Detail from Chicago Department of Health vaccination poster, produced by the Works Progress Administration, late 1930s (Library of Congress).


Responding to Infectious Disease

As the Zika virus spreads across the Americas, it’s worth looking at how the U.S. has responded to past epidemics. In this episode of BackStory, the hosts consider the impact of smallpox on New York City’s 19th century immigrant communities, and explore the rampant spread of diseases in the wake of the Civil War and the first World War.

00:00:00 / 00:00:00
View Full Episode Transcript

BRIAN: This is BackStory. I’m Brian Balogh. As the Civil War ground to a halt, the journey for millions of former slaves was just beginning. A smallpox epidemic was ravishing their camps, a terrible scene made more terrible by the callous attitude of their white neighbors.

JIM DOWNS: Some people fall back on this popular fiction of the 19th century that black people would go extinct if freed.

BRIAN: 40 years later, people in the margins were again dying from smallpox, this time in New York. But the response was different. Doctors and police officers burst into immigrants’ homes to vaccinate them by force.

MICHAEL WILLRICH: With mothers trying to hide sick babies, with men actually brawling with health officials and police to prevent them from scraping their arms and running the vaccine into their arms.

BRIAN: Today on BackStory, a history of epidemics, what has the government done and not done to stop contagious disease?

PETER: Major funding for BackStory is provided by an anonymous donor, the University of Virginia, the National Endowment for the Humanities, and the Joseph and Robert Cornell Memorial Foundation.

ED: From the Virginia Foundation for the Humanities, this is BackStory with the American Backstory hosts.

BRIAN: Welcome to the show. I’m Brian Balogh here with your co-pilot, Peter Onuf.

PETER: Hey, Brian.

BRIAN: The two of us are flying without our third co-host, Ed Ayers. He’s been down for the count with a nasty bug, and he’s not the only BackStory staffer sounding a little more frog-like this week. And as I look out from our studio, it seems to me that we’re at the peak of flu season. The reports have it that this year hasn’t been as bad as previous seasons.

In any case, we figured it would be a good time to dust off an old episode from our archives, in which we took on the history of contagious diseases. We were especially interested in the changing patterns of the government’s response to disease. And Peter Onuf here started us out with a story from the time when if I said germ theory, you’d probably think I was talking about a way to grow wheat. Here’s Peter.

PETER: It’s 1793, the dog days of summer, and we’re in Philadelphia. And I want you to get a picture of Philadelphia as a city, as 50,000 people, in those days the biggest city in the USA. And it’s the country’s capital, folks. It’s kind of smelly. It’s nasty, noisesome, unhealthy. And the people live so close together that when the disease comes, it comes on strong.

BRIAN: Yeah, what is the disease, Peter?

PETER: Well, people don’t know. I’m going to give you the description of poor Mrs. Parkinson, an Irish woman. She had severe head and back pains, great thirst, offensive stools, red spots on her face, blindness, sore throat, and hiccuping. And after all that, she died. But as she dies, she turns a particular hue of yellow.


PETER: Yellow fever, now you think, this is the nation’s capital. It’s where they got the best doctors, the most resources. They’re going to mobilize an effective response. But I got to tell you, 10% of the population– that would be 5,000 Philadelphians– die. And what does the government do? It leaves town.

ED: And if the people in the government had stayed, what could they have done?

PETER: Well, they would’ve died too. I think that’s the real problem here is that in early America, there is so much mystery about these epidemics. You don’t know where they come from. Many Americans would think it’s an act of God. It’s beyond our control. You’re being punished for something. It is a great mystery.

So how do you respond to an outbreak? We think now you’ve got to send in the National Guard, and you’ve got to get the government to do stuff. But in 1793, we just don’t have that kind of capacity. We barely had the capacity to make war on other nation-states and kill people. We certainly didn’t have the capacity to keep people alive.

BRIAN: Well, today on the show, we’re going to take a closer look at how government response to disease epidemics has evolved since 1793, when authorities essentially threw up their hands and ran. But before we launch into the history, let’s take a minute and check in with an expert on the science.

DR. ROBERT GAYNES: OK, my name is Dr. Robert Gaynes. I’m a physician.

ED: Dr. Gaynes is an attending physician at the Atlanta VA who has spent decades working at the Centers for Disease Control and Prevention, the CDC. We called him to help us understand what some of the diseases we’re talking about today actually looked and felt like. We began with one that shows up in all three of our centuries, smallpox.

DR. ROBERT GAYNES: This particular virus had a long period of incubation, so you would be exposed to someone, and it would take almost two weeks for you to become sick.

ED: Dr. Gaynes says that first, smallpox looked like almost any other illness. You have a fever, fatigue.

DR. ROBERT GAYNES: But by day four or five into the illness, a skin rash would appear. And this was a very characteristic skin rash. They began as fluid-filled, raised lesions that we call vesicles.

ED: It was like really bad acne, but all over your body.

DR. ROBERT GAYNES: And unfortunately for people who survived smallpox, they would leave permanent scars.

ED: A lot of those scars were on the face and left people looking pretty disfigured.

BRIAN: So, with that in mind, we want to take a look at how people dealt with an outbreak of smallpox in the past. We’ve already heard how impotent government was when disease struck in early America. But by the 20th century, the pendulum swings back. Not only have public officials decided that it’s their job to protect the public from smallpox. They’ve also decided that it’s OK to use force to carry out that job.

Michael Willrich is in an historian at Brandeis University, and he described one episode in particular to me. It was a 1901 night raid on an immigrant neighborhood in New York City.

MICHAEL WILLRICH: Smallpox had been discovered up in the Italian neighborhood on the Upper East Side, where Italian laborers and their families were living in very, very close quarters. So they assembled– the health department, that is, assembled a vaccine squad, as they called it, of 125 physicians accompanied by 125 police officers.


MICHAEL WILLRICH: And they cordoned off this city block of tenement dwellings in the middle of the night, because they understood that the working people would be at home and asleep, hopefully. And they burst through doors demanding that everybody move into corners so that they could be inspected to see if they had, see the scars from a previous case of smallpox or had the visible vaccine scar on their arm.

And if they didn’t, they had to be vaccinated at once or they would be arrested. And it was just a really chaotic scene with mothers trying to hide sick babies from the health officials, with men actually brawling with health officials and police to prevent them from scraping their arms and rubbing the vaccine into their arms. It was a scene of almost extraordinary violence, all in the name of protecting New York City from an epidemic of smallpox.

BRIAN: And did New York City need to be protected? I mean, what was the danger here?

MICHAEL WILLRICH: So smallpox was really the deadliest killer in human history as far as diseases go. It killed as many as 300 million people in the 20th century alone. Typically–

BRIAN: Well, time out, 300 million people?

MICHAEL WILLRICH: That’s correct, worldwide.

BRIAN: That’s incredible.

MICHAEL WILLRICH: In a typical outbreak, 25 to 30% of the population afflicted would die of the disease. And this was a very serious outbreak. About 800 people died in the city of New York. So yes, it’s quite serious.

BRIAN: And where did it actually– am I remembering this correctly that the vaccine actually came from cows, infected cows?

MICHAEL WILLRICH: That’s where a vaccine gets its name. The vaccine material is live cowpox or vaccinia virus that is essentially harvested from infected sores on the underbellies of calves. So yeah, this stuff was pretty disgusting to contemplate.

BRIAN: That’s attractive, yes.

MICHAEL WILLRICH: It’s an attractive image. The vaccine itself that was used at the turn of the century was an unregulated commercial product. That is, the government compelled people to get vaccinated during epidemics in order to serve the public good. But the government did nothing at all to ensure that those vaccines used were safe and effective. That’s an enormous contradiction.

BRIAN: So if I’m understanding this correctly, Michael, you’re saying that those people who resisted might have had some legitimate reasons for doing so? Or is that–

MICHAEL WILLRICH: That’s exactly right. Even when it worked well and was not riddled with impurities, smallpox vaccine caused people to have a fever, to have a swelling and soreness of the arm, to feel seriously sick for a couple of days. Workers had good reason to fear that if they took the vaccine, they would lose their capacity to earn for a period of days or even weeks, thus depriving their family of their earnings.

BRIAN: I’m now going to appeal to the legal historian in you, Michael, and also I should say an expert on the progressive era, that period at the beginning of the 20th century where expertise and scientific knowledge was brought to bear on a whole host of social problems. How did this change your understanding of progressivism? And let’s limit it to this police raid in New York. How did that change your understanding of what progressivism was all about?

MICHAEL WILLRICH: Well, compulsory vaccination is kind of a emblematically progressive intervention, right?

BRIAN: Right.

MICHAEL WILLRICH: You are asking individuals to sacrifice some part of their liberty on behalf of the general public, on behalf of the welfare of the many.

BRIAN: Employing science to do it.

MICHAEL WILLRICH: And using science to do it, right? This is the science being practically applied for the good of society, a classic progressive innovation. And I expected there to be some resistance. I knew that there had been some lawsuits generated around smallpox vaccination at the turn of the century, some legal challenges.

I had no idea the extent of resistance. There were dozens of court cases, legal challenges to compulsory vaccination that took place at the state, local, and ultimately the federal level. There were candidates who ran for local school board offices on a platform of resistance to compulsory vaccination. Granted, many of their arguments were sort of anti-scientific, but they were arguing for an expansive idea of their legal and constitutional rights.

And we would see these kinds of arguments surface again in the 1950s and ’60s in the era of the so-called rights revolution. They are arguing for bodily integrity as a fundamental right of human beings under the Constitution. They are arguing for the rights of parents to make choices for their children without interference from the state.

They are arguing for religious liberty. They are arguing for bodily autonomy and medical freedom. Many of these kinds of arguments would come to the fore again in the realm of what we now call reproductive choice.

BRIAN: And we would label all of that very progressive today.

MICHAEL WILLRICH: We might. We might. And what it helped me to appreciate was the extent to which the modern administrative and welfare state, this new sort of social state that’s being created in the progressive era, and that we have all benefited from was nonetheless quite controversial in its own times and involved a lot of control over ordinary people that inspired a kind of reaction.

BRIAN: That’s Michael Willrich, professor of history at Brandeis University. He’s the author of Pox, an American History. It’s time for a short break. When we get back, 4 million people are granted their freedom. But that freedom leaves them very, very sick. You’re listening to BackStory. Don’t go away.

PETER: This is BackStory, the show that turns to history to help untangle the America of today. I’m Peter Onuf, the 18th Century Guy.

ED: I’m Ed Ayers, the 19th Century Guy.

BRIAN: And I’m Brian Balogh, 20th Century History Guy. Today on the show, we’re looking at how the authorities in the US have responded or not responded to outbreaks of contagious disease.

PETER: In the first part of our show, we looked at how an aggressive government response to smallpox at the turn of the 20th century sparked a fierce battle over civil liberties. Now, we’re going to turn the clock back just a little to the 1860s. It’s the midst of the Civil War, and Southerners are fighting on two fronts.

On the one hand, Perryville, Shiloh, Vicksburg, on the other, smallpox, an epidemic swept south from Washington, DC, in 1862. And for the next few years, the disease decimated military and civilian populations alike.

ED: Recently freed slaves were among the hardest hit. After emancipation, they could move freely for the first time in their lives. But as millions of freed people spread out across the South to escape the fighting, they nearly all lacked adequate food, water, shelter, and medical care. And it’s hard to imagine a situation really more suited for a catastrophic outbreak of disease. I recently sat down with Jim Downs, an historian at Connecticut College, to talk about this little-known episode in our nation’s past.

JIM DOWNS: What I started to think about was what did it mean for enslaved people to actually liberate themselves from Southern plantations? And so we have this triumphant narrative that they run away. But where do they run to? And where do they sleep? And where do they eat? And how do they survive?

And so oftentimes, yes, there were cases in which the Union Army offered them shelter behind Union lines. But then all of these questions developed. Where would they find clothing and food? And the army didn’t have the resources. And it wasn’t because the army was a pernicious institution. It just often didn’t have enough resources for their own men.

ED: Yeah, it wasn’t built for this purpose.

JIM DOWNS: It wasn’t built for this, exactly right. And so they don’t have the resources available. And so as a result, they enter into these various refugee and contraband camps where all of these men are already suffering from pneumonia and from various other epidemic problems, which is the reason why Northern reformers decided to organize the Sanitary Commission.

ED: So people who have not paid too much attention to Civil War might not know what a contraband camp is. Maybe you could describe that for us, Jim.

JIM DOWNS: The contraband camp is essentially this refugee camp that sort of develops in response to this question of these various former slaves who fled to Union lines throughout the war. And so what happens is throughout the South, in various Union camps, there are these makeshift communities that form around the perimeter of Union camps.

And they’re considered contrabands. This is the military’s term to refer to newly emancipated slaves. In large part, it’s because they really don’t know what to call them at that particular moment, so they refer to them with this term contraband.

ED: So if their owners are claiming that they’re property, they’re saying, fair enough. Now you’re property of war.


ED: Which is what contraband would mean, right?

JIM DOWNS: Right. This is the world of freedom. This is the world that emancipated slaves entered. And many of these emancipated slaves living in these camps are often forced to go from one camp to the next, and they’re constantly on the move.

And this form of dislocation accelerates the spread of disease. And then also at that time, it’s the mid-19th century, and there are conflicting understandings about disease causation.

ED: So they have some idea that cleanliness is good, but they don’t really know why.


ED: And one of the horrific stories that you tell– maybe we could focus on it a little bit now– is the smallpox epidemic that emerges in this period, right after, kind of overlaps with the end of the Civil War, then extends beyond it, right?

JIM DOWNS: That’s right. So I started to first uncover references of the smallpox epidemic in Washington, DC, in the winter of 1862. By 1865 and early parts of 1866, the virus moved from the upper South into the Carolinas, into the Sea Islands, where it was infecting well over– I mean, these numbers are outrageous– but well over 800 people a week.

ED: Wow.

JIM DOWNS: The military doesn’t know what to do. And some of the military officials try to quarantine these emancipated slaves. Yet at the same time, there’s an uncertainty on how to even, where to quarantine them. Some people fall back on this idea that of course black people are dying at this moment. It began to sort of fulfill their idea, this sort of popular fiction of the 19th century that black people would go extinct if freed.

So there aren’t efforts to isolate the virus or investigate it. And it’s so interesting, because if one case of smallpox broke out in either a Confederate or a Union camp, they immediately declared there was an epidemic. And they would follow–

ED: Among the soldiers.

JIM DOWNS: Soldiers, among the soldiers, right, they would immediately declare there was an epidemic, and they would try to follow either a quarantine, which is a basic form of isolating the infected person. Or they would even go into inoculation or vaccination, which were two rudimentary forms of trying to prevent the virus among other susceptible people. But there was something done. And you could argue about the medical efficacy of it, but there was some policy in place.

ED: They at least tried.

JIM DOWNS: They at least tried. Yeah, they at least tried.

ED: Now, what’s a person with smallpox look like? What are the symptoms, Jim?

JIM DOWNS: So this is one of the questions that I have throughout writing this book. And there are no references. I mean, there are no images of emancipated slaves with smallpox. I can’t find any. And I started to realize that part of it was that the people that were in the South that were interested in helping emancipated slaves did not want to promote that image to other people in the federal government or back to the north.

ED: Right.

JIM DOWNS: And that black people themselves completely understood that if their family members were seen as being infected with smallpox that this could be problematic. So they’re hidden. I mean, they’re hidden from people in the 19th century, and they’re hidden from historians today.

ED: Do you have any sense, Jim, of how many people were lost in the smallpox epidemics of the immediate postwar era?

JIM DOWNS: It’s so hard, because the numbers often contradict each other. The first part that I would say is that in the very early part of the war, there was no mechanism or protocol within the military’s bureaucratic structure to even track the mortality. So people were dying constantly and no one was keeping an actual count. I mean, my rough estimate– I mean, I don’t even–

ED: I’m not going to force you.

JIM DOWNS: Yeah, no, no. This is like a question that you would get when I was defending my dissertation, and I always tried to dance around it. But I can’t. I’ve got to do it.

ED: Sorry, I don’t want you to have a flashback here.

JIM DOWNS: No, it’s already, it’s already there. The flashback has happened. So I would argue that over a million we know sought medical care. There is one estimate that over 60 to 70,000 died from smallpox. I actually would put it higher. I would say probably at least a quarter million.

I mean, the doctors write constantly in panic that they can’t even keep accurate notes. And then when they do, they report 700. And then you have to say, how do you count 700 people? I mean, there’s just so many issues with this. But it definitely is a large portion.

And this is the other part that I’m trying to deal with in the book is that even for those who don’t die, for those who witnessed a death of kin, the death of other people in their community, they’re still left with the scars of the epidemic. And I think that that certainly shaped their transition into freedom, into emancipation, that even if they survived in good health, what did it mean for them to know that family members, members of their community died in this very ironic unexpected turn of liberation.

ED: In the first moments of freedom.

JIM DOWNS: In the first moments of freedom, yeah.

ED: Jim Downs is an assistant professor of history at Connecticut College. His new book is called Sick From Freedom, African American Illnesses and Suffering During the Civil War and Reconstruction.

PETER: Well, guys, this really powerful story about smallpox and the Civil War evokes for me, well, the American Revolution. Hey, we had freed people or people escaping slavery to join the counterrevolutionary cause. And the black people who gathered, well, many of them died. In fact, most of them died of smallpox.

And that connection between race, gathering people together, containing them, and death is very powerful. And it suggests to me too that we should not forget how dangerous war is, and not just on battlefields. And it’s really, if you want to know how humans have dealt with disease, well, they’ve been the pathogens’ best friends by creating the optimal conditions for the spread of disease.

ED: That’s great point, Peter, because what we see is that war in many ways is massive, immediate urbanization. Not only the armies are coming together with no real capacity to contain that many people, but now in the Civil War, the contraband camps and the desperate search for freedom that grew up around those armies created a particularly lethal environment. And that doesn’t stop with the Civil War. I believe that goes forward even to the 20th century, doesn’t it, Brian?

BRIAN: That’s right, and what we find in World War I is the very movement of the armies that fought World War I are going to be the carriers of one of the great epidemics of all history, and certainly of the 20th century. That’s the great influenza epidemic of 1918, otherwise known as the Spanish flu. And guys, before we go any further, I want to bring back our friend from earlier in the show, Dr. Robert Gaynes, the epidemiologist at the CDC.

DR. ROBERT GAYNES: And numbers vary a lot on this between, depending on who you talk to, 20, 40, or even 60 million people worldwide in that one year died from influenza. And that makes it in one year the worst epidemic in human recorded history.

BRIAN: Now, normally, the very old and the very young are hit hardest by the flu. You guys know that already. But in 1918, something strange happened. The group hardest hit was healthy young adults. Hospital wards were full of dying 23-year-olds. And that demographic anomaly matters because of what else was going on in 1918, World War I.

DR. ROBERT GAYNES: And if you were the malevolent public health official and wanted to create an environment that would facilitate transmission of influenza, you would create trench warfare. That was an absolutely perfect place for that virus to go.

BRIAN: Those 23-year-olds, not only were they especially susceptible to influenza. They were being concentrated in military barracks, where the disease could easily be passed from one to the next. And they were being shipped from military base to military base, both here in the States and around the world. Dr. Gaynes read to us from a letter written by an Army doctor describing the carnage left by the flu at a military base near Boston.

DR. ROBERT GAYNES: We have lost an outrageous number of nurses and doctors, and the little town around here is a sight. It takes special trains to carry away the dead. For several days, there were no coffins, and the bodies piled up something fierce. We used to go down to the morgue and look at all the boys laid out in long rows. It beats any sight they ever had in France, I’ll bet.

BRIAN: The 500-bed hospital where the doctor worked was in Camp Devens, Massachusetts. And a few weeks before he composed that letter, a trainload of soldiers from Camp Devens was transferred to Philadelphia. A number of them were already infected. BackStory contributor Catherine Moore is going to tell us the story of what happened next.

CATHERINE MOORE: Picture the Port of Philadelphia, 1918. Workers at the largest shipyard in the world are grinding out warships. Over at the Navy Yard, sailors are scurrying in what would be the final months of their efforts to beat back the Hun. A few blocks away, the streets are packed.

It’s not just any crowd. It’s a parade, a Liberty Loan parade kicking off the government’s latest effort to fill up its ware coffer. Each state must do its part to meet the country’s $6 billion goal.

MALE SPEAKER: If you can’t enlist, invest.

CATHERINE MOORE: A poster drives home the by-now familiar message that true patriots put their money where their mouth is.

MALE SPEAKER: Every Liberty Bond is a shot at a U-boat. Crush the Prussian. Buy a bond.

CATHERINE MOORE: At the parade, spectacles abound. People lean out of windows to see an aircraft hull rolling down the avenue. Warplanes fly overhead. Songs and speeches cajole people into buying bonds. And over at Willow Grove Park, John Philip Sousa strikes up his band. That was the scene on September 28. Three weeks later, over 12,000 Philadelphians would be dead from the Spanish flu.

Let’s back up. Philly’s ticking time bomb really begins on September 7, when 300 soldiers from flu-stricken Boston arrive at the Philadelphia Navy Yard. By the 15th, 600 sailors here report sick. And just in case you’re picturing a bunch of guys with ickiness and some fever, considered that symptoms from the Spanish flu included frothing blood, brown spots, bleeding from the eyes and ears, and turning blue, so blue in some cases that one doctor found it hard to distinguish between his black and white patients.

The Naval Hospital runs out of beds. Patients are sent to the civilian hospital, where 3/4 of the medical staff is overseas at war. Meantime, soldiers have left Philadelphia on boats and trains, crisscrossing the country. Many are gravely ill upon arrival. And all this time, Philadelphia authorities haven’t done much of anything except deny that there’s a threat at all.

And the press isn’t exactly helping to ring the alarm bell. The news of the day was often told with a cheerful spin as editors strained to keep up morale. In fact, the Spanish flu gets its nickname from the fact that Spain, a neutral country, didn’t censor the horrors of the epidemic in its papers. Finally, on the 18th, a PR campaign is launched. A polite poster is printed.

MALE SPEAKER: When obliged to cough or sneeze, always place a handkerchief, paper napkin, or fabric of some kind before the face.

CATHERINE MOORE: By the end of the epidemic, the signs would read–

MALE SPEAKER: Spitting equals death.

CATHERINE MOORE: There’s some pressure to call off the parade. But perhaps more than disease, authorities fear public panic. A panicked country, after all, can’t win a war. And so the parade goes forward, and hundreds of sailors from the flu-ravaged Navy Yard rub elbows with a crowd of 200,000 that stretches for miles.

Within 72 hours, about the time it takes for the flu infection to develop, every hospital bed in the city’s full. And over the next several weeks, 12,000 Philadelphians will die. Wagons will roam the streets, medieval style, collecting the dead. Corpses will be stacked in tenement hallways. They’ll be buried in mass graves with steam shovels.

In the end, six times as many Americans would die from the flu than on the battlefield in World War I. But when the nation wrapped up its bond drive on October 19th at roughly the peak of the epidemic in Philadelphia, the country had met and exceeded its war bond quota.

PETER: That piece comes to us from reporter Catherine Moore. You can hear more of Catherine’s pieces on our website,

ED: That’s some powerful stuff, isn’t it, Peter?

PETER: Mm-hmm, yeah.

ED: It sounds a lot like what we were talking about earlier in the show about the epidemic in Philadelphia back in 1793. What’s changed?

PETER: Well, what’s striking is government could do nothing then, and it could do nothing in World War I. But there was capacity in government. In fact, that’s part of the problem, isn’t it, Brian? I mean, they could mobilize all those people.

BRIAN: We did. And look, we were very slow to mobilize for World War I. Let’s not kid ourselves. But once that mobilization got going, it was a juggernaut. And you can hear that in Catherine’s piece. $6 billion for a bond drive, millions of Americans contributing it. So a lot has changed, but it turns out that this function can be just as lethal as heading for the hills back in your days, Peter.

PETER: Yeah, well, we’re talking about urbanization and density in this instant cities. In a way, public health measures had made cities safer, but this was bringing people together on the streets. And that was just an incubator of contagion.

BRIAN: It’s time for a short break.

PETER: If you have a question about epidemics and how Americans have handled them, shoot us a message on our website. You can also weigh in on future topics. That’s We’ll be back in a minute.

BRIAN: We’re back with BackStory, where today’s debates find some context in American history. I’m Brian Balogh, 20th Century Guy.

ED: I’m Ed Ayers, the 19th Century Guy.

PETER: And I’m Peter Onuf, 18th Century History Guy. Today on our show, a history of epidemic disease. As we do with each of our shows, we’ve been inviting your comments and questions on and on Facebook. Today, we’re calling up a few of the folks who left us a note.

We’ve got Chivani on the line from Providence, Rhode Island. Chivani, welcome to BackStory.


PETER: So what’s on your mind today?

CHIVANI: So I’m a graduate student in health economics. So I’ve taken a few epidemiology classes in the last year, and I was struck by how difficult it can be to identify who is in the need of most help following a disaster or an epidemic. So I was wondering if you could talk more about the process of how they allocate who gets care and who doesn’t.

PETER: Yeah, great question, how do we allocate health care? How does that happen now? Of course, that’s a current events question. We’re going to try to give it some deep background. Ed, Mr. 19th Century, what do you say?

ED: I think there were two criteria back in the 19th century. One, who could afford it, and two, who posed a threat to those people who did have those resources. I generally try not to be cynical and generally succeed in not being cynical. But health care in the 19th century is a pretty clear example of those who have taking care of themselves and taking care of the other people when they have to.

PETER: Yeah, that’s certainly true, Ed, in the 18th century as well. It maps on pretty neatly to the social order that maybe the great achievement of Brian’s 20th century is to begin to pick that apart and to come up with new conceptions of disease and where you need to intervene. I mean, how are you going to stop the spread of a disease? In some ways, you have to go to the poor people first, right?

BRIAN: Yeah, well, a couple of things happen in the 20th century, Chivani. We treat people that we can get our hands on because they are in public spaces. So there are huge campaigns in the 20th century to vaccinate school kids. Why? Because it’s in my century that we start requiring people to go to schools.

That’s where the potentially diseased people are. That’s where we can access them. And it’s really not until quite recently that we started getting all of these vaccinations in doctors’ offices and private spaces. And the great irony is that, too, is changing, as you probably know, Chivani, if you’re in public health. Now you can get vaccinated in Walmart or CVS.


BRIAN: The privacy of vaccination is morphing yet again back towards these public spaces and back towards some of the things that Ed and peter were talking about, the people who can afford to do it.

PETER: Yeah, I want to throw something out for Ed, and that is the idea of the analogy of fire fighting. Early firefighting, the 18th and your century is the big fire century, all those wood buildings and growing cities. That’s a case where you have to intervene in ways that’s going to stop the spread. And it doesn’t matter who’s in your way. I wonder, is that a model for what becomes public health delivery?

ED: Yeah, and it’s a healthy model, so to speak, Peter, because it reminds me– this is not necessarily that people were worse in the 19th century. As Brian was suggesting, they simply did not have the capacity of understanding the origins of disease or what they would do if they did try to minister to people. And of course, sometimes the worst thing that could happen was to be ministered to with leeches, and bleeding, and all that.

PETER: Well, it was, true. Yeah.

ED: So I think that in some ways the idea that you could actually do something for an entire population about health is a very recent innovation.

PETER: Yeah, good point.

ED: And even now is deeply contested, So, Chivani, what do you think? Are you and your classmates filled with a sense that we’ve crossed some kind of bridge, and now we have a sense of how to really intervene in a useful way?

CHIVANI: Well, I think you’re right that there is that assumption that we do know what we’re doing as public health workers.

ED: Thank goodness.

CHIVANI: And the way public health is taught, I think we still have this faith that most actions are based on evidence. There is evidence-based medicine, and most public health practices do reflect the most current research. So there is still that faith that when we intervene, it’s to better social welfare.

PETER: Yeah, I got a question for you, Chivani. And maybe you don’t want to say this on national radio, but what do public health people think about the people in general? Do they sometimes think that they’re ignorant, bigoted, and reactionary?

CHIVANI: It depends on who you talk to. I think if you are talking more in the developing world, I think there is kind of a lot of looking down at the masses and prescribing what we think would be best for everybody. When it’s more about the developed world, it seems that people do take into account cultural norms and education.

PETER: Yeah, what an upbeat characterization of the American people. I love to hear it. You’re reviving my faith in democracy. Brian?

BRIAN: Well, one of the things I love about American history, Chivani, is for much of it, we are a developing country.

CHIVANI: Right, I agree.

BRIAN: And I think so much of what Ed and Peter had to say kind of demonstrates that.

PETER: Chivani, thanks for your call. It’s been fun talking to you.

BRIAN: Thanks a lot.

CHIVANI: Yeah, great, thanks for taking my call.

BRIAN: Bye bye.

ED: Sure, bye bye.

BRIAN: This is BackStory. If you’re just tuning in, we’re talking about the history of contagious disease in America.

PETER: And we’ve got Peter on the line from Montpelier, Vermont. Peter, welcome to BackStory.

PETER (CALLER): Thank you very much.

PETER: So what’s your question?

PETER (CALLER): Well, my question is the relation between disease or public health and immigration through our history.

PETER: Well, you have hit the big one, Peter, that is disease and immigration. Many people throughout American history would have said it’s the same thing.

ED: That’s right.

PETER: Yeah.

ED: Well, let’s go back to the beginning, Peter.

PETER: Yeah, OK.

ED: Let’s think about 17th-century Virginia. Goodness gracious, to be immigrant was to be dead, basically, wasn’t it?

PETER: Yeah, and of course, but then it was clear, because of course the immigrants were the settlers, the slave holders, the Indian killers. But they didn’t bring disease. They got hit by the diseases when they arrived. The big story of early American history is that immunities for smallpox and other contagious diseases which Europeans had earned over the millennia, they didn’t have them in native America.

And so you had a vast killing off of native populations, up to 90% of New World population. So in some ways, it’s the locals who are killed by the immigrants in the early period. But that idea lingers on in many ways. And of course once a population is established, the European population– that is the largely Northern European if not British population is established– then there’s great concern about foreigners bringing in not only their nasty habits, their foreign ideologies, but also diseases.

ED: You’re right. And the 19th century was the great century of massive immigration, from the Irish coming in who were seen as diseased and bringing not just unhealthy bodies, but unhealthy habits and neighborhoods with them. Where they came, they created places where diseases would flourish. And so on the other coast, the Chinese coming in were seen as especially dangerous.

European Americans were at least European at one time. But Chinese immigrants were bringing these kind of Asian diseases that seemed especially frightening. And in fact, at the turn of the century the plague comes to San Francisco and is seen as the great warning of what happens if we don’t curtail immigration from Asia. So all the way from the Irish in the early 19th century to the Chinese at the end of the century, it’s perceived that the immigrants are just bringing one wave after another of health problems.

BRIAN: Yeah, and what I would add to that in the 20th century is that we begin to use this very longstanding association between immigrants and disease as a substantive basis to cut off systematically the flow of immigrants into the United States. One of the arguments behind the Immigration Restriction Acts of the 1920s is that these immigrants are bringing diseases, epidemics, and what we would call today more genetically defined diseases, such as imbecility, that kind of thing, mental retardation we would have called it in the 1950s.

And the other thing that happens in the 20th century is that we target immigrant neighborhoods for the eradication of disease. So they’re here, but when there’s an outbreak of an epidemic, it’s usually the immigrant neighborhoods that are targeted.

PETER: But I think it’s important to suggest that the very fact that government gets involved the way Brian suggests as a response to immigration and the pathologies associated with it means that that’s the threshold of genuine, substantive exploration of public health issues. So in some ways you’ve got to start with these less than honorable passions, and concerns, and reflexes. And that’s the energy that’s channeled toward real improvement. I think that’s maybe the upbeat way to formulate that.

ED: So what do you think, Peter? Have we begun to address some of your curiosity about this?

PETER (CALLER): You have. It’s very helpful. It plays into the politics. It plays into the reality of both 18th, 19th century American science and what we knew about public health at the time, right up to the present. It has a moral aspect to it as well as a political one.

PETER: Yeah, hey, Peter, thanks.

BRIAN: Thanks, Peter.

PETER (CALLER): I appreciate it.

ED: Thanks a lot.

PETER (CALLER): Thank you.

PETER: Our last caller today is going to be Jhanavi. She’s in Saint Petersburg, Florida. Jhanavi, welcome to the program.

JHANAVI PATHAK: Thank you, professors.

PETER: Hey, whoa, we like those honorific titles. They make us feel really important. So, Jhanavi, we’re talking about disease. Share with us.

JHANAVI PATHAK: I am really excited about today’s topic. Not that I’m excited about disease, but my family, my father has been fighting cancer for the past eight years. And I started a nonprofit called the War on Cancer Foundation.

And a lot of thought went into what name we wanted to use. So it was a really deliberate choice. And I know why we use specific language, but given today’s topic, I would love to hear from you about the history of language in discussing sickness over the years as a war or a race.

PETER: Yeah, Jhanavi, a wonderful question that is the use of language to shape perceptions, ways we think about disease as a conquering host that we need to resist. And in a way, the response to disease, even back in my benighted period, was that the state had to step up and exercise what were then called police powers to maintain public health by keeping diseases out. They didn’t know how they traveled, but they knew they were coming.

For instance, the yellow fever, that came from the Caribbean. So you’re going to have to block trade, because somehow or another, this disease comes with that lucrative trade to the Caribbean. So war has been the trope of choice throughout American history. And we can see in that historic context why you would call your organization a war against cancer.

BRIAN: Yeah, Jhanavi, there’s a very noble tradition of wars on cancer that go back to the early 1950s. This is Eisenhower and some of his advisers who, in the wake of the tremendous success of World War II, decided to use that wartime metaphor to take on your topic, to take on cancer. And they called it a war on cancer.

And they invoked the success of the Manhattan Project and mobilizing federal research and development to defeat an implacable enemy and to do it with one clean sweep, as many felt the bomb had done to the Japanese. Now, of course, World War II and its ending was much more complicated than that.

And as you know better than anybody, Jhanavi, the war against cancer has turned out to be pretty complicated. But this clean metaphor and emotional metaphor of mobilizing the entire nation against this dread disease was very effective going back to the 1950s.

ED: It’s interesting, Brian, to think about in the post-World War II era how widespread this language becomes, because we have not only a war on cancer. We also have a war on poverty and then later a war on drugs.

BRIAN: And crime, don’t leave crime out.

ED: And crime, yeah, exactly. In the 19th century, in which I specialize, we weren’t confident enough to wage war on any disease. Basically there’s a sense of, oh my god, here it is. What are we going to do? And I think the metaphor is much more like a fire department than it is an army.

Here is something that has emerged in our midst that we need to mobilize ourselves all across the usual class boundaries and racial boundaries and try to extinguish it for the greater good. But then our goal is to get back to go normality as quickly as we can.

PETER: I have one thing about Brian’s century that I think might complicate a little bit, and that is the Cold War. Now, that’s the big war. And you could have said for many years, hey, that’s never going to end. And it didn’t seem like it was going to.

But that was a war that continued to energize and mobilize for good reasons and bad, paranoid and progressive. And ultimately, well, it was over. So sometimes they work. Sometimes the trope does too much work and people become cynical, too many wars.

BRIAN: Great point.

ED: So Jhanavi, you said that you had really thought this through for your own purposes. So what led you to go ahead and use that language?

JHANAVI PATHAK: Well, I think– I was 16 when my dad was diagnosed. So for the past eight years, essentially a third of my life, this has been a highly impactful element of my life. And when you mentioned the Cold War, for example, I think that is a great analogy for what cancer is for so many people.

People sort of coming in and out of these hot periods, whether they go into remission or the disease comes back. And one of the huge elements in naming the foundation the War on Cancer Foundation was the fact that for be it individuals or their families, it is so damaging, and not just in the physical or the clinical sense, but what we as a foundation have come to call collateral damage.

ED: Oh, that’s great.

PETER: Yeah.

JHANAVI PATHAK: What was funny, as you had mentioned, the use of the word war can have positive and negative connotation and effects, like with the war on drugs. But we actually got overwhelmingly positive responses from caregivers and especially women when using verbiage like the War on Cancer Foundation. Because it sort of gave testament to the experience that they’re having. It’s just this daily war with the disease, and then especially all the collateral damage that comes as a result of it.

PETER: Yeah, and we have so many combatants, and we have so many veterans. I think all of us have good friends who have had bouts with cancer as personal triumphs. And there are triumphs on various fronts of particular cancers that we seem to have under control. But the metaphor of war is one that does organize our holistic sense of the evil empire that we’re trying to overcome.

JHANAVI PATHAK: And I think one thing that resonated with me especially was the fact that, when you’re fighting something, I think we tend to think of war as the active period of fighting, but then there’s also the period of recovery and rebuilding.

BRIAN: There is winning the peace.

JHANAVI PATHAK: Exactly, and I think for a lot of people, even if they get through the cancer, then it’s a matter of that rebuilding and reconstituting a semblance of normalcy in their lives. How do you get back to even having a job to put food on your table and keep a roof over your head?

There’s so much rebuilding that goes on. And I think for us, one of our goals is not only in addressing this collateral damage. It’s doing a lot to provide support to the caregivers and the families as opposed to just the patients. And in that sense, that’s where we really see this notion of a war being so far reaching.

PETER: Yeah, Jhanavi, thanks for your call.

JHANAVI PATHAK: Thank you all very much.

ED: Good luck.

BRIAN: Bye bye.



BRIAN: That’s going to do it for us this week. You can find us at Facebook, Tumblr, and on Twitter @BackStoryRadio.

ED: You can also download all of our past shows virus free, which is important after hearing this one, at our website,

PETER: Remember, a little BackStory every day helps keep the doctor away. Thanks for listening, and don’t be a stranger.

BRIAN: Today’s episode of BackStory was produced by Tony Field, Jess Engebretson, Eric Mennel, and Anna Pinkert, with help from Nell Boeschenstein and Allison Quotes. Jamal Millner mixed the show. BackStory’s executive producer is Andrew Wyndham.

Major support for BackStory is provided by an anonymous donor, the University of Virginia, the National Endowment for the Humanities, and the Joseph and Robert Cornell Memorial Foundation. Additional support is provided by Weinstein Properties and History Channel, History Made Every Day.

FEMALE SPEAKER: Brian Balogh is professor of history at the University of Virginia. Peter Onuf is professor of history emeritus at UVA and senior research fellow at Monticello. Ed Ayers is president and professor of history at the University of Richmond. BackStory was created by Andrew Wyndham for the Virginia Foundation for the Humanities.

FEMALE SPEAKER: Hi there, podcasters. Have you ever wished you could take a class with one of the Backstory hosts? Well, now’s your chance. Our 18th Century Guy, Peter Onuf, is teaching a Massive Open Online Course– a MOOC– exploring the life and legacy of Thomas Jefferson.

The six-week long course is co-sponsored by the University of Virginia and Monticello. And enrollment is completely free. It begins on February 17, Presidents Day. And you can find out how to enroll on our website, Just look for the MOOC link at the bottom of our homepage.

View Resources

Not So Safe Space Listening Notes By Hayley Duncan, Middle School Social Studies Teacher, Lake Lure Classical Academy