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Public Health Versus Democracy: A History of Smallpox in Rhode Island

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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.

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Public Health Versus Democracy: A History of Smallpox in Rhode Island

  1. 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. 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. 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. 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
  5. 5. 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
  6. 6. 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.
  7. 7. 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.
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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.
  12. 12. 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.
  13. 13. • Variola major • Orthopoxvirus • brick-shaped • 200 nm wide • 250 nm long The Virus
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. Cycle of Infection: Stages of Rash
  18. 18. Smallpox in Colonial New England
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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.
  23. 23. 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
  24. 24. • An outbreak of smallpox in 1717 similarly affected meetings of the General Assembly. Smallpox in RI 1717
  25. 25. • 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
  26. 26. 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.”
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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.
  31. 31. 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)
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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.
  36. 36. 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
  37. 37. 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
  38. 38. “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
  39. 39. 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
  40. 40. 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
  41. 41. Inoculation in the Early American Republic
  42. 42. 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
  43. 43. 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…
  44. 44. 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.
  45. 45. Discovery of Vaccination
  46. 46. 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.
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. Brooklyn Life, 1894 New York Times, March 24 1894
  51. 51. 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
  52. 52. Providence Medical Journal, March 1902
  53. 53. • The 1902 epidemic was the last major outbreak of smallpox in Rhode Island 1902 Rhode Island Color Atlas Map
  54. 54. 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
  55. 55. 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
  56. 56. 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
  57. 57. 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.
  58. 58. 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…
  59. 59. Smallpox Eradication
  60. 60. 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.
  61. 61. 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
  62. 62. 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
  63. 63. 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
  64. 64. 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).
  65. 65. 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
  66. 66. 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.
  67. 67. 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…
  68. 68. 2. The State Research Center of Virology and Biotechnology VECTOR Koltsovo, Novosibirsk Oblast, Russia The end of smallpox…?
  69. 69. 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!
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