Pox (8 page)

As the disease spread back and forth along the rivers, roads, and rails of the southern states, a growing inventory of popular sobriquets traveled with it. “Cuban itch,” some called it, or “Porto Rico scratch,” “Manila scab,” “Filipino itch,” “Mexican bump,” “Nigger itch,” “Italian itch,” “Hungarian itch,” “Camp itch,” “Army itch,” “Elephant itch,” “Kangaroo itch,” “Cedar itch,” “Bean pox,” or simply “Bumps.” These invented diagnostic names, which some physicians adopted, expressed the lack of alarm with which ordinary people greeted this highly contagious, obviously itchy, and occasionally fatal eruptive disease. They'd seen worse.
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Like the rumors that everywhere circulated about the new disease, the made-up names traced its origins, in a matter-of-fact way, to particularly salient features of the social and political landscape of end-of-the-century America. Americans continued the practice, already old when smallpox first exploded across Europe, of ascribing the foul scourge to rival powers, the wandering poor, and other scapegoats. Surely, the Americans said, the “itch” came from the exotic colonial frontiers opened by the war with Spain. Or from the rowdy work camps that had sprung up across the southern countryside, wherever logs needed cutting, tracks laying, or coal hauling. Or from the bodies of a formerly enslaved people, now moving about the region in search of work and a greater measure of freedom. Or from the new immigrants who steamed across the Atlantic from unfamiliar parts of southern and eastern Europe. But behind all of these names, and the tales of origin they told, lay an old foe. “In nine out of ten cases,” said Passed Assistant Surgeon C. P. Wertenbaker of the U.S. Marine-Hospital Service, “these prove to be smallpox.”
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The full scope of these southern outbreaks may never be known. Many localities—and even some state governments, such as Arkansas's and Georgia's—had no public health board, much less any system for tracking the incidence of infectious diseases. Even where active health boards existed, the diagnostic confusion caused by the new “mild type” of smallpox ensured that many cases went unreported. The people most vulnerable to smallpox, unvaccinated African Americans and poor whites, were the members of southern society least likely to receive professional medical care—or to volunteer information about kinfolk and neighbors to police and health officials. When health authorities declared an epidemic, the public record thickened, because that declaration obliged local governments to seek out and isolate all infected people and their known contacts. But the efforts of state health boards and the federal Marine-Hospital Service to keep tabs on smallpox invariably came up short. The vast majority of Southerners who contracted smallpox during these years probably went uncounted.
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Still, a visitation of this magnitude did not go unrecorded. Local newspapers, state health boards, and the federal Marine-Hospital Service tried to survey the damage to people, commerce, and local reputations. Smallpox struck every southern state from 1896 to 1900, affecting hundreds of local communities. The first reported outbreak of the mild type began in Pensacola, in the Florida Panhandle, on November 20, 1896: 54 people caught the disease, and no one died. The first major epidemic began in the summer of 1897, some 250 miles north of Pensacola, in the manufacturing center of Birmingham and the surrounding coal camps of Jefferson County. Within a year, Alabama reported 3,638 cases with 51 deaths (a case-fatality rate of just 1.4 percent). Meanwhile, smallpox broke out in every state in the old Confederacy, as well as West Virginia, Kentucky, and a few northern and western states. A Kentucky Board of Health bulletin observed, early in 1898, that the disease showed “an unusual tendency everywhere to break over official control and assume an epidemic form.” By the end of 1901, the board had counted 394 separate outbreaks; only 9 of the state's 119 counties escaped infection. All told, Kentucky reported 11,279 cases with 184 deaths (1.63 percent). From January 1898 to May 1903, North Carolina reported 11,735 cases and 331 deaths (2.82 percent). In other states the story was much the same. Almost everywhere, health officials wondered at the exceptional mildness of smallpox—and the fact that they seemed unable to get rid of it.
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Leading health officials, including Surgeon General Walter Wyman of the U.S. Marine-Hospital Service, warned local governments and the public that they could not afford to take mild smallpox lightly. Smallpox was smallpox. Mild or not, the disease still caused suffering and occasional death, and epidemics slowed local industry and commerce. No one knew what made the mild type mild, and no one could predict how long it would remain so. Given the scientific knowledge available to them, responsible health officials proceeded under the reasonable assumption that smallpox could regain its full lethal force at any moment. Trying to convey this concern to a skeptical and predominantly rural public, North Carolina health officials warned that mild smallpox might be planting the “seeds” for a truly horrific epidemic.
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The wisdom of such predictions seemed confirmed by localized outbreaks that claimed many lives. The experience of New Orleans, the South's largest city, was worrisome. The mild smallpox reached the city, reportedly in the body of a “negro steamboat laborer,” in February 1899. (The theory of origin would have shocked no one: almost every epidemic to reach New Orleans since its foundation had been traced to a sailor or riverman.) That year, the New Orleans Board of Health reported 283 cases and only 6 deaths (2.1 percent). But the following year, during what city health officials described as “an almost incessant battle” with smallpox, New Orleans recorded 1,468 cases and 448 deaths (30.5 percent). Mississippi weathered deadly winter epidemics in 1900 and 1901. In just the first six weeks of 1901, the state reported 2,066 cases and 456 deaths (a 22 percent fatality rate)—a greater toll, noted the
Atlanta Constitution
, than the dreaded yellow fever had taken there in any year since the great epidemic of 1878. Outside the South, lethal outbreaks occurred around the turn of the century in New York, Philadelphia, Boston, Cleveland, and other cities. In Boston and Cleveland, these epidemics, in which hundreds died, came fast on the heels of outbreaks of mild smallpox.
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The slow accumulation of epidemiological experience would eventually persuade public health officials that mild type smallpox was a distinct disease entity. In 1913, Charles V. Chapin of the Providence Health Department, one of the preeminent American health officials of the early twentieth century, published the first major scientific article on the history of mild type smallpox in the United States. Basing his article on the evidence from public health reports, Chapin suggested that the mild type “seems to be a true mutation” with a marked tendency to “breed true.” That is, mild type smallpox begot more of the same. Mild smallpox could still give rise, in susceptible individuals, to horrifying confluent smallpox; it could even kill. Infants, the elderly, and people with preexisting health problems were especially vulnerable. But, said Chapin, “tho it is possible that a few outbreaks of the severe type may have developed from the mild type, there is no conclusive evidence that they have been numerous, or extensive.” Twenty years later, Chapin stated his claim in stronger terms. Citing the belief of “practically all epidemiologists and health officers who have had experience with smallpox in the United States,” he wrote, “there is no proof that, during the more than thirty years the mild type has been with us, it has
ever
given rise to a permanent strain of the severe type.” That remains the consensus of smallpox scientists today.
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Experts now believe that
two
strains of mild smallpox appeared for the first time at the tail end of the nineteenth century. One probably arose in the southeastern part of North America (the Pensacola strain), the other a bit earlier in southern Africa. Laboratory studies would eventually show that the two regional varieties of smallpox had different DNA, but their clinical and epidemiological characteristics were so similar that scientists created one term to cover both:
variola minor
. Classical smallpox was given a new name:
variola major
. Until the advent of genetic testing, the only sure way to tell variola minor from variola major was to count bodies. Variola minor was defined in the scientific community as that form of the virus that killed between 0.1 percent and 2 percent of its victims.
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Since the 1910s, the North American strain of variola minor has been referred to by its Brazilian name,
alastrim
, a Portuguese word that means “burns like tinder, scatters, spreads from place to place.” The name encapsulates its global history. Since many of its victims remained ambulatory, and because so much of the U.S. population at the turn of the century moved around the country in pursuit of work and profit, alastrim spread with unusual speed over great distances. From its likely southern origin, it traversed the United States from 1896 to 1902, slipped into Latin America, England, and Europe, then made its way around the world. In other words, the disease so many Americans called “Cuban itch” was almost certainly a U.S. export.
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Variola major did not go away. The classical form of the virus apparently caused those deadly epidemics in New Orleans, New York, Boston, and elsewhere in 1900 and afterward. The virus in its deadliest form continued to infect and kill millions of people around the globe until the 1970s. In the United States, however, the incidence of variola major declined sharply after 1905. (The last major epidemic struck Ohio, Michigan, and western Pennsylvania in 1924–25.) After the turn-of-the-century epidemics, then, the mild type became the only form of smallpox most American communities would ever know.
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Government officials must often act in tight situations with imperfect knowledge. It's part of the job description. Health officials in the late nineteenth-century South were fighting, in real time, against a mysterious disease whose capacity for taking human life no one could predict. In their eyes, there was only one sure way to permanently reduce the dangerous threat of smallpox: universal vaccination. Experience quickly confirmed that Jennerian vaccination worked just as well against the new smallpox as it did against the old—which was all the proof most health officials needed that the two diseases were, in fact, one and the same.

Because of the diagnostic confusion that followed “the mild type” wherever it went, public health officials found themselves fighting a hard public campaign on many fronts. They had to persuade town and county officials, who held the purse strings, to appropriate scarce funds for smallpox control. They had to convince skeptical physicians that this new disease was smallpox at all. They had to protect their own communities from infection by neighboring towns where lax or inept officials let epidemics spiral out of control. And they had to get the people vaccinated. This last task would prove the most intractable. Public health officials used every available tactic to secure universal vaccination among citizens who detested the procedure and feared its results. Those political tactics included education, intimidation, and, with the aid of local police, criminal sanctions. Especially when they confronted opposition from African Americans, the authorities readily resorted to violent force.

Public health imperatives alone did not determine the impact of smallpox in the South. Particular features of the region's social and political landscape eased the spread of the mild smallpox and made its eradication extraordinarily difficult. Faced with an escalating public health disaster of regional scope, many local and state governments would turn for assistance to an unlikely ally: the federal government.

 

 

S
mallpox burned across the South, without respect for such man-made boundaries as county lines and state borders. Even the color line, which for a while seemed to hopeful whites to hold the virus at bay, proved an ephemeral barrier. As indifferent as smallpox was to such political and ideological boundaries, they did shape how Southerners and their governments experienced and battled the disease. The smallpox epidemics of the end of the century constituted an event of regional and, ultimately, national significance. But in a more fundamental sense, they happened locally. And mild smallpox proved at least as adept as the most devastating variola major of the past at revealing the true boundaries and character of a community.

One place in particular—Middlesboro, Kentucky—showed the nation in the winter of 1898 just how much damage even the mild type of smallpox could do under the right social and political conditions. An Appalachian mountain city of 3,500 souls, Middlesboro occupied a shallow valley at the northern end of the fabled Cumberland Gap, just a few miles from the spot where the borders of Kentucky, Tennessee, and Virginia met. The “Magic City,” as local boosters called it, was just ten years old. Already it stood as a stark monument to the creative destruction of industrial capitalism. Before the epidemic there ended, the city would stand for failings of a decidedly more personal nature.
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Middlesboro was “west” before it was “south.” In the late eighteenth and early nineteenth centuries, thousands of westering Americans passed through Cumberland Gap, the natural passageway in the Appalachian range made famous by Daniel Boone, on their way to the Kentucky bluegrass and the North American interior. But few stopped long in the three-mile-wide geomorphic basin known as Yellow Creek Valley. Railroad construction bypassed the area in the early nineteenth century, and the traffic through the Gap reversed itself; the historic gateway to the West became a muddy conduit for men driving hogs to market in Tennessee and North Carolina. During the Civil War, Union and Confederate forces fought for control of the Gap. The mountain people of neutral Kentucky would not soon forget how troops from both sides had stripped their hills and homes. After the war, Yellow Creek Valley and its hillside grew isolated again, home to sixty farm families who lived close to the land and seemingly beyond the reach of the industrializing society of the United States.
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