WEBVTT

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Prof: Now that we've
discussed smallpox and its

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impact on the human body--
its symptomatology--this

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morning I want to concentrate
instead on the impact on

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history,
and I want to concentrate on

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three aspects in particular.

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The first part would be to look
at its impact in Europe.

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The second, and much more
dramatic story,

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is the impact that you're
reading about in Elizabeth Fenn,

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which is what happened with
smallpox in the New World,

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and also in Australia and New
Zealand.

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The third task for the morning
is to come to the very different

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story, which is smallpox and the
development of a public health

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strategy;
in this case,

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the development of the strategy
of vaccine.

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So, those are the three topics
I'd like to deal with this

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morning.

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And, so, let's begin with the
impact of smallpox in Europe.

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Smallpox has a legend about it.

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The legend, it goes like this.

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That it was brought back to
Europe from the Middle East by

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returning Crusaders in the
eleventh and twelfth centuries.

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As you know,
the Crusades lasted from 1095

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to 1291,
and those are said to be,

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this time of armies in movement
and transit,

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to be the means of transmitting
smallpox back to Western Europe.

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There's no reason for us to
accept the truth of that legend

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as accurate.

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But there is something
interesting about it.

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First, that there's some
support, which is that Saint

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Nicaise,
who was a Crusader of the Order

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of Saint John,
he had an unhappy experience in

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the Middle East.

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He was captured and beheaded.

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But thereafter he became the
patron saint of smallpox

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sufferers.

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A cult of Saint Nicaise--he's
from Reims,

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in particular--spread across
the continent,

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and churches were devoted to
him, and there were

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representations of this saint in
stained glass widows,

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in effigies,
and statues like this.

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This is Saint Nicaise at Reims
Cathedral, Saint Nicaise and an

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angel.

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There isn't any hard evidence
that smallpox did return with

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the Crusaders;
although, we all know that

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warfare is a time that favors
the spread of infectious

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diseases,
and it's probably true that

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smallpox had already been
present in Europe for centuries.

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But there's something about
this date,

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which is that what it tells us
is not when smallpox actually

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began,
but when it first began to

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attract attention.

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In any case,
we know too that smallpox,

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although it was present in
Europe during the Crusades,

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the conditions at that time led
to its beginning to have a more

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important impact,
that reached its highpoint in

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the late-seventeenth and then
throughout the eighteenth

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century.

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And that had to do with
preconditions that enabled it to

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flourish,
preconditions associated with

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industrial development,
the commercialization of

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agriculture,
and rapid, unplanned

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urbanization.

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In the eighteenth century,
smallpox had clearly replaced

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plague as the greatest and most
feared killer of its time.

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Now, in its history,
the fact that a sufferer--

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and we mentioned this last
time--who recovered possessed a

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robust,
lifelong immunity to this

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disease was important.

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No one was naturally infected
twice with smallpox.

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So, a typical pattern emerged
in the cities of Europe,

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and that was that smallpox
became an ever-present disease

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that most people who survived
childhood had suffered.

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The adult population therefore
possessed what we might call an

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extensive herd immunity to
smallpox as a disease.

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So, it became an endemic
disease of childhood.

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But at intervals,
perhaps every generation or so,

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smallpox would erupt as a major
epidemic among the general

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population.

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A couple of factors came into
play, to reinforce this pattern.

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Obviously not every child
contracted the disease,

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and so over time there'd be a
slow accumulation of non-immune,

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susceptible adults who could
fall ill of the disease.

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It was also true that European
cities in the early modern era

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were so unhealthy that they
sustained or expanded their

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population,
not by growth from within,

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but by a constant influx of
people from without.

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Peasants driven off the land,
perhaps by hunger or warfare,

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or the search for work,
failed harvests.

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And these newcomers,
in large numbers,

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to use contemporary medical
jargon, were immunologically

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na�ve;
that is, they were susceptible

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and added to the pool of
susceptibles in urban centers.

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In every generation or so,
urban centers,

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whose children had already
suffered smallpox as an endemic

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childhood disease,
suffered major epidemics among

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not only children but young
adults,

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adolescents and older people.

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So, smallpox is an example of a
disease--and we'll see malaria

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as another one--for which
there's no simple distinction

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between endemic and epidemic.

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Smallpox was both endemic year
in and year out,

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in Europe, and it was also
epidemic sporadically every

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generation or so.

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It thrived in crowded urban
environments,

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with throngs of people,
and poorly vented houses and

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workshops.

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Now, in the eighteenth century,
statistics are elusive.

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But smallpox is commonly
thought--and this is just a

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guesstimate--
to have caused perhaps a tenth

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of all deaths in the century in
Europe,

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and a third of all deaths among
children under ten-years-of-age.

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Half the population of the
continent is estimated to have

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been scarred or disfigured by
this disease.

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And smallpox was also the
leading cause of blindness.

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Across Europe,
perhaps half-a-million--this is

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again only a guesstimate--people
died annually from this disease.

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In other words,
it was the equivalent of--

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the largest city in Europe at
the time,

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in the eighteenth century,
was Naples,

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with half a million people--it
was if a city of that size

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disappeared from this single
disease every year.

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The nineteenth century English
poet and historian,

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Thomas Babington Macaulay,
wrote this about smallpox.

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"The havoc of plague had
been far more rapid.

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But the plague has visited our
shores only once or twice in

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living memory.

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But smallpox was always there,
filling the churchyards with

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corpses,
tormenting with constant fear

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all whom it had not yet
stricken,

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and leaving on those,
whose lives it spared,

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the hideous traces of its
power, turning the babe into a

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changeling,
at which the mother shuddered,

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and making the eyes and cheeks
of the betrothed maiden objects

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of horror to her lover."

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Two of the most famous
descriptions of smallpox in this

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century were those that
described it as "the

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speckled monster"
and "the most terrible of

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all the ministers of
death."

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Furthermore,
like plague though,

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smallpox was an airborne
disease--unlike plague--but like

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influenza.

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And it was an affliction that
was universal,

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and had no predilection for any
subset of the population,

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such as the poor.

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It wasn't really in that sense
a social disease.

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Even royal families were
scourged by smallpox in the

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seventeenth and eighteenth
centuries.

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Famous sufferers and victims
included King Louis XIV and

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Louis XV of France;
William II of Orange;

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Peter II of Russia;
the Holy Roman Emperor,

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Joseph I.

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In England, smallpox was even
directly responsible for a

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dynastic change.

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It extinguished the House of
Stuart.

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The last Stuart heirs to the
throne all died of smallpox,

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between the death of Queen
Mary, in 1694,

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and the death of
eleven-year-old Prince William,

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also from smallpox, in 1700.

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So this was a clear case in
which a disease produced a

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constitutional crisis,
and led to the Act of

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Settlement of 1701,
that prevented another Catholic

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from being crowned,
and brought in the House of

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Hanover.

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So, smallpox had a major impact
in Western Europe.

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But its impact is not a simple
repetition of the story of

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plague.

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Although it was dreaded,
smallpox did not give rise in

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Europe to mass hysteria,
scapegoating and a religious

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frenzy.

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And there are reasons for that
we can surmise.

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Unlike plague,
smallpox was not a sudden

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outside invader that took
society by surprise.

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Nor did it maximize its fury by
targeting young adults and the

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middle-aged, who were the
mainstays of families and of the

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economy.

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Smallpox was an endemic disease
that was ever-present,

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and so it was considered almost
normal,

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especially because it targeted
infants and children,

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as a rule;
although, as I've said,

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it did lead sporadically to
broader epidemics.

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So, as a result everyone had
some experience with smallpox,

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and half the people you might
meet on the street,

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in a city of Western Europe,
would be pockmarked,

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as a reminder of its passage.

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So familiar was smallpox that
it bred a kind of fatalism,

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the belief that it was
inevitable in people's lives.

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And this attitude was so
pervasive that it wasn't

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uncommon even for parents to
expose healthy children

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intentionally to mild cases,
in the hope that they could

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protect them from something much
more catastrophic.

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We could look at this attitude
by--or appreciate it--

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by thinking about European
literature,

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particularly British
literature, let's say in the

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eighteenth century.

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Let's think,
for example,

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of Henry Fielding's novel
Tom Jones.

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In that, when it was useful to
have a change in plot,

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all the author had to do was to
introduce the idea of smallpox,

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because no one would question
that that was appropriate,

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or consider that this was a
clumsy or artificial artifice.

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Everyone expected smallpox.

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And in Fielding's novel,
Joseph Andrews,

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we find that there's a heroine
who is pockmarked.

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Or consider Thackeray's The
Adventures of Henry Esmond,

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set in the eighteenth century,
where smallpox drives the plot.

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Smallpox, quite simply,
was just there,

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and it came to seem,
for many people,

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a terrible but everyday part of
the human condition.

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So, smallpox didn't cause great
European cities,

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like London,
to empty of their population,

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when people took the road in
flight,

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as plague did in the
seventeenth century and,

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as we shall see,
that cholera was to do again in

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the nineteenth century.

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And there wasn't an urge to
seek scapegoats for what seemed

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an almost natural or normal
event.

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But this is a generalization,
and there are reports of some

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who lost their nerve at the
approach of smallpox and sought

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refuge in flight.

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Let's return to our novel,
Henry Esmond.

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There's a heroine,
Lady Castlewood,

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who contracts smallpox as an
adult, in a country village.

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Her husband--and this was
surprising because we're told

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early on that he was an
extraordinarily brave soldier,

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but he was a man who couldn't
bear to face a disease that he

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couldn't fight and threatened
him,

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not only with death,
but this seemed to matter

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perhaps more to him than death
itself--

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he thought he was extremely
handsome and he was afraid that

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he would be maimed if he
survived.

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So, unwilling to put his fair
complexion,

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and his even fairer hair,
at risk, Lord Castlewood took

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to his heels,
and he deserted his household

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for the duration.

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But he wasn't part of a mass
exodus.

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Although Thackery does have
Henry Esmond,

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the hero of the story,
tell us himself that smallpox

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was,
in his words,

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"the most dreadful scourge
of the world."

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We also know that as a result
of her ordeal,

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Lady Castlewood lost her
beauty, and that her gallant

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husband,
on his return,

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no longer loved her as he once
did.

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As readers then,
we know that one of the effects

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of smallpox was that it had a
big impact on the marriage

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market.

16:47.090 --> 16:52.350
It disfigured people and made
them less likely to succeed in

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those sweepstakes.

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We learn that Lady Castlewood,
according to the author:

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"Her beauty was very much
injured by the smallpox.

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When the marks of the disease
cleared away,

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the delicacy of her color and
complexion was all gone.

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Her eyes had lost their
brilliancy.

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Her hair fell and her face
looked old.

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It was as if a coarse hand had
rubbed off the delicate tints of

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that sweet picture,
and brought to it a dread

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color.

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Also it must be owned,
her ladyship's nose was greatly

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swollen and red."

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In any case,
as you can imagine,

17:37.201 --> 17:41.601
having scars and pockmarks was
also a source of great

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psychological distress and
unhappiness,

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and this too was part of the
plot of Thackeray's novel as it

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unfolds,
and part of what we should

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remember as the impact of
smallpox on the terrible

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eighteenth century.

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But that was smallpox in
Europe: a major source of

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anxiety;
a major impact on population;

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a source of the Cult of Saint
Nicaise;

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a major factor in demography.

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But there's a more dramatic
story that we need to come to,

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as we cross the waters and turn
to the New World,

18:27.794 --> 18:30.974
or also Australia and New
Zealand.

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This is the story of what
happened when the disease was

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suddenly introduced to
populations in part of the world

18:40.930 --> 18:46.610
where it was a new invader;
where it arrived from outside,

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had never been an endemic
infection and therefore against

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which the native or aboriginal
population had no immunity at

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all.

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Then it produced real
catastrophes,

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events described as
"virgin soil

19:05.444 --> 19:07.494
epidemics."

19:07.490 --> 19:12.180
These were catastrophes that
accompanied European expansion

19:12.181 --> 19:15.661
to the New World,
Australia, New Zealand.

19:15.660 --> 19:19.570
And there smallpox,
and another childhood disease

19:19.567 --> 19:24.127
that accompanied it,
measles, had a transformative

19:24.125 --> 19:29.495
importance in clearing the land
and promoting settlement by

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Europeans with their robust
immunity.

19:33.200 --> 19:39.800
The impact of smallpox and
measles was greater than that of

19:39.803 --> 19:41.173
gunpowder.

19:41.170 --> 19:44.720
In the New World,
you'll be reading about this in

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detail in that wonderful book by
Elizabeth Fenn,

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Pox Americana,
and you might want to be

19:52.269 --> 19:57.979
reminded of the simple fact that
the author was actually a Yalie,

19:57.980 --> 20:02.110
and that the book that you're
reading began life here,

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as a Ph.D. dissertation.

20:05.568 --> 20:08.168
In any case,
though, I want to have a

20:08.165 --> 20:12.345
division of labor between the
lectures and the reading,

20:12.348 --> 20:17.778
and so I won't repeat the story
that Fenn tells so movingly and

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so well.

20:18.660 --> 20:23.250
But there are a few points that
I would like to highlight as

20:23.251 --> 20:27.301
specific examples,
and a couple of general points.

20:27.298 --> 20:31.408
And first the general idea we
should remember is that of

20:31.409 --> 20:35.369
something sometimes referred to
as "the Columbian

20:35.369 --> 20:36.789
exchange."

20:36.788 --> 20:41.838
That is to say that the
European encounter with the New

20:41.838 --> 20:46.698
World brought about the
large-scale exchange from one

20:46.702 --> 20:50.352
side of the Atlantic to the
other,

20:50.348 --> 20:56.118
and in the reverse direction,
of fauna and flora.

20:56.118 --> 21:00.768
Certainly, as you know,
Europeans brought back the

21:00.768 --> 21:04.368
potato, maize and quinine,
as examples,

21:04.373 --> 21:06.463
from the Americas.

21:06.460 --> 21:10.980
And there's been a debate as to
whether this also involved a

21:10.982 --> 21:12.672
microbial component.

21:12.670 --> 21:16.760
And there are those who
speculate that Columbus and his

21:16.761 --> 21:21.461
sailors brought back the disease
syphilis, as well from the New

21:21.461 --> 21:22.221
World.

21:22.220 --> 21:26.980
We'll be returning to that
argument later in the semester,

21:26.980 --> 21:31.240
when we come to talk about
syphilis as a disease.

21:31.240 --> 21:35.730
What's beyond doubt though is
that there was also a terrible

21:35.726 --> 21:39.296
movement of microbes in the
other direction,

21:39.298 --> 21:45.358
as Europeans unintentionally
introduced smallpox and measles

21:45.359 --> 21:47.209
to the Americas.

21:47.210 --> 21:51.330
Let's illustrate with a
specific example of the

21:51.328 --> 21:56.488
Columbian exchange--
the exchange Fenn tells us

21:56.491 --> 22:02.511
about--by looking at this
much-travailed island of

22:02.508 --> 22:07.168
Hispaniola,
the mountainous Caribbean

22:07.173 --> 22:12.033
island where Columbus landed in
the 1490s.

22:12.028 --> 22:16.268
Hispaniola--that is,
what is modern Haiti and the

22:16.272 --> 22:18.132
Dominican Republic.

22:18.130 --> 22:23.400
And as we know from today's
news, Haiti has a long history

22:23.403 --> 22:26.643
of natural and manmade
catastrophes,

22:26.643 --> 22:31.273
and the arrival of Columbus was
certainly one.

22:31.269 --> 22:37.099
The aboriginal inhabitants,
a tribe known as the Arawaks,

22:37.102 --> 22:40.232
are estimated,
or guesstimated,

22:40.226 --> 22:46.576
to have numbered something like
a million people in 1492.

22:46.578 --> 22:52.918
Columbus described Hispaniola
as almost an earthly paradise,

22:52.916 --> 22:56.566
a place of great natural
beauty.

22:56.568 --> 23:00.838
And he reported that the
Arawaks were a welcoming and

23:00.836 --> 23:04.856
non-warlike people,
who greeted the Spanish warmly

23:04.856 --> 23:07.726
and showed them great kindness.

23:07.730 --> 23:12.710
But unfortunately for them,
the kindness wasn't reciprocal.

23:12.710 --> 23:17.970
The Spaniards were interested
in profit, and international

23:17.970 --> 23:19.540
power politics.

23:19.538 --> 23:23.428
And Hispaniola was
strategically located.

23:23.430 --> 23:27.750
It also possessed fertile soil,
a favorable climate,

23:27.748 --> 23:32.658
and land that the Spanish Crown
coveted for cultivation.

23:32.660 --> 23:38.020
So, European interest was based
on commerce, profit and

23:38.018 --> 23:41.688
international power
considerations.

23:41.690 --> 23:46.350
The Spaniards militarily
dispossessed the Arawaks of

23:46.347 --> 23:50.917
their land, and intended to
reduce them to slavery,

23:50.915 --> 23:54.565
first in mines and then on the
land.

23:54.568 --> 23:59.218
They were assisted in the
process, up to a point,

23:59.224 --> 24:03.594
by two great assets:
gunpowder and disease.

24:03.588 --> 24:09.278
And as you know from reading
Fenn, the aboriginal population

24:09.278 --> 24:14.678
of the Americas lacked immunity
to European diseases like

24:14.679 --> 24:17.089
smallpox and measles.

24:17.088 --> 24:21.328
There's no evidence that there
was a plot of genocide or

24:21.327 --> 24:26.107
bioterror in the intentional use
of disease as a means to clear

24:26.105 --> 24:28.335
the land and resettle it.

24:28.338 --> 24:33.638
What happened was spontaneous,
and not intentional.

24:33.640 --> 24:38.280
But the encounter between the
Europeans and the indigenous

24:38.277 --> 24:42.587
peoples of Hispaniola resulted
in an extraordinary and

24:42.587 --> 24:44.457
terrifying die-off.

24:44.460 --> 24:49.780
Between 1492 and 1520,
the Native population was

24:49.777 --> 24:54.527
reduced from a million people to
15,000.

24:54.529 --> 24:59.679
Disease thoroughly cleared
Hispaniola for European

24:59.680 --> 25:04.410
colonization,
virtually without resistance.

25:04.410 --> 25:08.940
On the other hand,
smallpox thwarted the Spanish

25:08.935 --> 25:14.035
intention in Hispaniola to
enslave the aboriginals.

25:14.038 --> 25:19.838
They simply died off at too
extraordinary a rate.

25:19.838 --> 25:23.628
It therefore led the Spaniards,
out of necessity,

25:23.625 --> 25:27.645
to turn to a different source
of labor for mines and

25:27.647 --> 25:28.907
plantations.

25:28.910 --> 25:32.490
And since Africans and
Europeans shared disease

25:32.493 --> 25:36.083
reservoirs that were partially
overlapping,

25:36.078 --> 25:39.738
their people were resistant to
many of the same epidemic

25:39.742 --> 25:43.142
diseases that had destroyed the
Native Americans.

25:43.140 --> 25:47.930
So, disease was a major factor
in the establishment of the

25:47.932 --> 25:52.222
African slave trade and the
development of New World

25:52.221 --> 25:53.231
slavery.

25:53.230 --> 25:56.300
The Spaniards hardly delayed.

25:56.298 --> 26:02.018
1517 marked the beginning of
the importation of African

26:02.015 --> 26:04.445
slaves to Hispaniola.

26:04.450 --> 26:08.930
Santo Domingo,
by 1789, received into its

26:08.932 --> 26:15.882
ports every year some 1,600
ships, employing 24,000 sailors.

26:15.880 --> 26:21.270
And it accounted for 11 million
pounds of the French total of 17

26:21.266 --> 26:23.656
million pounds of exports.

26:23.660 --> 26:27.430
Its trade was the foundation of
the wealth of port cities,

26:27.430 --> 26:30.480
like Nantes,
Bordeaux and Marseilles,

26:30.480 --> 26:34.380
its cotton, a basis for the
French textile mills in

26:34.375 --> 26:38.165
Normandy,
and the growth was exponential.

26:38.170 --> 26:42.620
Between 1783 and 1789,
production doubled,

26:42.619 --> 26:49.459
and with it the importation of
slaves: 10,000 a year in 1764;

26:49.460 --> 26:55.670
15,000 in 1771;
27,000 in 1786;

26:55.670 --> 26:59.570
40,000 in 1787.

26:59.568 --> 27:02.438
The leading port of Santo
Domingo,

27:02.440 --> 27:06.040
the prosperous city of Le
Cap-Francois,

27:06.038 --> 27:10.408
had 20,000 people and was
called "the Paris of the

27:10.407 --> 27:11.457
West."

27:11.460 --> 27:16.780
The Columbian exchange played a
major role in the history of

27:16.784 --> 27:21.844
Hispaniola, and that was writ
large in the New World as a

27:21.836 --> 27:22.736
whole.

27:22.740 --> 27:30.450
A similar story could be told
about Hernan Cortez and his

27:30.452 --> 27:35.862
fellow conquistador,
Francisco Pizarro,

27:35.863 --> 27:43.463
with regard to the Aztec Empire
of Mexico and the Incan Empire

27:43.463 --> 27:47.303
of Peru,
which were destroyed not only

27:47.298 --> 27:50.628
by gunpowder,
but also by smallpox,

27:50.625 --> 27:54.975
that destroyed agriculture,
led to famine,

27:54.978 --> 28:00.588
destroyed the aboriginal
military capacity to resist,

28:00.588 --> 28:04.108
and had, we're told,
a tremendous psychological

28:04.105 --> 28:07.045
impact,
because their gods seemed not

28:07.045 --> 28:08.315
to protect them.

28:08.318 --> 28:13.448
And, so, there was a wave of
conversion to the European god,

28:13.449 --> 28:16.839
who seemed to protect his own
people.

28:16.838 --> 28:21.358
Now, you also know,
from reading Elizabeth Fenn,

28:21.358 --> 28:27.818
that although this process was
primarily unintentional,

28:27.818 --> 28:32.978
there were moments within it,
within the larger catastrophe,

28:32.980 --> 28:37.620
of occasional acts of
intentional genocide.

28:37.618 --> 28:43.408
And one was by Lord Jeffrey
Amherst--whom we're portraying

28:43.407 --> 28:48.787
here--who intentionally gave
Native Americans infected

28:48.788 --> 28:50.108
blankets.

28:50.108 --> 28:55.158
I thought I'd perhaps tell you
a little anecdote that I won't

28:55.156 --> 28:57.256
vouch for historically.

28:57.259 --> 29:02.319
I know of it from oral history,
from friends I had at the time

29:02.320 --> 29:07.380
who attended Amherst College and
told me about a demonstration

29:07.382 --> 29:10.372
that I think took place in 1968.

29:10.368 --> 29:14.508
But that was that the
plates--you've just seen Lord

29:14.509 --> 29:18.259
Jeffrey,
who actually intentionally

29:18.259 --> 29:23.609
aimed at the die-off of
aboriginal populations,

29:23.608 --> 29:30.148
and intentionally gave Native
Americans blankets infected with

29:30.146 --> 29:31.966
smallpox scabs.

29:31.970 --> 29:37.250
Well, the plates at Amherst
College in the 1960s looked like

29:37.252 --> 29:40.122
this,
and they show Sir Jeffrey

29:40.124 --> 29:44.094
scourging the Indian population
with a whip,

29:44.089 --> 29:45.529
on horseback.

29:45.529 --> 29:50.209
And, so, in 1968,
learning about the experience

29:50.211 --> 29:53.781
of genocide,
there was a demonstration when

29:53.784 --> 29:57.804
the students of Amherst College
stood up and smashed all the

29:57.804 --> 29:59.784
plates in the dining hall.

29:59.779 --> 30:03.709
In any case,
it was also the case that this

30:03.708 --> 30:09.038
sort of tremendous die off that
affected the Americas,

30:09.038 --> 30:12.668
cleared the land for European
settlement,

30:12.670 --> 30:16.380
was repeated,
again not intentionally,

30:16.380 --> 30:20.390
but with regards in Australia
to the Aboriginals,

30:20.390 --> 30:24.340
and in New Zealand with regards
the Maoris.

30:24.338 --> 30:29.028
But you have that story told
vividly, and on a large canvas,

30:29.030 --> 30:32.450
by Elizabeth Fenn's Pox
Americana.

30:32.450 --> 30:35.070
So, I'll leave you to read
about that.

30:35.068 --> 30:39.208
I'd like to turn now to our
third point of the morning,

30:39.210 --> 30:43.180
which was the importance of
smallpox for an entirely

30:43.182 --> 30:47.082
different reason,
and that is the development of

30:47.078 --> 30:50.198
a new and major public health
strategy;

30:50.200 --> 30:55.790
the strategy of inoculation
initially, and that becomes more

30:55.792 --> 30:59.872
definitively the strategy of
vaccination.

30:59.868 --> 31:04.478
Well, let's begin with
inoculation.

31:04.480 --> 31:07.830
What is inoculation?

31:07.828 --> 31:13.248
It was an empirical
practice--we might call it a

31:13.246 --> 31:17.336
folk art--
and it was developed in various

31:17.337 --> 31:22.927
parts of the world as a result
of two very simple observations.

31:22.930 --> 31:29.990
The first was that smallpox was
clearly contagious.

31:29.990 --> 31:34.730
The second was that those who
had recovered from the disease--

31:34.730 --> 31:39.350
and it was easy to know who had
suffered from it because they

31:39.345 --> 31:43.915
were scarred and pockmarked,
or also they were often

31:43.920 --> 31:48.970
blind--and it was a simple
observation that they never

31:48.967 --> 31:52.107
caught smallpox a second time.

31:52.108 --> 31:57.578
So, the idea developed that it
might be a wise measure to

31:57.584 --> 32:02.184
induce a mild case of smallpox
artificially,

32:02.180 --> 32:05.890
to protect a person,
or especially a child,

32:05.890 --> 32:11.280
from the risk of acquiring a
naturally occurring but severe

32:11.282 --> 32:14.912
and life-threatening or maiming
case.

32:14.910 --> 32:19.530
And the practice that resulted
was called variously

32:19.531 --> 32:24.431
inoculation, variolation,
or, in a gardening metaphor,

32:24.432 --> 32:25.822
engrafting.

32:25.818 --> 32:29.558
There were variations,
but the major technique was

32:29.557 --> 32:33.217
that liquid material from a
smallpox pustule--

32:33.220 --> 32:39.420
you saw those last time--of a
patient selected for having a

32:39.419 --> 32:44.869
very mild case was allowed to
soak into a thread.

32:44.868 --> 32:49.018
The thread was then inserted
into a superficial cut,

32:49.019 --> 32:53.379
made with the lancet--this
sharp instrument that you've

32:53.383 --> 32:57.693
seen pictures of,
in an earlier lecture--into the

32:57.692 --> 33:00.822
arm of the person to be
protected,

33:00.818 --> 33:05.588
and fastened there for
twenty-four hours.

33:05.588 --> 33:10.558
Twelve days later,
the subject usually fell ill

33:10.559 --> 33:15.019
with smallpox;
hopefully suffered from a mild

33:15.017 --> 33:20.127
case for about a month;
convalesced for a further month;

33:20.130 --> 33:24.360
and then remained immune for a
lifetime;

33:24.358 --> 33:29.578
hopefully not pockmarked or
blinded.

33:29.578 --> 33:34.898
This practice of inoculation
was common in places like Turkey

33:34.895 --> 33:39.765
in the eighteenth century,
but not in Western Europe.

33:39.769 --> 33:45.969
A major role in bringing this
practice to Britain and Western

33:45.967 --> 33:51.317
Europe was played by this lady,
the wife of the British

33:51.315 --> 33:56.085
Ambassador to Turkey,
Lady Mary Montague,

33:56.090 --> 34:00.580
who lived from 1689 to 1762.

34:00.578 --> 34:03.538
And she was preoccupied with
smallpox,

34:03.538 --> 34:08.658
in part because her own beauty
had been compromised by a severe

34:08.655 --> 34:13.145
attack of the disease,
and she elected to protect her

34:13.152 --> 34:16.482
own children by having them
inoculated,

34:16.480 --> 34:18.850
by the practice I've just
described,

34:18.849 --> 34:21.889
while they were in
Constantinople.

34:21.889 --> 34:28.719
She returned to England in 1721
and launched a one-person,

34:28.717 --> 34:35.307
a one-lady, mission to convince
society to introduce the

34:35.306 --> 34:38.656
practice of inoculation.

34:38.659 --> 34:43.589
She devoted herself to
propagandizing British society

34:43.585 --> 34:45.285
in the practice.

34:45.289 --> 34:49.109
She was able to convince the
Princess of Wales,

34:49.106 --> 34:53.166
who had her daughters
inoculated, and the practice

34:53.172 --> 34:54.752
spread rapidly.

34:54.750 --> 35:00.890
This was the first major public
health advance in dealing with

35:00.891 --> 35:02.001
smallpox.

35:02.000 --> 35:05.110
And, as I tried to suggest last
time,

35:05.110 --> 35:09.220
I would argue that it had a
role--note that I'm saying only

35:09.215 --> 35:12.425
a role,
not the role--as part of

35:12.425 --> 35:15.785
the background for the coming of
the Enlightenment.

35:15.789 --> 35:19.539
Indeed, leading
philosophes became ardent

35:19.536 --> 35:23.296
advocates of inoculation;
people in France,

35:23.295 --> 35:27.355
like Voltaire and Charles de la
Condamine;

35:27.360 --> 35:32.140
or on this side of the water,
people we might also describe

35:32.139 --> 35:35.519
as philosophes,
like Benjamin Franklin and

35:35.518 --> 35:37.248
Thomas Jefferson.

35:37.250 --> 35:40.310
Inoculation,
appropriately,

35:40.306 --> 35:45.136
gained most favor in England;
the epicenter,

35:45.135 --> 35:47.845
perhaps, of smallpox in Europe.

35:47.849 --> 35:51.889
But it gradually spread also to
France, Holland,

35:51.891 --> 35:53.441
Germany, Sweden.

35:53.440 --> 35:57.430
In Russia, the procedure was
introduced by Catherine the

35:57.427 --> 36:00.627
Great,
who imported an English

36:00.625 --> 36:04.715
physician to inoculate her in
1768,

36:04.719 --> 36:10.589
after which the nobility
rapidly adopted the practice.

36:10.590 --> 36:14.730
The cresting wave then,
of the smallpox epidemic,

36:14.730 --> 36:19.280
in the eighteenth century in
Europe was met by the first

36:19.284 --> 36:23.264
practical measure of public
health against it.

36:23.260 --> 36:28.800
Well, why did inoculation work,
at least to the extent that it

36:28.795 --> 36:29.335
did?

36:29.340 --> 36:33.810
And I would say that
inoculation was a partial

36:33.806 --> 36:34.796
success.

36:34.800 --> 36:38.840
Biological processes were at
work that are still poorly

36:38.836 --> 36:39.806
understood.

36:39.809 --> 36:43.539
But there are a couple of
relevant factors that we could

36:43.543 --> 36:44.023
note.

36:44.018 --> 36:49.398
One was that as a matter of
practice, this procedure took

36:49.396 --> 36:53.906
infective material only from
very mild cases.

36:53.909 --> 37:00.939
That was--the selection then of
cases was one reason behind its

37:00.936 --> 37:02.066
success.

37:02.070 --> 37:07.360
The infective matter also was
made to enter the body through

37:07.355 --> 37:11.155
the skin,
in a way that doesn't happen in

37:11.164 --> 37:16.134
nature,
and, for reasons that aren't

37:16.132 --> 37:21.352
understood,
attenuates the virulence of the

37:21.349 --> 37:22.089
virus.

37:22.090 --> 37:27.320
So, the portal of entry into
the body also seems to have made

37:27.322 --> 37:28.632
a difference.

37:28.630 --> 37:32.250
And lastly, for all that one
knows,

37:32.250 --> 37:36.020
those who were inoculated were
also selected,

37:36.018 --> 37:41.948
and you were only chosen for
inoculation if you were healthy

37:41.952 --> 37:43.262
and robust.

37:43.260 --> 37:46.230
There were, however, problems.

37:46.230 --> 37:52.240
Inoculation was also a
partially flawed procedure.

37:52.239 --> 37:56.159
All too often,
despite all precautions,

37:56.159 --> 38:01.009
it failed to produce the
desired mild infection,

38:01.007 --> 38:05.957
but led instead to severe
illness and death;

38:05.960 --> 38:10.550
and invariably it caused a
month or two of immense

38:10.554 --> 38:11.684
suffering.

38:11.679 --> 38:16.029
It was also costly,
since physicians insisted on a

38:16.032 --> 38:21.192
lengthy period of preparation
when they were performing the

38:21.186 --> 38:22.426
procedure.

38:22.429 --> 38:26.369
Wanting to ensure that those
they inoculated were in

38:26.373 --> 38:29.463
excellent health,
they selected patients

38:29.463 --> 38:33.333
carefully, and then isolated
them for a month before the

38:33.326 --> 38:35.996
procedure,
during which they regulated

38:36.003 --> 38:39.763
their diet,
their fresh air, their exercise;

38:39.760 --> 38:43.610
and this was obviously an
expensive process.

38:43.610 --> 38:48.380
So, inoculation was simply not
accessible to the poor.

38:48.380 --> 38:55.740
Another factor was that
inoculation could run the risk,

38:55.739 --> 39:00.459
because it introduced actual
smallpox cases,

39:00.460 --> 39:04.670
and therefore it ran the risk
of setting off an epidemic,

39:04.670 --> 39:08.200
unintentionally,
that those who contracted the

39:08.204 --> 39:12.374
disease would then spread it to
others around them.

39:12.369 --> 39:15.799
And to prevent that,
smallpox inoculation

39:15.795 --> 39:18.795
hospitals--
such as one in London,

39:18.804 --> 39:22.644
that opened in 1746--
were set up to care for the

39:22.635 --> 39:26.675
patients who'd been inoculated,
and to quarantine them,

39:26.675 --> 39:30.025
so that they were no longer a
risk to others.

39:30.030 --> 39:33.850
But nevertheless,
there was a spirited debate

39:33.847 --> 39:39.137
over the whole issue of whether,
on balance, inoculation saved

39:39.141 --> 39:42.181
many more lives than it killed.

39:42.179 --> 39:48.619
Well, that brings us to this
figure, a decisive figure in the

39:48.623 --> 39:54.643
history of medicine and public
health, and that is Edward

39:54.637 --> 39:55.817
Jenner.

39:55.820 --> 40:00.210
It was in the context of this
smallpox catastrophe of the

40:00.206 --> 40:03.896
eighteenth century,
and of disappointments and

40:03.900 --> 40:06.630
anxieties surrounding
inoculation,

40:06.630 --> 40:10.220
that we see a decisive
discovery in the history of

40:10.215 --> 40:15.215
medicine and public health,
associated with this English

40:15.222 --> 40:16.832
country doctor.

40:16.829 --> 40:21.159
To understand what happened,
we need to remember what we

40:21.161 --> 40:25.201
said last time;
and that is that there were

40:25.199 --> 40:29.699
three species of the genus of
orthopoxviruses:

40:29.699 --> 40:32.799
Variola major,
Variola minor,

40:32.800 --> 40:34.800
and cowpox.

40:34.800 --> 40:40.380
The first two are exclusively
infectious to human beings,

40:40.382 --> 40:44.172
but the third mainly affects
cattle.

40:44.170 --> 40:47.380
But the point is that,
under the right conditions,

40:47.380 --> 40:51.000
cowpox can be transmitted to
humans,

40:51.000 --> 40:54.940
among whom it induces a mild
illness,

40:54.940 --> 40:58.660
but it provides--and this was
the crucial point--

40:58.659 --> 41:05.519
a robust crossover immunity to
Variola major.

41:05.518 --> 41:09.908
Now, in Britain,
the people thought most likely

41:09.905 --> 41:13.335
to contract cowpox were
milkmaids.

41:13.340 --> 41:17.180
And Jenner--and this is why I
stressed that he was a country

41:17.182 --> 41:21.022
doctor;
this is his home in Barkley in

41:21.021 --> 41:24.661
Gloucester,
in the west of England--he made

41:24.659 --> 41:29.049
an observation that could only
have been made by a doctor with

41:29.048 --> 41:32.328
a rural practice,
in a dairy county,

41:32.329 --> 41:36.659
at a time of severe prevalence
of smallpox.

41:36.659 --> 41:41.359
And this observation was that
milkmaids never seemed to come

41:41.356 --> 41:43.026
down with smallpox.

41:43.030 --> 41:46.530
Jenner, like others--he wasn't
the first to make this

41:46.532 --> 41:50.442
observation, but he took it to
heart and attempted the next

41:50.440 --> 41:52.530
step of an experimentation.

41:52.530 --> 41:58.060
A crucial experiment occurred
in 1796.

41:58.059 --> 42:03.699
The milkmaid Sarah Nelms
contracted cowpox,

42:03.695 --> 42:09.595
and this is the--we'll see the
experiment.

42:09.599 --> 42:16.509
Edward Jenner took the
infective material from Sarah

42:16.510 --> 42:23.150
Nelms and vaccinated the
eight-year-old son of his

42:23.152 --> 42:28.202
gardener,
on his property,

42:28.201 --> 42:35.771
in 1796, and then,
after a period of time,

42:35.773 --> 42:44.783
had a challenge in vaccination
with live smallpox virus.

42:44.780 --> 42:49.970
And happily the experiment was
a great success,

42:49.974 --> 42:55.514
and Edward Phipps demonstrated
that he was immune,

42:55.507 --> 42:59.457
by this procedure,
to smallpox.

42:59.460 --> 43:04.690
And, so, soon thereafter,
Edward Jenner--

43:04.690 --> 43:07.570
whatever one thinks,
by modern terms,

43:07.570 --> 43:12.100
of the medical ethics of that
particular experiment--

43:12.099 --> 43:18.259
in 1798 Edward Jenner wrote one
of the most influential works in

43:18.260 --> 43:24.000
the history of medicine,
inquiring into the causes and

43:23.996 --> 43:28.266
effects of the Variola
vaccinae.

43:28.268 --> 43:32.268
His genius was not just to
devise the experiment;

43:32.268 --> 43:37.128
that was scientifically flawed,
perhaps, in the sense that he

43:37.128 --> 43:40.528
extrapolated from a very small
database.

43:40.530 --> 43:44.090
But in any case,
the point is that he recognized

43:44.090 --> 43:47.350
the significance of what he'd
discovered.

43:47.349 --> 43:51.509
He thought that he saw
immediately the possibility of

43:51.514 --> 43:54.724
eradicating smallpox from the
planet,

43:54.719 --> 43:58.629
an idea whose importance the
British Parliament recognized

43:58.628 --> 44:01.918
soon afterwards when it declared
vaccination,

44:01.920 --> 44:03.410
"the greatest
discovery"--

44:03.409 --> 44:07.159
I'm quoting--"in the
history of medicine."

44:07.159 --> 44:10.589
Jenner wrote,
in 1801, that he longed for,

44:10.594 --> 44:15.294
"the annihilation of the
smallpox, the most dreadful

44:15.286 --> 44:17.796
scourge of the human race.

44:17.800 --> 44:22.460
That must be the final result
of this practice."

44:22.460 --> 44:26.390
So, Jenner had the genius to
see the full implication of his

44:26.393 --> 44:28.853
discovery,
and then he devoted the

44:28.847 --> 44:32.437
remainder of his life
single-mindedly to the cause of

44:32.438 --> 44:35.198
promoting this revolutionary
method,

44:35.199 --> 44:38.439
not only in Britain but also
globally.

44:38.440 --> 44:42.850
It was also the first example
of a new and highly effective

44:42.853 --> 44:45.743
style of public health,
by vaccination,

44:45.744 --> 44:49.174
a method that's proved its
effectiveness;

44:49.170 --> 44:53.290
certainly with regard to
smallpox, but you could also

44:53.291 --> 44:55.671
mention polio,
tetanus, rabies,

44:55.668 --> 44:59.708
influenza, diphtheria,
shingles, and a host of other

44:59.710 --> 45:00.900
diseases.

45:00.900 --> 45:04.640
And Jenner soon made
influential converts,

45:04.639 --> 45:09.309
who established vaccination as
a major instrument of public

45:09.306 --> 45:13.896
health: Napoleon in France,
Pope Pius VII in Rome,

45:13.902 --> 45:19.662
Benjamin Waterhouse and Thomas
Jefferson on these shores.

45:19.659 --> 45:23.119
Jenner's method,
then, was a means to combat

45:23.123 --> 45:24.013
smallpox.

45:24.010 --> 45:29.370
And unlike inoculation,
vaccination didn't introduce an

45:29.365 --> 45:35.015
infection of smallpox itself,
and therefore had no risk of

45:35.021 --> 45:38.891
setting off an unintended
epidemic.

45:38.889 --> 45:43.509
It also had a low risk of
serious complications for the

45:43.510 --> 45:47.360
individual patient,
and no risk at all for the

45:47.360 --> 45:48.560
community.

45:48.559 --> 45:51.389
But there were problems with
Jenner's method,

45:51.389 --> 45:55.999
and it was to require a series
of subsequent improvements to

45:55.998 --> 45:59.748
make vaccination a fully
successful procedure.

45:59.750 --> 46:02.970
The problems involved such
things as he required,

46:02.969 --> 46:05.399
at the time,
an arm-to-arm method,

46:05.402 --> 46:09.682
and this entailed the risk of
spreading other diseases,

46:09.679 --> 46:14.089
in particular syphilis,
while trying to present

46:14.094 --> 46:15.154
smallpox.

46:15.150 --> 46:19.200
There were also failed
vaccinations that led to

46:19.204 --> 46:22.644
complications,
and Jenner made a crucial

46:22.641 --> 46:23.701
mistake.

46:23.699 --> 46:28.619
He made it an article of
dogmatic faith that the immunity

46:28.617 --> 46:32.917
derived from smallpox
vaccination artificially was

46:32.922 --> 46:36.422
life-long,
just like the natural immunity

46:36.422 --> 46:40.152
that was acquired,
and he steadfastly refused to

46:40.150 --> 46:43.990
consider evidence that ran
counter to his dogma.

46:43.989 --> 46:49.109
In fact, artificial immunity
wears off,

46:49.110 --> 46:52.640
it's now known,
after a period that's not quite

46:52.643 --> 46:54.973
understood,
but ten, fifteen,

46:54.972 --> 46:57.112
twenty years,
and requires,

46:57.110 --> 47:01.610
to still be valid,
re-vaccination.

47:01.610 --> 47:07.340
This blindness on Jenner's part
discredited vaccination in some

47:07.340 --> 47:10.550
quarters,
and was one factor--these

47:10.550 --> 47:14.670
various limitations then--
for one of the most powerful

47:14.672 --> 47:17.522
mass movements of the nineteenth
century,

47:17.518 --> 47:20.098
and one that's still with us
today,

47:20.099 --> 47:23.749
and that is the antivaccination
movement.

47:23.750 --> 47:28.430
Vaccination became one of the
contested debates of

47:28.425 --> 47:31.285
nineteenth-century medicine.

47:31.289 --> 47:35.759
In Britain, an Antivaccination
League was founded,

47:35.759 --> 47:39.499
and became a major political
influence.

47:39.500 --> 47:42.610
There were various sources of
opposition.

47:42.610 --> 47:46.440
There was the empirical
observation of failure,

47:46.438 --> 47:49.518
as I've said,
when people who had been

47:49.516 --> 47:53.176
vaccinated actually contracted
smallpox.

47:53.179 --> 47:56.959
There was the opposition of
liberals and libertarians to

47:56.956 --> 48:00.796
what they regarded as the
excessive power of the state in

48:00.804 --> 48:03.144
making vaccination compulsory.

48:03.139 --> 48:05.109
And there was religious
opposition,

48:05.110 --> 48:09.890
people who considered it an act
of impiety to introduce material

48:09.889 --> 48:14.939
from animals into a human body,
and there were sardonic posters

48:14.943 --> 48:19.573
featuring people undergoing
vaccination while they sprouted

48:19.574 --> 48:21.894
horns or turned into cows.

48:21.889 --> 48:26.839
But despite vaccination,
there was, in Britain,

48:26.835 --> 48:33.175
an Act of 1840 that provided
for free infant vaccination.

48:33.179 --> 48:37.339
And from that time,
the annual toll from smallpox

48:37.336 --> 48:40.826
began to plummet,
despite the fact that the

48:40.827 --> 48:44.907
nineteenth century provided
conditions that would have been

48:44.907 --> 48:48.697
favorable to promoting the
disease: improved and speedy

48:48.704 --> 48:50.884
transport,
with steamships,

48:50.876 --> 48:55.186
canals and the railroads;
crowding with a population that

48:55.192 --> 48:59.572
was ever more mobile,
massive growth and urbanization

48:59.574 --> 49:01.264
and large cities.

49:01.260 --> 49:07.190
And those changes and advances
were reproduced across Europe

49:07.188 --> 49:09.198
and North America.

49:09.199 --> 49:12.089
And there were technological
improvements as well--

49:12.090 --> 49:16.710
all of which leads me to the
end of this morning--

49:16.710 --> 49:21.250
which is to say in 1959,
the World Health Organization

49:21.248 --> 49:26.558
undertook the unprecedented step
of launching a global smallpox

49:26.559 --> 49:30.669
eradication program by means of
vaccination.

49:30.670 --> 49:36.240
In 1977, the final natural case
occurred.

49:36.239 --> 49:39.839
And in 1980,
smallpox was declared,

49:39.835 --> 49:45.015
by the WHO, eradicated
everywhere on the globe.

49:45.018 --> 49:50.218
So, vaccination then comes with
this extraordinary history of

49:50.224 --> 49:53.874
public health,
of combating a major disease

49:53.869 --> 49:57.859
like smallpox and actually
eradicating it.

49:57.860 --> 50:02.200
What we'll want to do,
as we move through the course,

50:02.195 --> 50:06.695
is to ask what are the
conditions that make vaccination

50:06.697 --> 50:10.197
an appropriate tool for public
health?

50:10.199 --> 50:12.059
When is it not appropriate?

50:12.059 --> 50:16.349
Why are there such difficulties
with poliomyelitis,

50:16.349 --> 50:18.579
as we're speaking today?

50:18.579 --> 50:22.969
Was smallpox the beginning of a
wave of diseases to be

50:22.965 --> 50:25.775
eradicated this way,
one by one?

50:25.780 --> 50:31.300
Or was smallpox an exception,
a special case?

50:31.300 --> 50:33.620
Well, stay tuned,
and we'll deal with that.

50:33.619 --> 50:38.999