Smallpox inoculation and quarantine in colonial America

In colo­nial America, quar­an­tine was a state-sponsored restric­tion on indi­vid­ual lib­erty in the name of pub­lic health, and was accepted by the pub­lic. Early inoc­u­la­tion, on the other hand, was done by indi­vid­u­als, and was imme­di­ately resisted by the public.

In the sev­en­teenth cen­tury, colonists in America, despite “strong reli­gious beliefs about pestilence-as-divine-punishment,” read­ily made the con­nec­tion between arriv­ing ships and out­breaks of small­pox. Their pop­u­la­tions, unlike urban cen­ters in Europe where out­breaks appeared ran­dom, were not suf­fi­cient to sus­tain small­pox as an endemic virus. Thus, out­breaks tended to occur with the arrival of ships, and could not be blamed on “unsan­i­tary neigh­bors,” as in Europe.

The ear­li­est step taken by European set­tlers in North America, then, was the quar­an­tine of arriv­ing ships. Some extended this approach beyond mar­itime quar­an­tines to include iso­la­tion of vic­tims to pre­vent the spread of the dis­ease, includ­ing early leg­isla­tive attempts in the colony of Virginia in the 1660s.Charleston, South Carolina man­dated the iso­la­tion of small­pox vic­tims at home as of 1738. Boston and New York City both estab­lished quar­an­tine sta­tions as of 1717 and 1755, respectively.

In 1721, Reverend Cotton Mather and Dr. Zabdiel Boylston intro­duced inoc­u­la­tion in the fight against small­pox for the first time, a move that “pro­voked a vio­lent con­tro­versy.” Inoculation brought forth stronger claims of per­sonal auton­omy and lib­erty than quar­an­tine had, likely because they involved pur­pose­fully infect­ing an unex­posed per­son with a poten­tially deadly dis­ease, as opposed to the main­te­nance of a kind of sta­tus quo as with quar­an­tine. Inoculation was viewed by some, espe­cially by Puritan New Englanders in the early eigh­teenth cen­tury, as “inter­fer­ing with the will of Divine Providence” in a way that quar­an­tine did not. Smallpox and other dis­eases were God’s “mech­a­nisms for con­trol­ling the bal­ance between the blessed and the damned” and served “as nat­ural con­trols over the size and extent of the poorer pop­u­la­tions.” According to James Hodge and Lawrence Gostin, “[t]his Malthusian analy­sis was one of the most widely quoted the­o­ries of the early anti­vac­ci­na­tion­ists.” This view sur­vived well into the twen­ti­eth century.

Reactions in 1721 were vio­lent. In the midst of Boston’s small­pox out­break, Mather and Boylston began inoc­u­lat­ing patients, begin­ning with Boylston’s son. They were roundly con­demned: “Physicians, min­is­ters, and cit­i­zens were out­raged and hor­ri­fied that Boylston had delib­er­ately infected some­one with small­pox.” Both received death threats, and Mather’s house was attacked with a home­made grenade.

Many oppo­nents of immu­niza­tion were espe­cially con­cerned with the poten­tial dan­ger of actively spread­ing small­pox to a com­mu­nity through the means of inoc­u­la­tion, a very real pos­si­bil­ity when deal­ing with a live small­pox virus (instead of Jenner’s much safer vac­ci­na­tions with cow­pox virus). From a reli­gious per­spec­tive, this kind of inter­fer­ence broke the “covenant between the com­mu­nity as a whole and God.” With inoc­u­la­tion in play, “no longer could the peo­ple be told con­vinc­ingly that their suf­fer­ing resulted from their sins, or that repen­tance was the only road to sal­va­tion.” From a med­ical per­spec­tive, inten­tional infec­tion with small­pox could be seen as con­tra­dic­tory to the Hippocratic oath and gen­eral ten­ants of med­ical ethics.

Early approaches to manda­tory pub­lic health mea­sures lacked the con­cept of a legally-articulated “exemp­tion” from the pol­icy for indi­vid­u­als. Any exemp­tion or excep­tion was applied in an ad-hoc man­ner, even as many pub­lic health inter­ven­tions were, in fact, ad-hoc responses to cir­cum­stances. Mather and Boylston, for exam­ple, acted as indi­vid­u­als, not as pub­lic health offi­cials, and their inoc­u­la­tions were nei­ther sys­tem­atic nor com­pre­hen­sive. Quarantine, on the other hand, was state-sponsored. It would be applied to incom­ing ships if small­pox was sus­pected, but there was no artic­u­lated pro­vi­sion for allow­ing any par­tic­u­lar to leave quar­an­tine early. The con­cept was to pro­tect the pub­lic as a whole, not to pre­serve indi­vid­ual liberties.

You can read my work­ing paper, “Lessons from Smallpox Vaccination,” in its entirety on SSRN.