Pandemics End When We Stop Caring About Their Victims

Posted by on June 9, 2021 8:00 am
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In the years after the Civil War, smallpox spread throughout the South, mainly infecting Black people. The story of an outbreak of a disease long since eradicated may seem remote from our own times. But the smallpox epidemic of the 1860s offers us a valuable, if disconcerting, clue about how epidemics end.

Terms such as pandemic and epidemic are biomedical explanations designed to define suffering and inordinate mortality, but they also have a narrative element embedded within them. They offer a beginning and an ending, characters and settings, rising action and falling action, conflicts and themes. As the Harvard historian of science Charles Rosenberg puts it, an epidemic is “an event” that has a “dramaturgic form.”

Epidemics, according to Rosenberg, “proceed on a stage limited in space and duration, follow a plot line of increasing and revelatory tension, move to a crisis of individual and collective character, then drift toward closure.” Statistical evidence suggesting that cases are declining gives way to a narrative that an epidemic is ending. But a focus on the overall number of cases may fail to attend to the fact that those who are continuing to get infected are typically the most marginalized.

[Jim Downs: The epidemics America got wrong]

The smallpox outbreak in the 1860s had an unequal impact. White people had the support of religious communities, municipal relief organizations, charities, friends, and families to protect them from the virus, so their rate of infection was lower. The federal government, focused on the smallpox epidemic’s denouement, neglected to address a series of outbreaks mostly among poor Black people that lasted for decades.

From the point when smallpox first appeared among formerly enslaved people in an abandoned lot in Washington, D.C., in 1862, not far from where President Abraham Lincoln drafted the Emancipation Proclamation, the course of the outbreak depended on how those in power decided to narrate it. The refusal of the federal government to acknowledge the smallpox epidemic rendered it virtually nonexistent. The Medical Society of the District of Columbia condemned the government’s neglect. “It is generally admitted that small-pox is one of the diseases due to domiciliary circumstances, and is at all times a preventable disease,” the physicians argued. “It has been stated over and over again by eminent authorities, that there need not be a single case of small-pox in any city; if the authorities will but take the proper steps to check it.”

Red Cross workers in 1918.
The St. Louis Red Cross Motor Corps during the 1918 influenza epidemic. (Underwood Archives/Getty)

As more formerly enslaved people liberated themselves from farms, homes, and plantations in Maryland and Virginia and sought refuge in the nation’s capital, the infection rate increased.

Smallpox victims burned up with fever, collapsed with fatigue, and became covered with red spots that morphed into pus-filled blisters.  Witnessing the arrival of formerly enslaved people to Washington amid these circumstances, Elizabeth Keckley, who served as a seamstress for the first lady, Mary Lincoln, noted, “Poor dusky children of slavery, men and women of my own race—the transition from slavery to freedom was too sudden for you! The bright dreams were too rudely dispelled; you were not prepared for the new life that opened before you.”

While Keckley observed the impact of the outbreak, Lincoln ignored it. He made no provisions in the Emancipation Proclamation for how formerly enslaved people were to find food, shelter, clothing, or, most urgently, protection from smallpox. He framed the proclamation as an outgrowth of military necessity, to deplete the southern economy and labor force. With no quarantine restrictions, the virus seeped out of Washington and infected the rest of the South. In South Carolina, close to 800 freedpeople succumbed to the virus in one week during the summer of 1865.  

[Read: The last smallpox patient on earth]

When the war ended in April 1865, newspaper headlines roared with the announcement of Union victory. These boasts of triumph dwarfed any references to smallpox. But for many in the postwar South, smallpox was hard to ignore. James E. Yeatman, the president of the Sanitary Commission, a civilian corps that responded to the poor health conditions in Army camps, called for the federal government to acknowledge the epidemic: “Small-pox has had its appearance at several posts and in one of our hospitals; every precaution has been taken to prevent it from spreading, but, in order to arrest and mitigate the horrors of this dreaded disease it is necessary that some obligatory order be issued to colonels of regiments, holding them responsible for the prompt execution of the same.”

Congress took notice of smallpox only when military officials began trying to recruit formerly enslaved people to return to the South to replant the profitable cotton crop—and came up short. In 1865, Congress established the first-ever system of federal medical care in the South, known as the Medical Division of the Freedmen’s Bureau, to respond to the smallpox outbreak. The Medical Division comprised 40 hospitals and employed 120 physicians.

The bureau’s record keeping triggered the press to begin reporting on the disease, signaling the official beginning of the smallpox epidemic. “The mortality of the Negroes in and near large towns and cities still continues to be very great,” The New York Times wrote in 1866. “The small-pox rages among them.” The New York Herald added that in Savannah, Georgia, although “whites have not entirely escaped, the number of cases yet developed is quite small and of a mild type,”  among the formerly enslaved population, “the disease travels almost with the speed of an epidemic.” The reporting on an outbreak can give the false impression that it is recording the start of a disease’s spread, but actually it’s just the start of the narrative. And like all stories, it needs to have an ending, even if the biological assault of the virus continues.

In 1866, many in the United States believed that the smallpox epidemic would end with the extinction of the Black population. “There has been considerable speculation as to the effect of freedom upon the physical condition of the former slave. By many it is thought that his ultimate fate will be that of the Indian, and for this opinion there seems to be some ground,” a reporter for The Nation posited. “That mortality and disease are largely on the increase cannot be doubted: of this fact I am assured by leading physicians, and the statistics would seem to confirm this statement.”

Even before the development of germ theory and virology and epidemiology, statistics gave medical and governmental authorities in the British empire and later in the U.S. a means to make sense of an epidemic. Counting the number of people infected and the number who died was a way of assigning order and logic to the confusion and terror that infectious disease engendered. Once the numbers declined, the statistics signaled the end of the story.

When Freedmen’s Bureau medical officials reported a slight decline in the number of smallpox cases in 1867, authorities determined that the epidemic had ended and decided to close the makeshift hospitals that had been used to quarantine the infected patients. Yet the statistics failed to capture the number of people outside the bureau’s purview who were still falling ill. Because smallpox is easily spread by human contact, the numbers spiked soon after the hospitals closed; without a hospital to shelter the infected, the epidemic increased. In February 1867, for example, six or seven weeks after federal officials ordered a hospital to be closed in western North Carolina, the virus returned, infecting more people than it had in its first wave.

[Elise A. Mitchell: The shortages may be worse than the disease]

Despite smallpox’s continued biological presence in the South, the federal government shifted its focus to a cholera pandemic that had originated in Asia, spread to Europe, and made its way across the Atlantic Ocean into Canada and the U.S. Unlike smallpox, which many in power believed was primarily a threat to formerly enslaved people, cholera was recognized by the medical authorities as a threat to the entire population. The surgeon general’s office called for sanitary measures and collected reports from officials stationed throughout the South, mostly in the military, who described their efforts to control the spread of the pandemic.

Meanwhile, smallpox continued to plague Black communities throughout the 19th and early 20th centuries. The outbreak never had a definitive end date; the only semblance of an official ending came more than a century after it began, in 1952, when the CDC declared that smallpox had been eradicated in North America.

What ended in 1867 was the narrative about smallpox, not the virus itself. Throughout the rest of the 19th century, officials warned about the epidemic’s continuation. In 1898, medical authorities in Kentucky warned physicians, public-health officials, and citizens about the threat of smallpox moving into the state, noting that it was “clearly prevalent amongst the negro population” and “widespread in Eastern Tennessee, North Carolina, Southwestern Virginia and Northern Alabama” as well as in Middlesboro, Kentucky, and Jellico, Tennessee, along the Kentucky border. Five years later, in 1904, Hiram Byrd, a physician who had served in the U.S. Medical Corps and later established the Florida Tuberculosis Sanatorium, photographed an unnamed Black male patient with smallpox, offering evidence of the epidemic miles away in Walton County, Florida.

The smallpox epidemic can help us understand how the coronavirus pandemic will end. The declining infection rate and rising vaccination rate have already set the stage.

From the beginning, the facts and numbers concerning the coronavirus have been fashioned into narratives. Some Americans cast Donald Trump as the villain and Anthony Fauci as the hero; others saw Trump as heroically battling bureaucrats like Fauci. Feuding over masks, shutdowns, and vaccinations further intensified the impulse to see the pandemic as a story of good versus evil. Though there is indeed a biomedical reality to all of these points—leadership matters; prevention protocols matter—an unspoken narrative element has been at work as well.

If we don’t recognize this narrative element, we will allow the pandemic’s story to end prematurely—and once again, the most vulnerable populations will suffer. The pandemic will be declared over. But in some communities, the infection will rage on, even as the continuing story goes untold.

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