increasingly important reason for exclusion, until it was the principal one. No wonder many recalled those hours at Ellis Island as the longest of their entire journey.34


Immigrants from a smallpox-infected ship, detained in 1901 at the quarantine station on Hoffman Island, N.Y. Photo by Elizabeth Allen Austen. COURTESY OF THE LIBRARY OF CONGRESS

Along the borders with Canada and Mexico, U.S. quarantine law called for aliens to enter only through designated points. Such rules proved difficult to enforce, particularly along the Rio Grande. Many Mexicans, accustomed to traveling freely across the border for work or to visit relatives, viewed the tightening system of inspection around the turn of the century as a violation of their rights. In a single week in February 1899, Acting Assistant Surgeon H. J. Hamilton and his staff at Laredo, Texas, inspected more than 2,500 migrants crossing the Rio Grande via the Laredo Foot Bridge, a truss bridge built in the 1880s, or by ferry or train. Most of the people he met at the footbridge insisted upon their “right to pass” without inspection. But that was a privilege the Service extended only to affluent travelers. While the Service routinely inspected all arriving passenger trains from Mexico, checking all second- and third-class passengers for “recent vaccine scars,” inspectors allowed travelers in the Pullman cars simply to swear to their immunity. In his time at the post, Hamilton concluded that the poorer class of Mexicans reckoned smallpox a fact of life and feared vaccination far more than the disease.35

In the winter of 1899, Surgeon General Wyman received a flurry of dispatches from Laredo, a border city of 15,000 people, the majority of them of Mexican descent. Virulent smallpox had raged there for months, with 376 cases and 83 deaths reported in January and February. (The death rate indicates an epidemic of classic variola major.) Hamilton advised the local authorities “to issue some law compelling vaccination, by force if necessary.” In March, Texas health officer W. T. Blunt arrived from Austin. City officials set about fumigating homes, vaccinating, and removing infected residents by force to the pesthouse. The actions targeted the poorer barrios on the east side of town. Meeting strong resistance from the residents, Blunt called in the Texas Rangers. In the ensuing violence, one Mexican American leader was killed, thirteen people were wounded, and twenty-one were arrested. A contingent of the U.S. Tenth Cavalry arrived, and Hamilton took charge of the local vaccination corps. Even with so many soldiers in the area, fifteen residents “had to be reported, arrested, and then vaccinated.”36

Even beyond the nation’s borders, the mark of vaccination became a powerful signifier of American rule. In September 1905, more than 650 black contract laborers from Martinique traveled aboard the French steamship Versailles to Colón, a port city located near the Atlantic entrance to the U.S.-controlled Panama Canal Zone. As the crowded ship approached the port, laborers in canoes paddled up to the ship, warning the passengers that poor treatment and harsh conditions awaited them on shore. The messengers said that vaccination, required of all immigrant laborers by the American sanitary regulations of the Isthmian Canal Commission, would produce “an inextinguishable mark” that would make it impossible for them ever to leave the Isthmus. The migrants refused to leave the ship. The next morning, officials persuaded 500 of them to land. But 150 men remained on board and demanded to be returned to Martinique. A force of Panamanian and Canal Zone police forced the migrants from the ship. According to The Washington Post, “nearly everyone of them had been clubbed, and several were bleeding from nasty wounds.” Many had jumped overboard. Later that same afternoon, all of the laborers were vaccinated, loaded on a train, and shipped out to Corozal, where they were put to work building the canal.37

In the hands of a subordinate people, a rumor can be a surprisingly potent political tool—a “weapon of the weak”—even when the rumor is not true. But the canoe riders of Colón did not exaggerate. In the Canal Zone, only the immigrant workers were compelled to be vaccinated. The doctors uniformly scraped their right arms. Foremen and canal officials used the marks—much as the slave catchers of the remembered past had used brands—to identify and apprehend runaway workers in the Panamanian jungle.38

Watching with dismay as smallpox spread across the American heartland in 1901, Dr. James Hyde of Chicago’s Rush Medical School urged state and local governments to use their full police powers to eradicate this affront to modern civilization. Like many of his professional peers, Hyde found the metaphor of the vaccine scar as passport irresistible. He urged that American governments require this medical mark for entry into the country’s civic spaces. “Vaccination should be the seal on the passport of entrance to the public schools, to the voters’ booth, to the box of the juryman, and to every position of duty, privilege, profit or honor in the gift of either the State or the Nation,” he declared. In one respect, vaccination seemed superior to a printed identity document; this government-certified ticket of immunity was stamped indelibly upon the body. Seasoned health officials did not trust the paper vaccination certificates issued by private physicians; they always asked to see the scar. As one writer noted in American Medicine, “This certain, well-defined sign cannot be forged.”39

That writer was wrong. As health officials and police tightened enforcement of vaccination at public schools, industrial work sites, and railroad depots, Americans started forging scars. Some tried plaster fakes. Others followed recipes printed in unorthodox medical journals and passed along by word of mouth. “Get a little strong nitric acid,” advised the Columbus, Ohio–based journal Medical Talk for the Home. “Take a match or a toothpick, dip it into the acid, so that a drop of the acid clings to the end of the match. Carefully transfer the drop to the spot on the arm where you wish the sore to appear. Let the drop stand a few minutes on the flesh. Watch it closely.” After a few minutes, the skin, stinging, turned red. That meant it was time to blot up the remaining acid. In a week, the nickel-sized spot turned dark. “This sore will gradually heal by producing a scar so nearly resembling vaccination that the average physician cannot tell the difference.” Health officials condemned the “vile crime” as the handiwork of a few antivaccination fanatics. But these intimate acts of civil disobedience were part of something larger, a groundswell of popular opposition to “state medicine.”40

“True compulsory vaccination,” as Health Officer Charles V. Chapin of Providence defined it, aimed to secure general immunity from smallpox by requiring every member of the community to be vaccinated and periodically revaccinated. The model was Germany, which boasted the world’s most vaccinated population and the one most free from smallpox. German law required that every child be vaccinated in the first year of life, again during school, and yet again (for the men) upon entering military service. The U.S. Constitution, as interpreted at the time, foreclosed any serious talk of achieving such a universal system through federal law. That left the matter to the states. Hard political realities—the diversity of state legal cultures, the uneven development of their public health systems, and the suspicion with which many Americans greeted any government interference with their personal liberties—assured that a German-style system of vaccination, covering the entire U.S. population, never came to pass. Most vaccination laws on the books were the residue of bygone epidemics. As the emergencies that begot those laws faded from memory, enforcement waned.41

For all of these reasons, the epidemics of 1898–1903 found many communities poorly protected by vaccination. New circumstances made health officials’ jobs even harder. The advent of a milder type of smallpox and heightened concerns about vaccine safety hindered the efforts of public health officials, who often received little support from lawmakers, government executives, and the public.

Still, when confronted with a costly smallpox epidemic, the same governments that during times of relative health shied away from compulsory measures readily resorted to coercion. The emergency powers they exercised were extraordinary—particularly in thickly populated spaces. In his definitive 1904 treatise The Police Power, Professor Ernst Freund of the University of Chicago Law School covered every form of state regulatory action from liquor licensing to the suppression of labor strikes to trust-busting. But he singled out compulsory vaccination to illustrate the outer limits of legitimate state action. “Measures directly affecting the person in his bodily liberty or integrity,” he wrote, “represent the most incisive exercise of the police power.” During the turn-of-the-century epidemics, millions of ordinary Americans could not enter their work sites, send their children to public school, or travel freely without showing their vaccination scars. To them, the metaphor of the passport seemed real enough.42

Besides soldiers, prisoners, and immigrants fresh off the boat, the most vaccinated members of American society were public schoolchildren. School vaccination rules paved the way for a growing array of measures governing the bodies and behavior of children, as more and more states made school attendance mandatory into the teenage years. By 1902, nearly 16 million Americans—72 percent of all children aged five to eighteen—attended public schools; another 1.2 million went to private schools. The great exception was the South, where most state legislatures had yet to compel school attendance or vaccination. In 1901, only five states had laws on the books requiring universal childhood vaccination in the first year or two of life. But most took measures to keep unvaccinated children from the public schools, especially when smallpox threatened. (Some states, including California and Massachusetts, mandated school vaccination by statute; others, such as New Jersey and Maine, authorized school boards to order vaccination; and in still other states, school boards simply issued orders at their discretion.) Almost everywhere, the requirements applied exclusively to public schools. Parents with the means to send their children to private schools could opt out.43

In an era when American governments took ever greater responsibility for children—through child labor laws, school laws, and new child-welfare institutions such as the juvenile court—the vaccination rules served multiple purposes. As some health officers pointed out, it would have been unconscionable for states to require children to spend half their day in crowded classrooms without protecting them against socially transmitted diseases. The measures, coupled with increasingly routine medical inspections in the public schools, also extended state authority from the school into the home, bringing working-class and immigrant parents into line with new progressive norms of hygiene. When unvaccinated children were excluded from school, their parents could face prosecution under education laws. Some officials even imagined that the requirement made a positive impression on the students—“familiarizing the juvenile mind with respect for authority,” as one put it, “whatever the merits of the medical expedient may be.”44

Compulsory vaccination turned American public schools into theaters of conflict. Parents, pupils, teachers, and sometimes even principals challenged the rules with tactics ranging from civil suits to civil disobedience. Parents decried the measures as a violation of their domestic authority and a threat to their children’s health. Officials in Chicago and New York uncovered what the Times called “an extensive traffic” in phony vaccination certificates. The school strikes that rocked Camden and Rochester after Camden’s tetanus outbreak were not isolated incidents. In Gas City, Indiana, two hundred mothers, holding their unvaccinated children by the hand, marched upon the public schools building on a December morning in 1902. Facing down a contingent of policemen at the schoolhouse doors, they demanded that their “scarless” children be admitted.45

In nearby Bluffton, Indiana, the school board squared off against the health board, refusing to enforce the latter’s vaccination order. In Delaware County, Pennsylvania, a group of female teachers refused to let physicians examine their arms for scars, protesting a policy that compelled them to undergo a risky medical procedure before entering their workplaces. Students caused trouble, too. Visiting Newburg, Ohio, Cleveland health officer Martin Friedrich came upon some children outside their school. The students called out to each other, “Are you vaccinated? Are you vaccinated?” Friedrich understood: the vaccinators were in the schoolhouse. He slowed his pace and listened. “Pretty soon I knew what they were up to,” he recalled. The corner grocery-man had told some of them that they should wash the vaccine from their arms to keep them from getting sore. “They communicated it to each other in a most lively manner, and all hurried as fast as they could to the grocery-store to wash their arms.”46


New York City schoolboys line up to have their vaccination marks inspected by a public health officer in 1913. COURTESY OF THE NATIONAL LIBRARY OF MEDICINE

Mass vaccinations at American workplaces generated their own dynamics of power and conflict. American workers were vulnerable not only to contagion but to arbitrary dismissal during epidemics. Domestic employers, fearing exposure to infection, shunned servants and laundresses, causing destitution in the tenements. When smallpox broke out, some factory owners abruptly suspended operations, with no thought of compensating their workers for lost wages. In a typical incident in Sayreville, New Jersey, two handkerchief manufacturers, acting upon the advice of physicians, told their employees to stay home until the local epidemic was brought under control. The order affected about three hundred workers, many of them the breadwinners of their families. Workers pleaded with foremen. One factory girl dropped to her knees and prayed. All to no avail. To employers and local health officials, the mere threat of smallpox justified the most overt acts of ethnic scapegoating. When a single Italian worker with smallpox escaped from quarantine in Bethlehem, Pennsylvania, in 1902, Bethlehem Steel Company summarily discharged all of its Italian workers. Italians were forbidden to ride the city streetcars until the outbreak subsided .47

Employers normally bristled at workplace health regulations. Key pieces of progressive labor legislation—including factory safety measures and laws to shorten the workday—were justified by reformers as necessary to protect the health of workers and the public. Manufacturers’ associations and individual employers challenged such measures in the courts, insisting they violated the “liberty of contract” between worker and employer. But when faced with the potentially expensive emergency of a smallpox epidemic that had a relatively cheap solution (vaccination), many industrial employers readily cooperated with public health officials. They willingly turned their private workplaces into public health stations.48

Many employers made vaccine refusal grounds for dismissal. In one 1901 episode, six Brooklyn health department physicians, policemen in tow, appeared at the sugar refineries of Havemeyer & Elder, just in time for payday. As each worker stepped forward to receive his wages, a city doctor vaccinated him. Railroad and streetcar corporations, liable for damages if an employee with smallpox infected a passenger, were particularly vigilant. In the winter of 1903, as smallpox raged in the Pennsylvania coal region, officials of the H. C. Frick Coke Company, a vast industrial enterprise of coal mines and coke works, ordered all of its employees and their families to get vaccinated. According to the Chicago Tribune, the order affected 300,000 men, women, and children.49

When employers joined forces with local health officers and police to enforce vaccination, a crowded factory floor could become as confining as a prison. In April 1901, a female worker at the American Tobacco Company in Passaic, New Jersey, died of smallpox. She had continued to work during the early contagious stages of her disease. In such an instance, any responsible employer would want to secure the safety of his workplace by assuring that the workers got vaccinated. But the measures taken at the American Tobacco Company went well beyond that duty. A squad of government physicians and police entered the plant, determined to vaccinate all 350 women and girls who worked there. Informed they would have to submit to vaccination, some workers fainted, “others became hysterical, and there was a general rebellion,” The New York Times reported. Two hundred of the women tried to escape, but they found all of the factory exits locked. “[A]ll were finally vaccinated.”50

As C. P. Wertenbaker observed time and again in the South, workers’ natural fears of vaccination were intensified by their need to earn. Many American industrial workers feared, with good reason, that vaccine would cause their arms to swell, making it impossible for them to support themselves or their families for a period of days or weeks. And they knew better than to expect their bosses or the state to support them during that period of disability. Some washed off vaccine (as Martin Friedrich spied workmen doing at an Ohio factory). Others walked off job sites rather than be vaccinated. African American workers, in particular, dreaded vaccination. In June 1900, the New York State Board of Health ordered the vaccination of five hundred black workers at the Wash & Company brickyard in Stockport, New York, about thirty miles down the Hudson from Albany. According to The New York Times, when fifty of the laborers “refused to submit,” Governor Theodore Roosevelt sent in the Hudson Company of the state militia, “ninety men strong,” to enforce vaccination against the “unruly negroes.”51

Violence was always a possibility when health officials clashed with American workers. In 1902, smallpox struck the neighboring mining cities of Lead and Deadwood, in the Black Hills of South Dakota. Both cities ordered a general vaccination, but the miners balked. The city physician of Lead—accompanied by four assistants, the sheriff, and five deputies—conducted a nighttime raid of the city’s crowded saloons, gambling dens, and theaters. At the Gold Mine Saloon, the officers covered both entrances and proceeded to vaccinate everyone in the place. Several fights broke out, but eventually the police overwhelmed the miners.52

Controlling smallpox on the nation’s vast network of railroads was obviously a crucial step to stamping out the American epidemics. But how? In the winter of 1902, Chicago health officials announced a Chicago-sized plan. The Second City stood at the hub of the nation’s transportation networks. The same central geographical position that made Chicago such an economic force—bringing grain, lumber, and livestock from the rural hinterland to American markets and sending Montgomery Ward catalogues back in the other direction—made the city vulnerable to smallpox outbreaks all over the Middle West. In January 1902, about 10,000 cases of smallpox—roughly three fourths of all reported cases in the United States—occurred within a few hours’ train ride from Chicago. The Chicago Health Department decided to use the Second City’s position as the railroad hub of the Middle West to stamp out smallpox in a ten-state region with 25 million inhabitants. City health officials made an agreement with officials of the major companies serving Chicago to spur “wholesale vaccination and revaccination in every infected locality” of the region by enforcing a strict inspection of all travelers from those communities. The railroads also ordered all of their employees serving the Chicago routes to submit to vaccination or lose their jobs. And every car entering the city from any direction had to be fumigated for six hours before new passengers were allowed to enter it.53

Across the American political landscape, public ambivalence about compulsory vaccination during the turn-of-the-century epidemics registered in the statute books. Mississippi, one of the states hardest hit by virulent smallpox in 1900 and 1901, enacted a new law authorizing county boards to order compulsory vaccination (which many refused to do). Rhode Island passed a new law in 1902 that mandated vaccination of all children before their second birthday and empowered the state board of health to order vaccination of all “inmates of hotels, manufacturing establishments, hospitals, asylums, and correctional institutions.” That same year, Massachusetts gave local health boards authority to compel vaccination at will.54

Other states, though, moved the other way. Wisconsin governor Robert M. La Follette vetoed a new compulsion statute in 1901, insisting (as the Journal of the American Medical Association remarked with disbelief) that “he does not believe an emergency exists which demands a law repugnant to so many good citizens!” In Utah that same year, grassroots opposition to compulsory public school vaccination spurred the legislature to pass a law banning compulsion. The Wasatch Wave applauded the statute: “it robs the tyrant of his power to rob the people of their right to ‘life, liberty and the pursuit of happiness.’ ” And two years later, well-organized antivaccination activists in Minnesota persuaded the legislature to forbid compulsion in the absence of an actual smallpox emergency.55

New York lawmakers debated a compulsory vaccination bill in 1902. The state had long banned unvaccinated children from the public schools. But beyond that the legislature had not ventured, prompting The New York Times to assert, “compulsory vaccination is a thing utterly unknown in this State.” In February 1902, State Senator James McCabe, a physician from Brooklyn, introduced a bill that would have been one of America’s strongest vaccination laws. It required cities to enforce universal vaccination whenever the health department called for it. Any resident who refused vaccination was subject to a $50 fine and imprisonment for ten days. Companies with more than ten employees were forbidden to hire anyone not vaccinated within the past five years. The New York County Medical Association championed the measure. So did the Times. Remarkably, the New York City Board of Health opposed the bill. The city’s new health commissioner, Dr. Ernst J. Lederle, explained that the legislation would simply hand the city’s antivaccination leagues a tool for recruitment. Compulsion was unnecessary, Lederle insisted. His department had encountered “no serious difficulty . . . in persuading the people to submit to vaccination.” The bill died in the New York Assembly.56

Residents of New York City—at least those who lived in the tenements or read the daily papers—must have found Ernst Lederle’s public position on compulsion baffling. A Ph.D.-bearing chemist, Lederle had taken office in January 1902, appointed by the city’s new reform mayor Seth Low to head up both the board of health (which promulgated health regulations for the city) and the department (which carried them out). High on the list of disgraceful conditions that Low’s administration promised to eradicate was smallpox, which had continued to spread despite the aggressive tactics of Alonzo Blauvelt’s vaccination corps. Nearly 2,000 cases, with 410 deaths, had been reported in the city’s five boroughs in 1901, making this New York’s worst smallpox epidemic since 1881.57

For Lederle, smallpox was the most interesting problem confronting a modern department whose activities covered everything from making vaccine to policing milk dealers to arresting the spitters who spread the city’s deadliest endemic disease, tuberculosis. Smallpox concentrated Lederle’s mind on the larger purpose of his office: to extend the benefits of modern medicine to the city’s “great tenement population—ill-housed, illnourished, bred in the foul air of the slums; above all, ignorant of the laws of cleanliness and right living, and willing to go to any lengths to hide the evidence of disease from the municipal physicians.” Tellingly, Lederle expressed admiration for the work of the U.S. Army Medical Department in Havana, “a striking example of what can be done in a short time.”58

Under Lederle, the health department managed compulsion well enough without a law that would have strengthened the political base of antivaccinationists and given Albany a greater hand in the affairs of local health departments. Lederle publicly denied that coercive legal power was necessary, even as his department routinely exercised just such power in the city’s tight spaces. Lederle added more than 150 new men to the vaccination corps. By the end of his first year in office the department performed a record-breaking 810,000 vaccinations—more than twice as many as in any previous year. The commissioner sent letters to the owners of all the city’s larger factories, offering them the services of a vaccination squad, at any hour of the day or night. His board of health ordered lodging houses to refuse shelter for more than one night to anyone who failed to provide proof of recent vaccination. Discovery of a pimple-faced passenger aboard a trolley in the Bronx in March 1902 was sufficient cause to reroute the train, with all the passengers aboard, to the nearest police station, where a city health officer got busy with lancet and virus. “Those who objected were sternly admonished and the work went on.” The following month, James Butler, a hostler, and his wife, Kate, living on the third floor of a Third Avenue tenement in Harlem, were discovered “suffering from smallpox in an advanced stage.” A vaccination squad arrived, backed by twenty police officers. Men, women, and children fled down fire escapes or climbed to the roof. “But policemen were at hand at every place of egress, and appeals and entreaties were unheeded,” the Times reported. By the raid’s end, 300 residents had been vaccinated, “the majority of them very much against their will.” James Butler was found hiding in a coal bin. After a struggle, he and Kate were taken to North Brother Island.59

In November 1902, a health department inspector discovered a person with smallpox in a tenement on West Twenty-sixth Street inhabited by forty African Americans. The inspector summoned the police. They stormed the door. As the Times reported, “When the attacking party entered, some of the inmates went to the roof, some climbed out to the fire escape, and others tried to gain the street.” City physicians took out their instruments and began vaccinating the residents. Four were vaccinated in the hallway, others “in the corners of rooms where they had huddled together for refuge.” Still others received their “treatment” on the roof. One of the lodgers, twenty-four-year-old Eva Gerry, climbed out onto the fire escape, lost her balance, and fell three stories to the sidewalk, breaking both of her arms and several ribs.60

The department under Lederle did not do away with compulsion. It expanded the scope and intensity of the same old tactics. In fact, Blauvelt continued to head up the Division of Contagious Diseases. The department’s measures undoubtedly did much to bring the New York City small-pox epidemic of 1901–2 to an end. In 1902, the Division of Contagious Diseases reported 1,516 more cases with 309 more fatalities. Most of them occurred in the first six months of the year, after which the epidemic tapered off. In 1903, only 67 cases were reported, with just 4 fatalities; 40 percent of the people with smallpox treated in the municipal hospitals were new arrivals to the city. The department performed an additional 215,000 vaccinations that year, bringing the grand total under Lederle’s two-year regime to well over a million, roughly one third of the city’s population.61

As Scientific American noted, in a laudatory article on Lederle’s department, the city’s “crusade against smallpox” had engendered “bitter opposition.” It was strongly “opposed by the ignorant and superstitious, and by a considerable body of the more intelligent who were opposed to vaccination on principle. The inspectors were openly abused and resisted, and it was only through the co-operation of the police that an effective campaign was conducted.”62

In November 1903, Mayor Seth Low ran for reelection on a campaign that trumpeted his administration’s victorious war on smallpox. Campaign posters placed on elevated trains displayed the words of the reformer Jacob Riis, who urged New Yorkers to vote for the man who had driven prostitution from the tenements and “wiped out the smallpox in six months.” The voters, though, were not sufficiently impressed. They returned control of City Hall and the health department to the Democrats. Ernst Lederle left the department and founded the profitable Lederle Antitoxin Laboratories, manufacturers of vaccine, sera, and other biological products.63

New York was not the only American city to deploy paramilitary vaccination squads. The Chicago Health Department sent teams of physicians and police on nighttime raids to the tenements and into the cheap lodging houses along South Clark Street. In Boston, a notorious “hotbed of antivaccinationism,” nineteen citizens were prosecuted for refusing to submit to vaccination as city physicians and police made door-to-door sweeps. One night in November 1901, the health department sent a “virus squad” to the “five and ten cent” lodging houses in the South End. Physicians carrying lancets were accompanied by club-wielding police. The squad busted down doors. Policemen held down struggling men on their cots while doctors performed the operation. According to a Boston Globe reporter, the “tramps” fought back. They “kicked and clawed and also fought with teeth and heads against what some of them declared was an assault upon their rights as otherwise free and independent American citizens.” The homeless men uttered “every imaginable threat from civil suits to cold-blooded murder.”64

One American city tried a very different spatial approach to the fight against smallpox. Like most public health authorities of his day, Cleveland health officer Martin Friedrich believed in compulsory vaccination; it was, after all, national policy in his native Germany. With his gold spectacles and close-trimmed beard, the thirty-six-year-old physician might have been mistaken for Sigmund Freud as he entered cheap lodging houses in the middle of the night and urged free vaccination upon the rowdy bachelors he encountered.65

In the spring of 1901, mild type smallpox struck the cities along Lake Erie. (More than 1,200 cases would be reported by year’s end, but only 20 deaths.) Friedrich launched a wholesale vaccination campaign concentrated in the city’s immigrant working-class neighborhoods. But four people died of tetanus following vaccination, and many more took ill. With a candor all too rare for a health official of the day, Friedrich announced that the available vaccines were unreliable at best, toxic at worst. “A man would have to have a heart of stone if he would not melt at the sight of the misery it produces,” he said.66

Backed by the progressive mayor Tom Johnson, Friedrich ceased vaccination and embarked on a different sort of campaign to fight smallpox. He ordered all smallpox patients isolated from the general population. Then he hired a corps of medical students to go house-to-house with formaldehyde generators and fumigate every home in the city. The disinfection campaign took months to complete, but by the end of 1901 it seemed to bring smallpox under control, making the Cleveland experiment national news and Friedrich a reluctant hero of the antivaccination movement. When a physician named J. H. Belt accused Friedrich of “furnishing aid and comfort to the enemy,” the health officer responded that his campaign had won hearts and minds where compulsory vaccination had won only enemies. “A sigh of relief went over the city when I stopped vaccination,” he wrote. “The people began to work in harmony with us, opened their houses for us to disinfect them, gave us all the information we wanted, and helped us in every way conceivable.”67

For the many contemporaries who applauded Dr. Friedrich’s Cleveland experiment as a more palatable alternative to coercion, time delivered an unsettling rejoinder. Friedrich’s candor about vaccine safety was laudable. His formaldehyde clouds appeared to stamp out the disease, enabling him to duck the most controversial public health issue of his generation—compulsory vaccination. But this dispensation was only temporary. Friedrich’s policy left people unprotected.

A homeless man from Hoboken, New Jersey, entered the city in May 1902, carrying in his feverish body smallpox of the severest type. As Friedrich said, it was “the smallpox ‘we read about.’” The city launched a sweeping campaign in which more than half the city’s residents were vaccinated through an extraordinary public effort involving civic groups, religious leaders, and the local Academy of Medicine. Chastened but still cautious, Friedrich used the city’s new bacteriological laboratory to test the vaccines on the market for one that was safe and reliable. The vaccination campaign finally stamped out the epidemic by early 1903. But by that time, 246 people lay dead from smallpox.68

On January 25, 1902, the Philadelphia Medical Journal published an update on Pennsylvania’s smallpox epidemic. The report included the following lines: “At Resetto, an Italian settlement near Bangor, the attempt of the police to bury a woman who died of smallpox, without religious services, resulted in a riot. The Italians seized the coffin, bore it into the church, and then stood guard, chasing the policemen away.”69

Roseto (as the place was actually called) was a close-knit settlement of fifteen hundred people at the edge of slate quarries in eastern Pennsylvania. The place had recently been named after the hill town in southern Italy from which most of its residents had come. The incident, reported without comment in a leading American medical journal, shows the determination of one immigrant community not to let even the deadly serious matter of smallpox interfere with a proper Catholic burial for one of its members. The people of Roseto rioted. They seized the body from the police. They bore it to a sacred space, their sanctuary. They drove the police from their church and stood guard so that the proper religious rites could be performed. In doing so, they unknowingly contributed a few sentences to a swelling archive of popular opposition to public health authority at the turn of the century—an archive most officials would have agreed showed the ignorance and superstition that hindered their efforts to stamp out smallpox.70

The power to remove and isolate an infected body—whether dead or alive—was fundamental to public health. “The power of removal,” said Leroy Parker and Robert Worthington in their treatise on American public health law, “is unconditional and unqualified.” But as the tenement mothers of Italian Harlem showed Blauvelt’s vaccination corps, the power was not uncontested. The most common form of resistance was concealment, hiding sick people, sometimes entire families, from public view. When health officials and police went looking for hidden cases of smallpox—sometimes acting on a tip from suspicious neighbors, school officials, or employers—they often walked into a fight. Experienced health officers expected trouble when they came for children. Fathers and mothers responded with tears, fists, and shotguns.71

Charles Chapin of Providence, one of the more self-reflective public health officials of his era, reckoned that people had good reasons for dreading the pesthouse. For their comfort and survival, smallpox patients desperately needed attentive personal nursing in a healthy environment. A few U.S. cities—including Cleveland, Milwaukee, and the District of Columbia—built permanent smallpox isolation hospitals, modern facilities involving large public investments. Chicago spent the unheard-of sum of $83,000 on its isolation hospital, an elaborate campus of buildings on Lawndale Avenue, complete with electricity and ten acres of well-appointed grounds. But the typical American pesthouse was a crude wooden shed, built in haste and on the cheap. Most lacked plumbing, plaster, or decent furniture. They were located far from their patients’ friends and families, a hard journey over bad roads or, as in the case of Boston and New York, across water to an island.72

American newspapers were filled with pesthouse scandals. A former patient of the New Orleans pesthouse decried the “horrors” of his confinement in a shanty built upon a swamp. Salt Lake City’s pesthouse was a public “menace.” One survivor of the New York City pesthouse on North Brother Island objected to “the uncleanliness and unsanitary way in which the patients are treated,” calling the “mockery for a hospital” a poor example for its inmates. In 1901, James Kerr willingly surrendered his young smallpox-afflicted daughter to city health officials only to have her die—of tuberculosis—on North Brother Island. Adding insult to grief, the city returned to Kerr the wrong body. As Chapin recognized, the scandalous conditions of many American pesthouses lay behind much of the resistance to removal of “patients.” “It is not to be wondered at that patients and their friends resort to every deception to conceal the disease,” he said, “in order that they may not be carried to such a place.”73

Improvements to the typical pesthouse came only on those rare occasions when a well-to-do smallpox patient was confined in one. The American pesthouse was, without apologies, a class institution—the medical equivalent of steerage. Pesthouses were designed for the isolation and treatment of smallpox patients who lived in tenements and other dwellings too crowded to allow for their isolation at home. By long practice, affluent members of the community who lived in spacious quarters, at some remove from other dwellings, were entitled to convalesce at home. Health officials who failed to heed this commonly recognized American practice risked litigation and political censure. When Mary Kirk of Aiken, South Carolina, returned from missionary work in Brazil with a case of leprosy, the board of health ordered her removed from her house in the heart of the city to the four-room pesthouse by the city dump. Kirk sued. A “woman of culture and refinement” had no business in the pesthouse, a place “coarse and comfortless, used only for the purpose of incarcerating negroes having smallpox and other dangerous and infectious diseases.” Awakened to Kirk’s plight, the city council promised to build her a “comfortable cottage” on the outskirts of town, “supplied with all modern conveniences.” Meanwhile, a circuit judge issued an order, forbidding the board from removing Kirk to the pesthouse. Calling this “an exceptional case,” the state supreme court affirmed that action.74

The poorest members of an American community were not only the ones most likely to be sent to the pesthouse; they were also the people most likely to have one opened up in their neighborhood. Best public health practices called for locating a pesthouse at a safe remove from the local population. Usually, pesthouses were located on the outskirts of town. In some places, state law forbade public health boards to erect pesthouses too close to other dwellings. There seemed to be sound science behind such rules. While most public health officials believed smallpox contagion could not be carried through the air more than two hundred feet without being destroyed by oxidation or dilution, the Journal of the American Medical Association conceded, “This belief is purely empiric; there are no scientific data for its foundation.” In one 1903 study, an English health officer suggested that one “smallpox ship,” a floating pesthouse moored on the Thames, had caused an epidemic in a village half a mile away. As the London Times said, “smallpox hospitals may become sources of serious danger to the unprotected populations in their vicinity.”75

That sense of danger made a pesthouse, in one medical writer’s estimation, “the most unpopular neighbor that a man could have.” Health officers seeking sites for a new pesthouse were turned back by shotgun-wielding farmers in Durham, North Carolina; writ-bearing “taxpayers” in Omaha, Nebraska; petition-signing citizens in Houston; and blaze-setting residents in Union County, Kentucky. In Bradford, Pennsylvania, three hundred men and women burned down a vacant schoolhouse that local officials had turned into a pesthouse. In Turtle Creek, eight miles outside of Pittsburgh, a “Quaker mob,” two thousand in number, rioted to prevent the board of health from trying the same thing. Firemen turned their hoses on the unruly Friends.76

Whether the agitators were immigrant laborers or white “taxpayers,” whether they favored the axe or the writ, collective action to keep out the kept-outs had an inherently conservative aspect. These turf defenders did not necessarily object to the pesthouse as a political response to contagious disease. In most cases, their quarrel would evaporate if the government chose another site—somebody else’s backyard. Grievances and interests varied. Property owners feared that a pesthouse in the neighborhood would diminish real estate values. Poor residents protested the endangerment to their health as well as the constant reminder that they lived in their town’s dumping ground.

In March 1901, two cases of smallpox were discovered in Orange, New Jersey, a city of 24,000 known for its hat-making industry. The board of health hired a builder to construct a pesthouse at the city dump. But the site was surrounded by tenements filled with Italian workers and their families. As the carpenters set to work, a crowd gathered. By evening, 300 angry residents and just two policemen had gathered at the site. The crowd rushed the pesthouse. Someone lit a pile of wood shavings, and within minutes a blaze was making its way toward the structure. Firemen arrived, but a group of the residents stood on their hose, while one tried to cut it with a knife. Clubs flying, the police arrested three men. More police arrived, the crowd was driven back, and the fire was extinguished. The next night, a single pistol shot rang out at the dump. Men carrying axes and crowbars poured out from the surrounding tenements. In a few minutes they reduced the building to splinters. For good measure, a crowd returned later and set fire to the pile of broken wood.77

In the wake of the incident, the Orange Common Council refused to authorize construction of another pesthouse. The New York Times lamented that the revolt illustrated “the readiness with which well-ordered and generally law-abiding communities revert to barbarism when their fears or evil passions are aroused.” But one letter writer from Orange, a self-described “Sympathizer with the People,” saw justice in the crowd’s actions. “Simply because the residents in the vicinity of the ‘dump ground’ are working people they are to be made uncomfortable and their health and that of their children endangered because the Board of Health—so-called—chose to put a pesthouse up in the midst of their dwellings,” the sympathizer wrote. “Legally, I suppose, the people were in the wrong, but morally they had every right to act as they did.”78

The altogether ordinary Americans who defied public health measures during the nation’s turn-of-the-century war on smallpox left a deep mark upon the historical record. In their actions rather than their words—which, unlike those of the well-organized, predominantly middle-class antivaccinationists, were rarely recorded—they created a public transcript of opposition to the growth of institutional power in everyday life during the Progressive Era.

That record of dissent had political consequences. It forced compulsion to show its true self. It emboldened the antivaccination movement. It raised doubts in the heads of some lawmakers and a governor or two. And it even made an impression upon the institutions most removed from the common people, the courts. “It is a matter of common knowledge that the number of those who seriously object to vaccination is by no means small,” observed Justice Orrin Carter of the Illinois Supreme Court, “and they cannot, except when necessary for the public health and in conformity to law, be deprived of their right to protect themselves and those under their control from an invasion of their liberties by a practically compulsory inoculation of their bodies with a virus of any description, however meritorious it might be.”79

Compulsion engendered resistance even in those tightest of spaces whose inhabitants had no legal claim to liberty at all: prisons and jails. Vaccination was a routine part of penal discipline in the United States, as the young Jack London discovered when he was arrested for vagrancy during his long tramp across North America in the 1890s. London recounted the experience in a chapter of his book War of the Classes (1905), entitled “How I Became a Socialist.” While traveling near Niagara Falls, he was “nabbed by a fee-hunting constable, denied the right to plead guilty or not guilty, sentenced out of hand to thirty days’ imprisonment for having no fixed abode and no visible means of support, handcuffed and chained to a bunch of men similarly circumstanced, carted down country to Buffalo, registered at the Erie County Penitentiary, had my head clipped and my budding mustache shaved, was dressed in convict stripes, compulsorily vaccinated by a medical student who practiced on such as we, made to march the lock-step, and put to work under the eyes of guards armed with Winchester rifles.”80

For London, living the hobo’s life as a member of America’s “submerged tenth,” the underclass of his day, compulsory vaccination was but one in a litany of injustices that prompted his conversion from a working-class individualist into a socialist and a citizen of the world. During the experience, he said, some of his “plethoric national patriotism simmered down and leaked out of the bottom of his soul somewhere.” In another telling, London recalled with warm solidarity how another inmate, a veteran of the penal system with whom London had shared some tobacco, advised London to “suck it out”—literally to suck the vaccine from his arm. The writer was glad that he did. For afterward he saw “men who had not sucked and who had horrible holes in their arms into which I could have thrust my fist.” London could muster no sympathy for his fellows in prison stripes who had done nothing to stop the state of New York from making its mark on their bodies.81

“It was their own fault,” he said. “They could have sucked.”82

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