Deep Dive into Prior Pandemics: Part 2, The Smallpox Epidemic in the US from 1775 to 1782.

The Event Missing from our High-School History Books

Pox American: The Great Smallpox Epidemic of 1775-82 by Elizabeth A. Fern is a powerful analysis of a major public health event that played an important role in the future of the nation later known as the United States of America.

It could have cost the Continental Army a win in the Revolutionary War with Britain.  It made conquering the interior of the country easier after smallpox killed 50 to 90 percent of the Native American population.

By the time I read this book, I had already read books on Ebola in 20th century US, cholera in 19th century England, the Black Plague in 14th century France, malaria across the centuries and across the world, and the Spanish flu in 20th century US.  But this book carried more emotional weight.  Without ever saying as much, its pages spoke of great sadness and fear. 

The viral illness was endemic to the Old World.  By the late 1700s, many men in the British army had been exposed to it and so had life-long immunity to the disease.  Officers inoculated any troops who might not carry the immunity. This hardiness among troops gave the British a very large advantage against the Continental Army populated by New World soldiers who had no immunity.

George Washington had fallen ill with the disease in 1751 during a trip to Barbados with his brother. He knew its debilitating course of recovery and worried deeply for the health of his troops.  He kept them safely outside besieged Boston in 1775 where the disease killed many civilians while the British army occupied the city.  Eventually abandoning Boston, the British army and fleeing civilians carried smallpox to other parts of the east coast.  In the south, the Continental Army could not evade it.  African-Americans from southern states joined the British army in late 1775 and 1776 in exchange for the promise of freedom.  But, these men and women, known as the Ethiopian Regiment, saw high levels of death often isolated on foul pestilence ships or on islands without food, water, or care. Southeast Indian tribes, who often tried to trade with both sides or remain neutral in the conflict, also saw high levels of infection and death.

In the early days of the epidemic, survival depended on the severity of the virus, nursing care, and a person's general health before the illness.  Scientists suspect that the virus mutated over time, and it may have become more virulent during the Revolutionary War.  But, less virulent strains existed, which doctors later exploited to create less risky inoculations.  As Washington knew, the illness took over a month to run its course.  If a sick person did not have access to good nursing care, he or she would die of starvation, dehydration, and neglect.  If a person was already malnourished or otherwise immuno-compromised, he or she would not likely survive infection with smallpox. 

The risk of the disease to his troops became clear to Washington after the disastrous failure to subdue Quebec by siege in late 1775.  His troops suffered high losses from a smallpox outbreak.  Yet, he was afraid to inoculate troops because they would be out of action for a month.  Eventually, he required all troops and new recruits to receive inoculation, first in several locations along the eastern seaboard, then in Philadelphia, a hotbed of infection, and then later in quarantine hospitals located outside his Morristown, New Jersey camp in the spring of 1777. This decision created the first government-sponsored inoculation program. 

In the early days of the epidemic, doctors inoculated people by making a cut in the skin on the thigh or arm and then laying in the wound a piece of string infected with the virus.  People who survived the treatment had life-long immunity.  Others died.  Next, doctors infected people using a strain of the microbe that did not seem as lethal taken from people who survived infection (known as the Suttonian process).  Finally, in 1796, Edward Jenner discovered that inoculation with the similar cow pox virus conferred lifetime immunity to small pox.  His published results came out a year after Washington died.

This inoculation process, call variolation after the offending smallpox virus called Variola, was expensive.  Only the rich could afford the doctor's fees and nursing care.  Thus, middle-income people, the poor, and slaves had no access to the process. 

Many colonies made the process illegal because inoculated people were infectious for half of the month-long disease process and could start an epidemic in a pox-free community.  Accordingly, the rich flocked to the few jurisdictions that allowed the process.

On the other side of the continent, beginning in 1779, Catholic parish burial records show an outbreak in Mexico City.  The author, in a feat of diligent research, tracked the spread of the disease north through parish records.  It hit "New Spain" in 1780, and quickly infected most of the Native American tribes living there.  At the time, Native Americans traded widely with other tribes and with white trading companies.  Based on available records, the author posits that the Comanches got the disease as the Mexican pandemic spread north.  Shoshones trading with the Comanches carried it north in a surprisingly short time because they were one of the few tribes using horses to traverse long-distances.  Canadian tribes suffered greatly.  The record shows that the white trading companies had far fewer animal furs because so few Native American trappers remained alive.  Explorers on the northwestern coast of the US found deserted villages full of human bones.  The infection likely crossed the mountains with Native American fur traders. 

Weakened by the collapse of the population and its social structure, Native American tribes had fewer braves to fight off white intrusions into their territories.  The balance of power among tribes also changed.  The Sioux became the lords of the Plains, and the Blackfeet ruled further north.

The disease itself, now eradicated from the world except for some virus kept in test labs, was frightening and painful.  The virus incubated for ten to fourteen days. It started with flu like symptoms of intense headache, backache, fever, vomiting, and general listlessness. The fever crept up by day four of the infection and the first skin sores appeared in the mouth, throat, and nasal passages.  During the next 24 hours, the rash covered the surface of the skin in raised pustules on the soles of the feet, palms of the hands, face, neck, forearms, and back. Victims could bleed to death internally.  If the pustules joined together, in an oozing mass, the patient had a 60 percent chance of dying.  The sores in the mouth could lead to malnutrition and dehydration because of the pain of swallowing. When the pustules cracked, they emitted a foul smelling discharge.  At this point, the disease could damage the eyes, leading to blindness in survivors.  Secondary bacterial infections could set in.  (George Washington's brother died of tuberculosis within four years of his smallpox infection.)  Scabs started to form after two weeks. In some patients, this hard crust made moving excruciatingly painful.  Death came after ten to sixteen days. After a month, the patient would still have lesions on the soles of the feet and the palms of the hands.  Persons accustomed to walking barefoot would shed the entire sole of the foot, prolonging their suffering. 

Exhaled droplets, scabs, and dried-out body secretions carried the infection.  It survived for weeks outside the body in clothing and bedding.  Carefully stored, it can infect someone years later. 

During this eight-year epidemic, the author estimates that at least 130,000 people died of the disease in the United States and western regions.

Something about the painstaking account created by the author and excerpts from contemporaneous writings captures the horror of this disease.   War exposed the virus to more susceptible hosts, both military and civilian.  You sense both the dread and the resignation that people felt when they had so few resources for fighting the disease. Pasteur did not publish his germ theory until 1861, but people knew how this disease was transmitted and that quarantine could prevent contagion.  They knew that an infection conferred life-long immunity, and used immune persons to nurse inoculants and other infected persons. 

Nonetheless, people let other values guide behavior. They visited relatives in Boston during the outbreak, went to public events and church after receiving inoculation making them infectious, and otherwise put themselves and others at risk.   Smallpox did not prevent living, but it did exact a high cost for carrying on life as the new country formed.

Postscript:  "J. Michael Lane, an epidemiologist who helped see to its end the global campaign to eradicate smallpox, a disease that killed hundreds of millions of people over centuries before it was vanquished in one of the most celebrated feats in the history of medicine, died Oct. 21 at his home in Atlanta. He was 84.

Dr. Lane, the last director of the smallpox eradication bureau at what is now the Centers for Disease Control and Prevention in Atlanta, was one of the “disease detectives” who stalked the smallpox virus around the globe until the last naturally occurring case was identified in Somalia in 1977. Never before or since has a human infectious disease been eradicated through medical intervention."