Exercise developed and produced by:

Johns Hopkins Center for Civilian Biodefense Studies

National Memorial Institute for the Prevention of Terrorism

Office of Justice Programs, National Institutes of Justice, U.S. Department of Justice

The Alfred P. Sloan Foundation

Transcript  [Listen to this talk] [View the slides]

DR. URSANO: Another area for us to turn, we've looked at the individual. We're looked now at the study of groups, is to look at previous experience, which draws us to the question of history, history in our past, far past, history perhaps in our present. It's important to remember that there are communities in the United States in which terrorism is endemic as we speak, long before 9/11. In Baltimore, Angela Dawson's house was fire bombed. She died, and her five children. The intent of the fire bomb which was thrown by a drug dealer was to discourage what she had done, which was to tell the police about the marketing of drugs going on in her community. Terrorism has been around for quite some time, and biological events have been around for quite some time.

Dr. Judith Leavitt is presently the Ruth Bleier WARF professor of medical history. She focuses on the issues of 19th and 20th Century public health and women's health. She's recently published the book Typhoid Mary: Captive to the Public's Health. She's the past president of the American Association for the History of Medicine, and this morning she's going to talk to us about "Public resistance or cooperation? Historical perspectives from Smallpox." Judith.

DR. LEAVITT: Thanks very much. I'm really so pleased to be here, and honored to be here. Let's see if I can get this going. And you see, I changed the title a little bit. I'm really going to talk about only two outbreaks of Smallpox in two different cities, so I call it a "Tale of Two Cities". And the images that I want to begin with are images of the two cities. One is Milwaukee, Wisconsin, which experienced a Smallpox outbreak in 1894 of fairly major proportions, and caused urban rioting for about a month in the city streets. And here you see Leslie's illustrated rendition of that rioting in 1894. And the second one I'm going to talk about is New York City during the last Smallpox outbreak in this country in 1947. And the lines here are illustrative of something very different from the Milwaukee riots, and that is total order. These people stayed in line, in these kinds of lines for hours, full days, came back the next day in some cases, and there was no sign of the kind of riot that we saw in Milwaukee. So let me start first with Milwaukee in 1894.

This was an outbreak that came to the City of Milwaukee hitting every ward in the city by June of 1894, at the same time as a brand new health commissioner, Walter Kempster, had taken office. Now Kempster was someone who did not believe in political patronage for the health department, and refused to give jobs to the people in his own political party, so he started off immediately on the wrong political foot. Everybody was mad at him, and then on top of that, Smallpox comes. Well, he treated it in the same way as previous health officers had. He started a vaccination campaign. He used the isolation hospital, and he used home quarantines.

Now it happened that he used home quarantines for the most part in the middle or upper class parts of the city because he felt that people could be isolated in home there more effectively; whereas, in the poor immigrant sections of the city, he used forcible removal to the isolation hospital. And you can imagine that discrimination there was not helping, so the Smallpox, as I said, spread city-wide. It began concentrating in the immigrant wards, and health department activity concentrated there also. This is just to show you what home placarding looked like in a case of Mumps, but take a look at the uniforms. The uniforms of the health officers became an issue also. So there was enormous resistance, and it focused mostly in the immigrant wards where the Smallpox itself focused.

Part of the resistance to health department activities in 1894 were specific to Kempster; that is, he was a very unpopular man right from the start. We're in the middle of an economic depression in 1894, and he was not giving people jobs who thought they deserved them politically.

Another big part of the resistance came from the anti-vaccinationists. This was an organized movement at the end of the 19th Century to prevent people from getting vaccinated. Now these are people who thought vaccination was a dangerous procedure. It was centered in immigrant wards, but it was certainly not exclusive to immigrant wards. And the physicians in the city were split probably one-third/two-thirds. One-third against vaccination, two-thirds for it. There was significant, as that tells you, significant medical disagreement, so anyone who turned to a medical authority would have gotten various and mixed messages.

There was great immigrant fear of government authority, in general. Government authority that came knocking on your door in a uniform in specific, especially when it was trying to take your child to the isolation hospital against your will, and so that was a big focus for the problem.

There was a perception, I think there was also a fact of injustice in the way that government policy was handled; that is, the rich were allowed to stay home and be quarantined, the poor were taken to the hospital. There was this phrase, "The scum of Milwaukee" in the newspapers quite a bit, and the people who lived on the southside of Milwaukee felt that that's the way the rest of the city viewed them, as the "scum of Milwaukee" and, therefore, it didn't matter what you did to them, so there was definite unequal application of the policy. And the immigrants responded by not reporting cases of Smallpox, by hiding them when people came to the door. And ultimately, by rioting against forcible removal, and against vaccination.

The riots in Milwaukee were characterized this way, women played a large role in them. Mobs of Pomeranian and Polish women armed with baseball bats, potato mashers, clubs, bet slats, salt and pepper and butcher knives lay in wait all day for the isolation hospital van. The van was, of course, drawn by horses in 1894, and they also had some scolding water to throw on the horses. The riots lasted about a month, and were depicted nationally, as you saw in this case. And the Health Department responded in a very dismissive, inflexible and incentive way, and these are quotations from the Health Commissioner, from Walter Kempster. "But for politics and bad beer, the matter would never have been heard of." He dismissed the whole thing.

"I am here to enforce the laws, and I shall enforce them, if I have to break heads to do it." And, of course, it's the break heads that people heard. "The question of the inhumanity of the laws I have nothing to do with."

Well, I don't have time to tell you the whole story, but Kempster goes on to get impeached, thrown out of office, and ultimately after a year reinstated, but in the process of that impeachment, the Health Department lost a lot of the authority it had gained over the whole of the 19th Century, including the authority to remove anybody to an isolation hospital. And Milwaukee took at least the next 25, 30 years to recover some of those powers.

The story was very different in New York City in 1947, and some of you may know this story because Burton Rushay has told it so nicely, and the man from Mexico.

Eugene Le Bar was a citizen of Maine who had gone with his wife to Mexico on vacation, and had taken a bus back on his way back from Mexico to Maine. He was not feeling well when he got to New York, and so he got off the bus, checked into a midtown hotel and wandered around the city for five days, before finally his rash erupted. He was feeling so badly he couldn't get out of bed, he said, and he was finally taken first to Bellevue Hospital to the dermatology ward. New York had not seen a case of Smallpox in a generation and a half, and nobody thought of it when he came in.

He was ultimately switched to the isolation ward at Willard Parker Hospital, and he died before a definite diagnosis was made of Smallpox, so he had a chance to expose people in the streets of New York, in Bellevue Hospital, and the nursing and medical staff at Willard Parker Hospital before he died. This led to the largest mass vaccination campaign in U.S. history. Here is a case of somebody who was exposed to Eugene LeBar who got Smallpox, and another one from that same outbreak.

Now the Health Department activities in 1947 differed greatly from the Health Department activities in Milwaukee 50 years earlier. They relied on case tracing, voluntary mass vaccination, daily press conferences. We've heard already, and I'm sure we're going to hear more how important it is for information to keep flowing, and New York did that so well. Israel Weinstein was the health commissioner and Mayor O'Dwyer was also very active in this.

There were signs and buttons around everywhere, "Be safe. Be sure. Get vaccinated." There was multiple daily press conferences and radio shows about the diagnosis when it finally came, the spread of it, every case was announced, and there was a perception, and I would argue also a reality of honesty and justice from the Health Department and from the city government at this time, because people felt they were being informed as things were unfolding. Here you see the case tracing tree from Eugene LeBar here, and the one other person who died in the outbreak. There were 12 cases all together.

The vaccination campaign, as I say, started and ended really with free and voluntary vaccinations. Now this was despite the fact that the Health Department had the authority to do forcible vaccinations, or at least to bring people in for vaccinations against their will, but they didn't do that, and they didn't need to do it.

Vaccinations were given in 13 hospitals, 84 police precincts, and every school around the city of New York, and daily press, as I said, and radio reports. In two weeks, five million New Yorkers were vaccinated, and in four weeks, six million three hundred and fifty thousand New Yorkers were vaccinated. And in the next week, another few, they always said it was six and a half million, although these are the documented ones.

President Truman came to visit New York after being very publicly vaccinated. There was a lot of federal and local cooperation in this outbreak, and especially around vaccine production. New York could rely on the federal laboratories to bring in -- to produce and to bring in vaccine. And laboratories public and private around the city were pushed into service and cooperated. The drug companies were a little less cooperative until Mayor O'Dwyer locked them into City Hall, and said you are going to produce more vaccine, and you're going to do it very quickly, or you're not leaving this building, and they surprisingly agreed.

There were a lot of volunteer workers helping this effort from the Red Cross, to teachers' groups, to women's clubs around the city. And remember, it was a voluntary vaccination program so those people standing in line were there in a voluntary fashion. Public compliance was incredibly high. Now I don't have to remind you that this is immediately post World War II, and that did have something to do also with the level of organization in the city and the cooperative effort.

Here you see another photograph of people lined up. This is in Brooklyn, lined up waiting for their vaccine. And this one you've seen already. This is really my favorite picture. There was one day when vaccine ran out and everyone had to come back, and apparently they did so without a peep. This is inside one of the vaccination centers where you can see the people lining up for vaccine. So it was a successful program, I think, partly because of federal and state, and local communication, voluntary vaccinations, public information blitz, that it was seen as, and was non-discriminatory. That is, every part of the city and every population group was targeted, that there were networks of citizen activity which were coordinated through the Health Department, and there was a very strong Health Department infrastructure. And so, instead of the four thousand some cases and nine hundred some deaths that they would have anticipated based on the previous New York outbreak of Smallpox, they reported 12 cases and 2 deaths, so it was quite convincing.

Now here I just did a little matrix to show you. Milwaukee had a strong Health Department also when it started out, some state Health Department help, strong-arm tactics for everybody, not just drug companies, very discriminatory in its policies, limited information, mixed messages, no citizen activity, and consequently a raging epidemic. Whereas, New York City had also a strong Health Department, state and federal cooperation, information and respect for people shown at every stage, even-handed in its policy, a media blitz with a clear message despite what Lee just said. It wasn't just one person, but it was a clear message. Use of citizen groups and confined, very confined outbreak.

So the implications for today, I think, of all of this, and obviously, I've raced through it and not given you the full historical context that I would have liked to, is that the response of the public historically has covered the spectrum from strong resistance and rioting to strong cooperation. There is, obviously historically shown a need for well-supported integrated public health structure, and by that I mean integrated not just locally, but local, state and federal integration. That coercion where it has been tried has not worked historically, and has led to more problems; whereas, cooperation with a strong education component has been much more successful.

Public support, I think is based on frequent and honest information and communication. Media has played an enormously important role in giving the message. The media during the Milwaukee outbreak was very partisan, pro or anti-Kempster down the line; whereas, the media in the New York outbreak was an outlet for information. And the information given always demonstrated respect for the public's need to know, which I think is an important part of leaders' roles, is that to respect that, and to give them the knowledge they need, because then they know how to respond. Without that knowledge, they don't. And a perception of justice and equity. Actually, the reality of justice and equity would be what we would aim for. So just in case you want to do any further reading, you can see that I've published on both of these outbreaks, and can lead you to a lot of other sources, as well. Thanks very much.

DR. URSANO: Thank you, Judith. Marvelous reminder of both the importance of history to inform us around modern problems, such as vaccination programs, as well as the importance of terror as an element which can make present the faults that are always lurking within our society, frequently around issues of social justice, which we tend to fall down on way too often.

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