The eradication of smallpox in 1980, with the exception of two known stores maintained in government laboratories in the United States and Russia, is considered one of the greatest public health victories of the modern world. Smallpox devastated populations beginning in the ancient world, where skeletons entombed in Egypt still show the scars left by this vicious virus. It has a relatively high mortality rate of 30% with higher rates of long-term disability, including blindness and scarring. It is also highly contagious, so the fact that it was eliminated from the world through the concerted application of vaccination reflects the tenacity of public health efforts in the face of even the most aggressive viruses. While it seems logical to use vaccination to end a disease that cost billions of lives between the first ancient outbreak and the final recorded case in 1977, it actually caused serious debates in the early modern world when inoculation (which preceded vaccination) first proved to be effective. This section focuses on the seventeenth-century religious debates that occurred in the United States and in other Protestant countries over the relationship between divine will and disease. While this might seem like a uniquely early modern debate, its echoes are heard today in the refusal by people of some faiths to accept some forms of medical treatment, such as Jehovah’s Witnesses who will not accept transfusions, and those who reject vaccinations on religious grounds, such as Christian Scientists and the Dutch Reformed Church. The issue of refusing vaccination on religious grounds has never been more relevant: increasingly, parents are opting out of vaccinating their children, and they are using religious grounds for that refusal. Forty-seven states allow this practice, and parents are not required to provide proof that their basis for refusing vaccination is, in fact, religious.96 While antivaccination propaganda inaccurately portrays vaccinations as the cause for autism and other developmental disorders, it simultaneously ignores the reality that vaccinating less than a high proportion of a population will permit epidemics to re-emerge. The rise of small outbreaks of measles, mumps, and other previously eradicated (in North America) childhood killers demonstrates the critical importance of vaccination. Perhaps a look at early modern religious debates over smallpox immunization will help to clarify our current situation.

Inoculation is the practice of taking pus from the pox of an infected patient, scoring an uninfected person’s arm, and placing the pus directly over the scoring. The practice was widely used in China and the Middle East before being imported to England and then North America through the efforts of Lady Mary Wortley Montague, an English aristocrat who had been badly disfigured by smallpox and lost her brother to it. She was married to the English ambassador to Turkey, where she encountered the procedure and observed that it caused a much less severe case of smallpox to occur in the recipient individual but still conferred immunity. She inoculated her own children and was a major force in introducing the practice to the English aristocracy upon her return home. Inoculation carried risks, including the potential for starting a new epidemic and the death of the inoculated patient, but it was a far more effective solution than any other available before Edward Jenner’s vaccine. The debate over whether to inoculate rested not in any question about whether inoculation was successful in preventing smallpox or on its potential dangers. Instead, it lay in the interpretation of disease as part of divine will. For some Protestants, if God sent a virus to assail his followers but there was a known preventative or cure available, it was immoral not to use it. For others, accepting suffering was a means of demonstrating faith, and disease was a test of faith given by God. In 1583, for example, a physician who wrote to magistrates about the use of natural remedies to protect against or treat the plague during an epidemic warned against trying to protect oneself in opposition to divine will, stating if anyone of “conscience and religion shall be persuaded to think that he resisteth the will of God, [or] if by the help of man he labor to avoid his punishment, he must suffer himself to be better taught.”97 Susan Emlen, a Quaker woman in 1814 Philadelphia afflicted by breast cancer who chose to have a mastectomy (a rare procedure at that time, done without anesthesia and having significant complications), wrote of her spiritual understanding of her cancer in letters to her father and husband. She repeatedly referred to her cancer as a trial for her soul sent, in a quote from Lamentations, by a gracious power “who afflicts not willingly.”98 Note that despite her deep religious calling and spiritual comprehension of her cancer, Emlen sought the most aggressive treatment possible, perhaps in part because her brother-in-law was “the father of American surgery,” Phillip Physick, who held a medical degree from Edinburgh and had practiced for three years under the renowned London surgeon John Hunter.99 Emlen, supported by her surgeon and husband, saw no conflict between seeking every possible solution for her cancer and experiencing her spiritual trial. A century before Emlen was diagnosed, however, Boston saw a heated contest between religious and medical authority and different interpretations of Protestantism in the context of a debate over smallpox inoculation.

The Reverend Cotton Mather was the proponent of smallpox inoculation in this case, which occurred during the smallpox outbreak of 1721. It was a major outbreak, in which 6000 cases were reported in a city of

11,000 people, and the mortality rate was 14%. This was the deadliest smallpox outbreak in New England of the seven that occurred during the first half of the eighteenth century.101’ Mather was a member of the Royal Society with a strong interest in natural philosophy and the traditional understanding that clergy are responsible for the health of their flock’s bodies as well as their minds. As a result, he maintained a healthy interest in medicine, although he had no formal training in it. In 1716, he wrote the Royal Society to indicate that he had read the article in the Transactions discussing smallpox inoculation in Turkey, but he also asserted that he had already heard of this procedure through a discussion with his African servant, Onesimus, who had been inoculated before being transported to the Americas. Mather confirmed Onesimus’ account by querying other Africans about the practice, and upon learning that it was effective, became a strong proponent of the procedure. When smallpox hit Boston again, he found a doctor, Zabdiel Boylston, to help him inoculate volunteers. Mather believed inoculation was a divine gift sent to help save lives and ignoring it would be tantamount to rejecting divine assistance, but he also seemed very interested in the practical applications of the practice. His efforts were most vociferously countered by the physician William Douglass, who remained convinced that inoculation was ridiculous on two fronts: first, because Mather’s trials were based on the report of an African servant and a Royal Society article about a practice in the Middle East, and he did not value knowledge generated in non- European contexts, and second because he feared it would only hasten the spread of smallpox by exposing more people to it and creating more cases. Douglass was one of the few practicing medical men in Boston who actually held a medical degree, and historians have attributed some of his resistance to the inoculation trial to an effort to establish authority over medical practice at a time when the profession was dominated by people without university training. Douglass’ racialized perspective on which people could produce valuable knowledge were typical for his time, as was his urge to defend his professional territory.101 Mather, on the other hand, was a bit of a maverick, as he combined his traditional area of knowledge with his deep passion for natural philosophy and medicine. While Mather and Boylston were brave for putting their reputations on the line to defend inoculation, it is the volunteers who truly deserve recognition. Two hundred eighty-seven individuals chose to be inoculated, and not much is known about their backgrounds or what drove their decision. What is known, however, is that the mortality rate among those who were inoculated was 2%, a remarkable relative risk reduction, compared with the overall mortality rate for that outbreak.102 Mather and Boylston’s use of the most sophisticated study design available, employing control and experimental groups, underlined the validity of their results and encouraged other practitioners in New England to adopt inoculation. It also damaged the ongoing argument that all diseases occurred differently in people of different races, putting an early nail in the coffin of racial medicine. Mather and Boylston’s efforts were perhaps the first North American clinical trial, and they proved critical to the adoption of inoculation in the colonies.

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