"Pox: An American History" went above and beyond my expectations. The REAL disease in this book is racism, having direct effects on the spread and vaccination of smallpox.

The author begins with Middlesboro, KY. In 1897 smallpox invaded the American South. Unvaccinated black people were the most vulnerable, living in close proximity to each other due to segregation, and malnourished without regular access to medical care. They were viewed as "irresponsible" for catching the disease. Middleboro quarantined its black population but not the white (same situation as the Chinese in San Francisco). Black sufferers starve and die due to local white beauracracy fighting over who should pay for their care. As black people flee due to localist neglect, it spreads to other states. Finally the federal government is forced to step in, but it is a debacle. Cut to the Span-Amer War, and the peak of American imperialism and expansionism. Smallpox became epidemic in each of the 3 major theatres of the war and all involved virulent, deadly smallpox. Vaccine supplies did not survive long in the heat. Azel Ames creates the first vaccine farm in Puerto Rico but it becomes a military operation through and through. Increasing federal control in the name of public health. Then there's the American invasion of the Philippines. Maj. Frank Burns, the leader of the board of health in Manila, begins relying on local physicians to create a spy system for the U.S. military. Racism is rife, blending health surveillance with espionage to counteract the Filipino independence movement. Understandably Filipinos associated the vaccinators with the foreign army they served.

Finally the author covers the changes in the American legal system that we see today. Anti-vaxxers (majority white) will refuse vaccination due to medical beliefs, religious tenants or argue parental rights or notions of personal liberty. ( )

When did the current controversy about vaccines really start? According to Willrich’s history, the controversy about vaccines started all the way back with Jenner’s discovery of vaccination. Although smallpox once killed thousands of people each year in America, vaccination against smallpox was still controversial. A small fraction of people had adverse reactions, including death.

Obviously, this scared people. It especially scared those who were in oppressed groups, like blacks in the American South. This book tells their story in a greater narrative of how science and popular belief tried – again and again – to reconcile to each other.

The resolution of Willrich’s tale lies with the Supreme Court case of Jacobson v. Massachusetts in 1905. In the final chapter, he masterfully brings out the drama and nuance of this case. (If this book consisted of just that very chapter, it would be worth reading.) In the decision, SCOTUS upheld the rights of states to force vaccination, but in tension, it also upheld the right for people with real beliefs (not just “obstinacy”) to decline forced vaccination.

This book is worth reading for those with medical or historical interests. It also provides a worthy pericope into popular American history. In contemporary culture where science can sometimes become overbearing, this story reminds us that “scientific triumphalism” and “antiscientific denialism” are really two sides of the same coin.

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Using smallpox vaccination as a case study, Willrich explores the broader progressive era movement in America (late 19th to early 20th century): the shift from liberty as an ideal specific to individuals to the gradual adoption of the idea of a social liberty (in an increasingly urbanized and interconnected society, the good of the many can trump the sovereignty of the individual).

Decades have elapsed since the last variola major outbreak (significantly more deadly form of the smallpox virus), leaving the general population largely unvaccinated and unaware/unconcerned with its particular horrors. Fledgling health departments across the country have identified the reappearance of the disease and issue mandatory vaccination orders to curb its devastation. Unsurprisingly, there's a strong class divide in enforcement: the rich/influential are taken at their word that they've been recently vaccinated while the poor/immigrant/black populace is vaccinated by a growing police force if they neglect to volunteer. Contributing to the populace's increased resistance to vaccination: the majority of the cases during this time period are variola minor (significantly less deadly, although no less contagious, than its major counterpart), the impurity of the vaccine (local/state governments have NO quality control over the vaccines they mandate upon their citizens resulting in horrific side effects/death from opportunist assholes, most notably the Camden tetanus/lockjaw deaths - primarily affecting children), the lack of compensation/recourse for missed work/injury due to vaccination side effects, and the authorities' insistence that vaccination is indisputably safe. Medical professionals point to countries like Germany and Sweden where smallpox vaccination is near universal and their consequent success at having eliminated the devastating disease. Also to domestic cases where large-scale vaccination efforts successfully halt growing epidemics.

Anti-vaccinationists use their growing platform to decry the vast increase of police force/reach into their communities and the growing intrusion of government into their homes/bodies (as many public schools mandate vaccination of their pupils/staff or bar entry). The federal government is also gaining power via the greater good health argument requiring vaccination as a prerequisite for entry to the nation and launching wide-scale vaccination campaigns in its military holdings (i.e. the Philippines). Compulsory vaccination is often equated with war, officials have the right to defend their borders and protect their people against an insurgent (disease). Several state supreme courts uphold compulsory vaccination laws/edicts during outbreaks, yet recognize and prohibit excessive police force and allow for exceptions for unfit children. Eventually the federal supreme court rules in Jacobson v. Massachusetts (1905) that compulsory vaccination is legal, but limits excessive police force and requires that exceptions be made for both adults and children that are unfit to undergo the procedure. Setting a standard in the argument of individual v. social liberty:

"There is, of course, a sphere within which the individual may assert the supremacy of his own will and rightfully dispute the authority of any human government, especially of any free government existing under a written constitution. But it is equally true that in every well-ordered society charged with the duty of conserving the safety of its members the rights of the individual in respect of his liberty may at times, under the pressure of great dangers, be subjected to such restraint, to be enforced by reasonable regulations, as the safety of the general public may demand." (Justice Harlan writing for the majority)

Via compulsory vaccination, smallpox is eventually eradicated in the United States and throughout most of the world. The author cautions that scientific health advancements need to be tempered with education programs and intelligent/compassionate enactment in order to prevent the blunders of the past. Vaccination in theory is a powerful weapon against debilitating, contagious disease - its execution by fallible humanity wants improvement.

Cannot handle the level of interesting this compendium holds and pathways I now have to explore. ( )

How smallpox shaped the American public health system, both by accustoming public health authorities to mandatory vaccination, sometimes at gunpoint, and often convincing groups of Americans to resist it, sometimes even violently. (One thing reading this very near to finishing the Pinker book made me think is how much less violent today’s vaccinators and antivaccinators are.) Some things don’t change: like today’s legislators voting not to acknowledge sea level rise, a county worried about the economic impact of quarantine/vaccination voted that there was no smallpox in the county. Also, as with health care reform, there was always great capitalist involvement: mandatory vaccination turned out to bolster the bottom line of drug companies, something that made opponents suspicious; government production was barely tried even as government regulation came to seem more and more important given the dangers of bad vaccine.

Any topic in US history has its racial component: Immigrants arriving in New York were required to be vaccinated—except if they came over in first or second class; the same thing happened at the Mexican border, where all second- and third-class passengers needed recent vaccination scars to get through, but Pullman passengers could swear to their immunity. Likewise, whites in the South often discounted the risks of smallpox because they thought that only blacks would get it; Willrich points out that this speaks to greater physical segregation in the late 19th-century South than is often imagined, but also notes that white Southerners were routinely disappointed in their imaginings that whites were more resistant.

A chapter on vaccination in the Phillippines situates vaccination within the imperial project, and draws out the connections between progressivism and imperialism. It also contains the great line “Forget the Maine.” (He continues: “In Hoff’s [one of the public health officials important in the book] decidedly contrarian view, the Spanish-American War was decidedly a police action, taken against a delinquent neighbor that had allowed its properties to overflow with yellow fever and smallpox.”) Willrich also argues that vaccination lawsuits gave the Supreme Court the language of “clear and present danger” later used in First Amendment doctrine, as well as providing a rationale for later eugenic projects. Overall, the book is an engaging account of an important episode in American progressivism. ( )

A look at smallpox around the turn of the century, Pox explores the history of the disease and of vaccination, as well as the influence smallpox had on the role of government in public health. The subject matter itself is fascinating, in part because it is so sensational. The history of vaccination - and the horror stories accompanying it - are what I term "intellectually gruesome", meaning it's interesting on a brainy level while simultaneously appealing to the more basic need for blood, pus, and guts.

Despite my fascination with the subject though, I found myself getting a bit bored from time to time as Willrich piled a stack of facts too big for my small brain to process. At a few points, the accumulation of numbers, percentages and statistics, which were taking page space away from the more sensational anecdotes, had me setting the book aside. I don't want to give the impression, however, that it was some sort of prurient need for graphic nastiness which kept me from enjoying the more fact-based sections of the book. A larger part of the problem for me was the repetition of the same ideas - or the same story structure - throughout the book. I honestly believe the book could have been cut by many, many pages.

What kept me going though - and not skimming - was Willrich's writing. I really enjoyed his style, and at times found myself more interested in how he was constructing his sentences, in his word choice and pacing, than I was in what he was actually saying. Then the next super-interesting tidbit or anecdote would pop up, and I would once again be engrossed in the story. It was definitely a roller coaster ride of enjoyment. Some sections or chapters held my interest obsessively while others had my eyes glassing over.

My ultimate judgment is positive, and I would recommend this book to anyone interested at all in the subject. The sections of the novel which really engaged me were more prevalent than those which had me stifling a few yawns. ( )