Long before threats to public health were coordinated by the Center for Disease Control, the response to epidemic disease handled almost entirely at the local level, with support provided only when needed from provincial governments. Using Rhode Island as a case study, this presentation will outline the provincial laws that gave sweeping authority to town officials to act in the best interest of the community. At the same time efforts by officials to prevent outbreaks in the first place through inoculation and vaccination were often met with fierce local opposition. With the passage of the Fourteenth Amendment, opposition to vaccination programs in neighboring Massachusetts were ultimately settled by the Supreme Court. And conflicting priorities over public health, civil liberties and individual freedom are alive and well today despite the victory of medical science over the variola virus.

1. Public Health versus Democracy:
A History of Smallpox in Rhode Island
Mark Kenneth Gardner
Archivist, Western Rhode Island Civic Historical Society
HistoryCamp Boston 2017
Suffolk University Law School
Boston MA

2. “Disease Vector Theory” of History
• Hans Zinsser Rats Lice and
History (1935)
– a "biography" of typhus fever
• William McNeill Plagues and
Peoples (1976)
– An “epidemiological history” of
smallpox in Mexico, bubonic plague
in China, and typhus in Europe
- Role of domestication of animals in many endemic/epidemic diseases
- Patterns of disease transmission paralleled trade and migration routes

3. Impact on History
• 2nd
Century - increased trade with Rome and China introduced (or
reintroduced) smallpox to both empires
• 6th
Century - Increased trade with China and Korea introduces
smallpox into Japan
• 7th
Century - Arab expansion spreads smallpox into northern Africa,
Spain, and Portugal
• 11th
Century - Crusades further spread smallpox in Europe
• 15th
Century - Portuguese occupation introduces smallpox into parts
of western Africa
• 16th
Century - European colonization and the African slave trade
import smallpox into the Caribbean and Central and South America
• 16th
- 17th
Century - European colonization imports smallpox into
North America
• 18th
Century - Exploration by Great Britain introduces smallpox into
Australia
• 19th
Century – Smallpox epidemic unleashed after the Franco-
Prussian War killed 500,000 in Europe
- Source: Centers for Disease Control and Prevention www.cdc.gov

4. Impact on History
• Smallpox Deaths
– Pharaoh Ramses V
– Roman Emperor Marcus Aurelius
– Shunzhi Emperor, Tongzhi
Emperor, Qing dynasty, China
– Emperor Go-Kōmyō, 110th
emperor of Japan
– Cuitláhuac, 10th
Aztec tlatoani
(emperor)
– Inca emperor Huayna Capac
– Pocahontas
– Queen Mary II (of William & Mary
fame)
– Holy Roman Emperor Joseph I
– King Luis Ferdinand of Spain
– Tsar Peter II
– Louis XV of France (“Louis the
Beloved”)
– Henry Gray (author Gray’s
Anatomy)
– Theologian Jonathan Edwards
– Samuel Ward, delegate to
Continental Congress, RI
• Smallpox Survivors
– Elizabeth I of England
– Mary, Queen of Scots
– Maximilien Robespierre
– George Washington
– Andrew Jackson
– Abraham Lincoln
– Sitting Bull
– Ludwig von Beethoven
– Wolfgang Amadeus Mozart
– Mary Shelley
– Joseph Stalin

6. Origins
• Smallpox is an orthopoxvirus believed
to have been acquired by humans from
an African rodent
• Genetic evidence suggests smallpox
emerged between 1400 and 6300 years
BP, and perhaps as early as 16,000 to
68,000 BP
– Maybe long before agriculture and
civilization…
– Archaeological and historical evidence is
incomplete
– Better estimates of mutation rates in
orthopoxvirus are needed to make a more
accurate guess

7. Smallpox: Earliest cases…?
• China: earliest definitive description 1700 BC
• Egyptian pharaoh Ramses V in 1157 BC; earlier cases in 18th
and 20th
dynasty mummies c. 1570 BC
• Egyptian prisoners probably spread smallpox to Hittites c.
1246 BC
• Plague that struck Athens c. 431 BC was probably smallpox –
lost Peloponnesian War to Sparta
• Sanskrit records from India 1500 BC describe smallpox-like
symptoms, while the worship of a Hindu smallpox deity dates
from the first millennium BC
• Smallpox-like symptoms were described among Alexander’s
army when the Greeks invaded India in 327 BC
• Smallpox apparently stopped Carthaginian soldiers from
taking Syracuse in Sicily in 395 BC, yet smallpox was not
described by Hippocrates, a contemporary of the siege at
Syracuse
• Smallpox is also not clearly described in the Bible or in Greek
or Roman literature.

8. Mummy of Ramses V
Lesions found on
Ramses face seem to
indicate that he suffered
from smallpox, and is
thought to have caused
his death.

9. Smallpox and the Roman Empire
• Plague of Antonius AD 164 - AD
180
– Greek physician Galen’s
observations and description of the
epidemic suggest the plague was
smallpox
– the disease killed one-third of the
population in some areas and
devastated the Roman army
– An estimated 5 to 7 million Romans
died including the emperors
• Lucius Verus AD 169
• Marcus Aurelius AD 180 - last of
the “Five Good Emperors”
– Turning point for Roman Empire

10. Smallpox in the Middle Ages
• Nicasius of Rheims 450, patron
saint of smallpox
• Saint Gregory of Tours AD 580
– Gregory was the first to use the
term variola to describe smallpox
• Ahrun (Aaron) of Alexandria, AD
622
• Arab armies, 7th
and 8th
centuries
 S. Western Europe
• 9th
century Persian physician
Rhazes
– Book of Smallpox and
Measles, which remained in
print into the 19th
century
• Crusades & smallpox

11. Smallpox and the Conquest of the New World
• In 1519, Hernán Cortés landed in Mexico
– An African slave who came arrived with a
Spanish expedition from Cuba in 1520 had
smallpox
– One of Cortés soldiers contracted the
disease from the African and died
– The Aztecs contracted smallpox from the
dead soldier
• As the Spanish were forced out of
Tenochtitlan, smallpox raged through the
Aztec capitol, putting the Aztec forces into
disarray and allowed the Spanish to escape
• While Cortes organized an army of former
Aztec vassals, between 60% and 90% of
the population of Tenochtitlan died.
– "As the Indians did not know the
remedy of the disease…they died in
heaps, like bedbugs. In many places it
happened that everyone in a house
died and, as it was impossible to bury
the great number of dead, they pulled
down the houses over them so that
their homes become their tombs.“
- Toribio Motolinía, Florentine Codex, 1524

12. Smallpox and the Conquest of the New World
• The epidemic left the Aztec army weakened and
demoralized, as Spanish remained unaffected
• Cortés easily defeated the Aztecs
Illustration from the Florentine
Codex showing Nahuatls of
conquest-era central Mexico with
smallpox.

13. Smallpox and the Conquest of the New World
• When Francisco Pizarro
invaded the Incas of Peru in the
1530s, a similar set of events
led to the conquest of the Inca
Empire.
• The Spanish expeditions of
Narváez, de Soto and
Coronado between 1527 and
1542 introduced smallpox (and
measles and chicken pox) into
the Puebloan and Mississippian
cultures
• Mass depopulation and societal
disruption in wake of Spanish
exploration, contributing to the
collapse of the Mississippian
civilization.

14. • Variola major
• Orthopoxvirus
• brick-shaped
• 200 nm wide
• 250 nm long
The Virus

15. Cycle of Infection: Contagion
• 50:50 chance of
infection
– higher among
populations with no
prior exposure, up to
90-100%
• Duration: 3 weeks
• Most contagious first
several days
• droplet infection
• Corpses, scabs and
infected clothing

16. Cycle of Infection: Incubation
• incubation period usually 9
days
– victims not contagious
– virus quietly replicated itself
by the millions by hijacking
the cell’s reproductive
functions, until infected cells
became overly packed with
virus and ruptured
• prodromal phase: 2-4 days
– headache, fever, chills,
nausea, backache
– some victims experienced
convulsions or delirium,
terrifying dreams, others
developed a diffuse scarlet
rash
– fever briefly subsides at end
of prodromal stage

17. Cycle of Infection: Stages of Rash
• Flat reddish spots appear on the face,
then spread rapidly over the arms, chest,
back and finally the legs
• Flat spots become raised pimples, then
blisters, then pustules; victims reeked with
a peculiar sickening odor
• If pustules converged into what was
known as “confluent smallpox” mortified
skin would come off in sheets; victims
usually died
• Pustules dried up, turn into crusts or
scabs
• Meanwhile the virus also attacked the
throat, heart, lungs, liver, intestines
• Possible secondary infections of wounds
in skin, blindness (2%)
• 1 out of every 4 victims died (25-30%)
• Black smallpox (rare): internal and
external hemorrhaging
– was always fatal

18. Cycle of Infection: Stages of Rash

19. Smallpox in Colonial New England

21. Smallpox strikes the Wampanoag
• In 1617 the first epidemic of smallpox
swept through the native tribes living
along Massachusetts, when it ended
in 1619 an estimated 90% of those
who had caught the disease were
dead from infection.
• A year later in 1620 when the
Plymouth colonists arrived, they had
their pick of cleared land
– "Thousands of men have lived there,
which died in a great plague not long
since: and pity it was and is to see so
many goodly fields, and so well seated,
without men to dress and manure the
same.“
– Edward Winslow
Map of Plymouth Harbor, 1605
by Samuel de Champlain

22. Smallpox strikes the Wampanoag
• In 1633 another epidemic in
Massachusetts was seen as a gift
from God by some Puritans.
– "The Indians began to be quarrelsome
concerning the bounds of the land they
had sold to the English; but God ended
the controversy by sending the
smallpox amongst the Indians at
Saugust, who were before that time
exceeding numerous. Whole towns of
them were swept away, in some of
them not so much as one Soul
escaping the destruction."
– Increase Mathers

23. Smallpox and Settlement of Rhode Island
• The pre-contact epidemics which swept
New England before 1620 missed the
isolated Narragansett along the cast and on
the islands of Narragansett Bay.
• They emerged from this disaster as the
dominant tribe in southern New England.
• By 1620 the Narragansett had already
experienced contact with Europeans and
traded with the Dutch at Fort Ninigret in
Charlestown
• In 1633 the Narragansett experienced their
first smallpox epidemic; lost 700 of their
people
• A second epidemic struck in 1635, the year
before Roger Williams arrived and
purchased land near a major Narragansett
settlement in Providence
1636 conveyance of
land from the
Narragansett tribe to
Roger Williams

24. Smallpox and King Phillip’s War
• In the wake of the mass movement
of both Natives and English during
King Phillip's War, a smallpox
epidemic struck southern New
England, as noted in Boston
records.
• But given that nearly every building
on the mainland in Rhode Island
had been damaged or destroyed
during the war, it is not surprising
that an outbreak of smallpox was
overlooked (or records of it lost) at
a time when most inhabitants were
homeless and the colony nearly
destroyed.
• It is important to note that Rhode
Island's seventeenth-century
records are spotty even in times of
health and prosperity.

25. Smallpox in RI 1690
• The first major
(recorded) outbreak
of smallpox among
white RI settlers, in
the wake of the
Glorious Revolution,
brought the RI
government to a
virtual standstill in
1690

26. • An outbreak of
smallpox in 1717
similarly affected
meetings of the
General
Assembly.
Smallpox in RI 1717

27. • An ACT to prevent the spreading of the
Small-Pox and other contagious
Sickness in this Colony (1721)
• Based on Feb. 1711 An ACT, to Prevent
the Spreading of Infectious Sickness
• Amended in 1743 and 1748
Smallpox Laws in Rhode Island

28. Smallpox Laws in Rhode Island
• An ACT, to Prevent the
Spreading of Infectious
Sickness, the first RI
law to address the need
to contain the spread of
infectious disease, was
passed in February
1711, in response to the
potential for ship-born
contagions
• Smallpox quarantines
were to be enforced by
“the justice of the peace,
or some combination of
governor, assistants, and
justices of the peace.”

29. Smallpox Laws in Rhode Island
• The first law to specifically address
the spread of smallpox – An ACT
to prevent the Small Pox being
brought into this Colony from
the Town of Boston, &c. (1721)
• Goods from Massachusetts to be exposed to sun and “Aired and Cleaned”
for 6-10 days
• Goods subject to forfeiture
• Cleaning supervisors
• Owners of goods to pay 5s per diem to clean goods
• Ships with smallpox on board must remain at least 1 mile away from shore,
and all passengers must remain on board or owners / masters fined £100
• All persons entering RI from MA had to remain at the border for 5 days or be
fined 40s; tavern owners had to report cases of smallpox or be fined £5

30. Smallpox Laws in Rhode Island
• In response to further
smallpox outbreaks in
Boston in 1729, Rhode
Island Governor Joseph
Jencks had copies of
Rhode Island’s 1721
smallpox law sent to
Rhode Island towns to
remind officials to obey
quarantine laws

31. An ACT to prevent the spreading of the
Small-Pox and other contagious Sickness in
this Colony (1748)
Sec. 1: statewide maritime quarantine of 1 mile; governor or assistant or 2 JPs issue
license to enter port or ship masters fined $400/ £60
Sec. 2. unlicensed individuals sent back to ship- £12 fine or 1 year in prison
Sec. 3. governor/justices send doctor to ship to make report
Sec. 4. town council to have vessel secured
Sec. 5 council to confine all on board or some pest-house
Sec. 6 goods suspected of exposure to infection cleaned/licensed
Sec. 7 JPs seize uncleaned / unlicensed goods
Sec. 8 Town council to set wages for cleaning, fix charges
Sec. 9 Stop mariner pay until requirements met
Sec. 10 penalty for entering from infected places
Sec. 11 taverns must report smallpox-infected boarders
Sec. 12 pest houses - guards & cleaning expenses
Sec. 13 JPs/council remove sick to hospital or quarantine in home
Sec. 14 no visitors to pest house or home of persons infected by smallpox /penalty
Sec. 15 punishments for deliberately spreading on purpose
Sec. 16 jailing of such persons
Sec. 17 physicians refusing to render aid at town behest - penalty

32. Smallpox outbreaks in South
Kingstown RI,1760s
• RI town councils were
empowered to deal quickly and
decisively with any outbreak of
epidemics disease
• Councilmen had vast powers
over ships, taverns, and their own
citizenry when it came to dealing
with small pox and other
contagions: from quarantine to
seizure of property and remedy in
court from any that defied the
council’s directives.
• The scope of the response
testifies to the extensive police
powers wielded by local officials
and to the deadly threat posed by
epidemic disease.

33. Grounding of the Pest Ship Nabby,
Point Judith RI, 1756
Fully Rigged Colonial-era Sloop
(Howard’s Encyclopedia of 1788, care of http://chickgeek.org/maine-shipwreck)

34. Smallpox Inoculation (variolation)
• First method used to immunize people against
smallpox
• Procedure dates to Medieval China c. 6th
century AD
• Chinese physicians ground dried scabs from
smallpox victims along with musk and applied the
mixture to the noses of healthy people

35. Smallpox Inoculation (variolation)
• In Ottoman Turkey: fluid from active smallpox pustules were inserted
into superficial scratches made in the skin.
• Pustules would develop identical to those caused by naturally occurring
smallpox, but usually producing a less severe disease than naturally
acquired smallpox.
• Italian physician Dr. Emmanuel Timoni of Constantinople wrote a letter
describing the method in detail which was later published in the
Philosophical Transactions in 1714

36. Smallpox Inoculation (variolation)
• 1718 Lady Mary Wortley Montagu,
inoculated her five-year-old son,
Edward Montagu, in Constantinople.
• After her return to England she had her
four-year-old daughter inoculated in
the presence of physicians of the royal
court in 1721
• Both variolations proved successful
• Despite opposition, variolation became
a mainstream medical treatment
across England.
• Statistics confirmed that variolation
was a safer alternative than contracting
smallpox naturally
• However, in the period that inoculated
individuals suffer from a mild version of
the disease, they are contagious and
can pass real smallpox on to people
without immunity
Portrait of Mary Wortley Montagu

37. Variolation in Colonial America
• Puritan minister Cotton Mather
learned about inoculation from his
slaves c. 1706, several of whom
had been inoculated in North
Africa prior to being brought to
America
• In 1714 Mather read Dr. Timoni's
article in Philosophical
Transactions
• Mather tried variolation in 1721
when Boston suffered a smallpox
outbreak although others strongly
opposed the idea.

38. Arguments against Cotton Mather’s
inoculation program were mostly religious
• Inoculation was not mentioned specifically in the
Bible.
• Many Puritans viewed inoculation as a direct
affront to God's right to determine who was to
die and how and when death would occur.
– Belief that smallpox was punishment for the sins of
those who contracted the disease, or a punishment to
the community for those that had sinned (Covenant)
• Other’s argued that using the by-product of such
a deadly disease to prevent said disease was an
insult to logic

39. Smallpox and the American
Revolution
• Elizabeth Anne Fenn
Pox Americana: The
Great Smallpox
Epidemic of 1775-82
(2001)
• Fenn argues that the
Americans nearly lost
the Revolutionary War
because of smallpox

40. “THE Smallpox! The smallpox! What shall we do with it?"
- John Adams, June 1776
"Disease has destroyed ten men for us, where the sword
of the enemy has killed one"
- John Adams, April 1777
John Adams: Smallpox and the Revolution

41. Smallpox and the American
Revolution
• Smallpox was instrumental to the defeat
of the American expedition in Quebec
December 1775; Americans believed the
British deliberately infected them
"Smallpox was sent out of Quebec by Governor Guy
Carleton, inoculating the poor people at government
expense for the purpose of giving it to our army."
- Captain Hector McNeal
• Benedict Arnold reported that nearly 1,200 American
troops at Montreal were also suffering from
smallpox:
"From the 1st of January to the 1st of March, we
have never had more than seven hundred effective
men on the ground, and frequently not more than
five hundred.".
Benedict Arnold, March 30, 1776
In May 1776, British reinforcements forced
Arnold’s diminished army to retreat from
Quebec; the US invasion of Canada had failed

42. Smallpox and the American
Revolution
• Evidence that by December 1775 the British were
intentionally introduced smallpox among the
Continental forces laying siege to Boston and to
troops entering Boston after Evacuation Day.
• During the first year of the Revolutionary War,
Washington’s tactic of isolating army patients of
smallpox didn’t stop the disease; smallpox caused the
deaths of more Continental troops in 1776 than died
on the battlefield.
I have therefore determined, not only to inoculate
all the Troops now here, that have not had it, but
shall order [doctors] to inoculate the Recruits as
fast as they come in to Philadelphia.
- General George Washington, February 5, 1777
• inoculation was done in secret as Washington feared
that the British might take advantage of the situation
and attack.
• Before the end of 1777, nearly 40,000 troops had
been inoculated. In the year following the start of
mass inoculation, the infection rate from smallpox in
the Continental Army fell from 17 percent to 1 percent.
Washington “Was strongly attaced
[sic] with the small Pox” on a trip to
Barbados in 1751

43. Inoculation in the Early American
Republic

44. An ACT to prevent the spreading of the Small-
Pox, and other contagious Sickness in this
State (1798) added a section for inoculation
• The RI General Assembly’s attempts to legalize and encourage inoculation in 1772 were
met with intense opposition
• Town councils were given this independent authority in 1798 in order to bypass the
democratic tendencies of Rhode Island town meetings, which had a history of refusing to
allow inoculation programs enacted by the General Assembly

45. Local Resistance to Inoculation in
Rhode Island, 1800
• Despite the council’s
empowerment from the state,
the South Kingstown Town
Meeting had the final word on
small pox inoculations.
– September 25, 1800, the town meeting
enacted an inoculation program
– October 6, 1800, another town meeting
repealed the inoculation program
– The South Kingstown town council
never voted on the matter either way…

46. From Inoculation to Vaccination
• English physician Edward Jenner,
observing that milkmaids seemed
immune to smallpox, theorized that the
pus in the blisters that milkmaids
received from cowpox (a disease
similar to smallpox, but much less
virulent) protected them from smallpox.
• May 1796, Jenner tested his
hypothesis by inoculating James
Phipps with cowpox matter
• He later injected Phipps with smallpox
matter on several occasions; Phipps
never fell ill with smallpox. He was
immune
• The English medical establishment
deliberated at length over his findings
before accepting them.

47. Discovery of Vaccination

51. Vaccination in America
• Benjamin Waterhouse (born 1754,
Newport RI), studied medicine
extensively in Europe before
returning to Newport in 1781
• When he learned of Dr. Jenner’s
successful vaccination experiments,
Waterhouse immediately wrote to
then-President John Adams about
cowpox vaccinations
• When President Adams proved
unresponsive, he wrote a letter to
Vice President Thomas Jefferson
entitled "A prospect of exterminating
the smallpox.“
• Jefferson replied with a letter and
offered his support.

52. Vaccination in America
• Once Jefferson became President the
following year, Waterhouse introduced
Edward Jenner's method of cowpox
vaccination in the United States
• On July 8, 1800, Waterhouse inoculated his
5 year old son and others with a pure cowpox
vaccine which he had received from
England.
– He then commissioned a controlled
experiment where he was Professor of
Theory and Practice of Physics at
Harvard for the Boston Board of Health
– 19 vaccinated and 2 unvaccinated boys
were exposed to the smallpox virus
– The vaccinated boys demonstrated
immunity and the 2 unvaccinated boys
succumbed to the disease
• In an attempt to control access to the serum
to ensure its purity and effectiveness, he was
accused of trying to profit from the
procedure
Benjamin Waterhouse in 1833

53. Vaccination in America
• However, Waterhouse’s concerns would
be born out over the course of the 19th
century, and many Americans became
suspicious and fearful of vaccination
• Mix-ups between cowpox serum and
smallpox would lead to deaths rather
than immunity
• Attempts to cull serum from human
sources often led to the spread of
syphilis and hepatitis; opportunists sold
bogus serum; an outbreak of lockjaw
was traced back to cowpox serum taken
from a horse infected with tetanus
• In response to the tetanus outbreak in
which dozens of children died, Theodore
Roosevelt signed “An Act Regulating
Biologics” in 1902 to ensure a safe
supply of smallpox vaccine

54. Vaccination in America
• Vaccination was regulated by individual states,
the first to impose compulsory vaccination being
Massachusetts in 1809. There then followed
sequences of compulsion, opposition and repeal
in various states
• But vaccination was proven effective and over
the 1800s smallpox mortality rates declined
– 1854-1873: smallpox caused 170 deaths per million
persons
– 1874-1893: mortality declined to 8 deaths per million
• As periods between severe outbreaks grew
longer and longer, health officials often grew lax,
then a sudden epidemic would cause a panic

55. Brooklyn Life, 1894
New York Times, March 24 1894

56. US Smallpox Epidemic 1897-1902
• Much of the country had not seen an outbreak since the
1860s or 1870s
• Many (but not all) victims were infected with a milder form
of smallpox named variola minor
• Confused public and health experts alike
– Was it smallpox? (yes)
– Had variola major transformed into less deadly disease? (no)
– Did people still need to get vaccinated? (yes)
• Confusion over morbidity and issues with vaccine quality
led to much resistance to compulsory vaccination
programs across the US
• Ironically at the same health officials were met with stiff
public resistance in the United States, the US Naval
Hospital enacted mandatory vaccination programs in the
Philippines, Cuba and Puerto Rico that proved how
effective compulsory vaccination could be

57. Providence Medical Journal, March 1902

58. • The 1902
epidemic was
the last major
outbreak of
smallpox in
Rhode Island
1902 Rhode Island Color Atlas Map

59. Jacobson v. Massachusetts (1905)
• Pastor Henning Jacobson in Cambridge,
Massachusetts refused the vaccine stating it was an
"invasion of his liberty.”
– The fine for refusal was a $5 fine (equivalent to about
$130 today)
• Jacobsen appealed on the basis of the Fourteenth
Amendment, that the State was "restricting one aspect
of liberty" by forcing people to get vaccinated.
Jacobson had also argued that the law requiring
vaccination was "arbitrary or oppressive.“
• SCOTUS upheld the authority of states to enforce
compulsory vaccination laws. The Court's decision
articulated the view that the freedom of the individual
must sometimes be subordinated to the common
welfare and is subject to the police power of the state
• In 1922 in Zucht v. King SCOTUS ruled that schools
could deny admission to children who failed to provide
a certification of vaccination for the protection of the
public health The Old Senate Chamber is a room in
the United States Capitol that served as
the Supreme Court chamber from 1860
until 1935
Henning Jacobsen

60. Folklore Cures
• In spite of the proven effectiveness of the
smallpox vaccine, folkloric methods of treatment
and protection against infection remained
popular in the late 19th
and early 20th
century
• Such remedies included vegetarianism,
meditation, and numerous patent medicines
• Another especially popular remedy was treating
the disease with red objects and light.
– This therapy dated back to tenth century Japan and
was still in use in the United States in the early
twentieth century and in Europe through World War I

61. Dr. Charles Chapin and the
Modernization of Health Services
• Dr. Charles V. Chapin was an American
pioneer in public health research and
practice during the Progressive Era and
superintendent of health for Providence,
Rhode Island between 1884 and 1932.
• His popular reputation came from his strong
attacks on popular misconceptions, such as
that filth caused disease or that diseases
were indiscriminately transmitted through
the air by bad odors
• His scientific observations on the nature of
the spread of infectious disease gained
widespread support.
• His books The Sources and Modes of
Infection and A Report on State Public
Health Work Based on a Survey of State
Boards of Health influenced physicians and
public health officials across United States
and Europe
“As it takes two to make
a quarrel, so it takes two
to make a disease, the
microbe and its host.”
- Charles V. Chapin

62. Current Disease Quarantine Laws in Rhode Island
Quarantine
Generally.
R.I. Gen. Laws
2003 § 23-8; § 23-
8-4
Authority. If the state director of health, or his or her duly authorized agent,
determines, upon investigation, that a threat to the public health exists
because any person is suffering, or appears to be suffering, from a
communicable disease, the director or his or her authorized agent may cause
that person to be confined, in some proper place, for the purpose of isolation
or quarantine, until the threat to the public health has abated.
Governor's
Authority.
R.I. Gen. Laws 1956 § 23-8-18
The power to establish quarantine in this state shall also be vested in the
governor; and whenever the governor shall deem it advisable for the
preservation of public health and the prevention of the spread of infectious
diseases, he or she may, by proclamation, place under quarantine the whole
state or that portion of the state that he or she may deem necessary, and he or
she shall authorize and empower the state director of health to take any action
and make and enforce any rules and regulations that may be deemed
necessary to prevent the introduction and to restrict the spread of infectious
diseases in the state
Local
Authority.
R.I. Gen. Laws
1956 § 23-8-21
It shall be the duty of the several city and town councils to require their
officers to enforce the rules and regulations mentioned and referred to in this
section within their respective cities and towns.

63. 2017 Federal Quarantine
Regulations
• In the wake of the 2014-
2016 Ebola outbreak, the
US Centers for Disease
Control and Prevention
issued new regulations in
January 2017 that gave the
agency broad authority to
quarantine Americans
– However, state and local
authorities have, since the
founding of the republic, always
dealt with quarantines during
epidemics.
– This raises questions not just of
federalism but also of practicality.
– Local health departments have
staff and experience to set up and
manage quarantine facilities. The
CDC, whose main job is to provide
expertise, does not…

64. Smallpox Eradication

65. Smallpox Eradication
• Smallpox is the only infectious disease to have
ever been eradicated
• Smallpox was a good candidate for eradication
for several reasons
– The disease is highly visible: smallpox patients develop a rash that is
easily recognized
– The time from exposure to the initial appearance of symptoms is fairly
short, so that the disease usually can’t spread very far before it’s
noticed.
– Smallpox infects only humans. Unlike many other diseases smallpox
has no animal reservoir. Aside from the human population, it has
nowhere to hide.
– There is no such thing as a “carrier” of smallpox.
– People who survived smallpox naturally developed lifelong immunity
against future infection. For everyone else, vaccination was highly
effective.

66. Refrigeration and Air-Dried Vaccine
• Refrigeration was a key breakthrough keeping a supply of
potent vaccine in industrialized nations
• Still a problem in developing world – use of the “cold-chain”
only worked 30% of the time
• 1930s-1950s: process for manufacturing a stable freeze-
dried smallpox vaccine was perfected by Dutch, French and
British scientists
• Last outbreak of smallpox in US was in Texas in February
1949
• Scientists also discovered that the vaccine strain in use was
not even Jenner’s cowpox virus, but an orthopoxvirus that
did not exist in nature
– Named “vaccinia,” it is genetically distinct from both variola
and cowpox
– Source of vaccinia remains a mystery to this day

68. World Health Organization
Eradicates Smallpox
• After death of Stalin, USSR joined the WHO, began pushing for
smallpox eradication
• 1966 President Johnson decided that as part of International
Cooperation Year the US/CDC would join the WHO eradication
program
• The “bifurcated needle” replaced the US Army’s vaccine “injector
gun;” ease of use made vaccination almost foolproof

69. New Vaccination Strategy
• Old strategy: mass vaccination of 80% of
population, which created “herd immunity”
• New strategy: surveillance-containment
– Early detection of outbreaks
– Isolate smallpox patients
– Vaccinate everyone they came in contact with
– Create a “ring of immunized persons” around each
outbreak to prevent the virus from infecting new hosts
– Similar to the idea of a “firebreak” to stop forest fires

70. Dr. Donald Henderson
• In 1966 the United Nations World
Health Organization (WHO)
funded a campaign to eradicate
smallpox in all nations.
• American Dr. Donald Henderson
devised the strategy of
surveillance-containment and led
the WHO’s team
• “Henderson’s field workers…
trained not only in recognition of
the disease and in vaccination
techniques but also in such
mundane skills as truck-engine
maintenance. These self-reliant
teams ventured to the most
remote, inaccessible corners of
the globe” (Aronson).

71. Success!
• Surveillance-containment initiated in 1967
• In the early 1950s an estimated 50 million
cases of smallpox occurred in the world
each year
• Dr. Henderson’s team quickly eradicated
smallpox in just a few years
• The last major European outbreak of
smallpox was in 1972 in Yugoslavia
• The last naturally occurring case of
variola major was detected in October
1975 in two-year-old Rahima Banu of
Bangladesh
• The last naturally occurring case of
variola minor was diagnosed in Ali Maow
Maalin, a hospital cook in Merca,
Somalia, on October 26 1977
Rahima Banu
Ali Maow Maalin

72. Eradication!
• The last cases of smallpox in the world
occurred in an outbreak of two cases
(one of which was fatal) in Birmingham,
UK in 1978.
• Janet Parker (1938–1978), a British
medical photographer, was accidentally
exposed to a strain of smallpox virus that
had been grown in a research laboratory
on the floor below her workplace.
• Many people had close contact with
Parker before she was admitted to
hospital. The outbreak resulted in 260
people being immediately quarantined
• Of those potentially infected, only
Parker's mother contracted the disease
but survived.

73. The end of smallpox…?
• After Janet Parker’s
death in 1978, all
known stocks of
smallpox were
subsequently
destroyed or
transferred to two
WHO-designated
laboratories:
1. the CDC in
Atlanta and…

74. 2. The State Research Center of Virology and Biotechnology
VECTOR
Koltsovo, Novosibirsk Oblast, Russia
The end of smallpox…?

75. Public Health versus Democracy
A History of Smallpox in Rhode Island
Mark Kenneth Gardner
Archivist, Western Rhode Island Civic Historical Society
HistoryCamp Boston 2017
Suffolk University Law School
Boston MA
This presentation is
dedicated to my daughter
Inara Gardner, a true
Primary Source of
Inspiration if ever there
was one!

76. Bibliography
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Bartlett, John Russell. Records of the Colony of Rhode Island and Providence Plantations, in New England. Printed by
Order of the General Assembly. Ed. By John Russell Bartlett, Secretary of State. 10 vols. Providence: A. C.
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