Immunizations
Major American Epidemics Of Yellow Fever (1793-1905)
Yellow fever appeared in the U.S. In the late 17th century. The deadly virus continued to strike cities, mostly eastern seaports and Gulf Coast cities, for the next two hundred years, killing hundreds, sometimes thousands in a single summer.
1. Philadelphia; August-November 1793; approximately 5,000 deadThis outbreak killed about 10% of the city's population, and thousands more fled, including an infected Alexander Hamilton and his wife. Dr. Benjamin Rush, who stayed, issued guidelines for avoiding infection and helped set up a "fever hospital" for victims.
2. New York City; July-October 1795; 730 deadNew York City, which in 1793 had turned away refugees from the epidemic in Philadelphia, suffered its own epidemic two summers later.
3. Boston, New York City and Philadelphia; Summer 1798; more than 5,000 deadConcurrent epidemics hit the nation's three major cities.
4. Baltimore; Summer 1800; 1,200 deadAs the 19th century wore on, yellow fever outbreaks would increasingly be confined to the southern United States.
5. New Orleans; Summer 1853; 8000 or more deadThis outbreak illustrated a racial disparity in yellow fever mortality; 7.4% of white residents died, but only 0.2% of blacks.
6. Norfolk; June-Oct 1855; 2,000 deadThis epidemic, like many others in America, began with the arrival of a disease-carrying ship from the West Indies.
7. Mississippi Valley; May-Oct 1878; 20,000 deadStarting in New Orleans, this epidemic spread up the Mississippi Valley to Memphis. More than half of the 47,000 residents of Memphis fled the city; more than 5,000 died that summer of yellow fever.
8. Cuba; Summer 1898; hundreds deadDisease killed more than five times as many American soldiers as enemy bullets during the Spanish-American war; yellow fever was among the culprits, and its impact led to the establishment of a U.S. Army Yellow Fever Board led by Walter Reed that would unravel the mystery of yellow fever transmission and lead to its eradication in America.
9. New Orleans; May-October 1905; more than 900 deadYellow fever epidemics took more than 41,000 lives in New Orleans from 1817-1905, but the 1905 outbreak was America's last. Today, yellow fever continues to appear in small outbreaks in South America and more serious epidemics in West and Central Africa.
A Lesson From History: How The Yellow Fever Epidemic Changed Society
Asked how she was fairing during the shelter in place, Stanford University historian Kathryn Olivarius reflected on being a researcher studying early American epidemics during the COVID-19 crisis.
"I write about yellow fever by day and worry about COVID-19 at night," she said.
Olivarius, an assistant professor of history, was working on her doctoral dissertation on slavery around the time of the Louisiana Purchase in 1803 when she discovered voluminous documents on recurrent epidemics of yellow fever in New Orleans. The letters, advertisements and news articles changed her work in profound ways.
Yellow fever killed more than 150,000 people in New Orleans between the Louisiana Purchase in 1803 and the Civil War, according to Olivarius.
"Once you see it, every single source is covered with references to yellow fever. I could not discard it as background noise. This is really important stuff in the background of this place," she said. "It put me down the path of thinking about yellow fever — and not just death — but about life and how it fundamentally shaped institutions."
She was writing a book, "Necropolis: Disease, Power and Capitalism in the Cotton Kingdom," due out next year, when the coronavirus epidemic broke out. Now she's seeing parallels between what happened in the South and her own experiences with the coronavirus pandemic.
The earlier viral disease shaped society and the economy, just as COVID-19 is shaping our own, she said. The experience of yellow fever, much like COVID-19, permeated everything.
New Orleans in the early 19th century was a hub of the cotton, sugar and slave trades, yet it was constantly besieged by yellow fever. Outbreaks roiled the city about every three years, shaping social status, slavery, government and jobs, she said.
If the coronavirus continues to infect populations for months or years, present-day society and government will be faced with dilemmas similar to those that confronted New Orleans.
"It's possible we can't find a vaccine. How are we going to live with this disease?" she said.
What the world is experiencing now as a crisis is something people lived with perpetually in the 19th century, she said.
Without antibiotics, antiviral drugs or even knowledge of the underlying cause of yellow fever, staying healthy was a major concern.
"You had to reconcile yourself to this precarity in the past," she said.
Yellow fever was fearsome, killing 50% of its victims. The disease started with a fever, aches and pains, a severe headache, weakness, fatigue, nausea and vomiting. Recovery took weeks or months.
After a week and a short remission of a few hours or a day, one in seven people developed severe liver disease with bleeding and jaundice. Shock, organ failure and death could ensue.
Although rare in the U.S. Today due to vaccinations and mosquito control, there's still no cure and no treatment for yellow fever. Between 30% and 60% of people with severe symptoms still die, according to the U.S. Centers for Disease Control and Prevention.
Beyond the danger of the viral infection, yellow fever revealed the disparities between rich and poor that existed in the antebellum South, Olivarius said.
New Orleans became a stratified society of those who were thought to be "acclimated" to yellow fever and those who were "unacclimated," meaning they either had or did not have immunity.
Old, white Louisiana families considered themselves "acclimated" to the disease, either having survived it — or able to avoid getting it. They had advantages that others did not, however, with respect to the latter.
"The rich in any city have a tendency to separate themselves from poor people," she said. "We know places such as docks, levees and tenement houses were breeding grounds. They knew this too. They had the ability to distance themselves from the most dangerous spaces."
When a newspaper story announced a case of yellow fever, wealthy residents fled to a hotel in the country, moved to plantation homes out of the area or traveled overseas to escape, Olivarius said.
Not so the middle class, poorer newcomers and slaves, who would see their city transformed overnight by a mass exodus. During fever season, from July through November, they heard the constant ringing of church bells for the dead. Loud booms carried throughout the city as officials fired cannons to try to drive away the miasma, Olivarius said.
An immunocapitalist society
As a result of its culture and its inability to tackle or even understand the nature of the disease — people didn't know it was mosquito-borne — New Orleans decided it would not fight yellow fever. The city was at the base of the Mississippi River and was a major export hub for the cotton industry. It couldn't just move, Olivarius said. Instead, people decided they would have to live with the disease and focused on maintaining New Orleans' economic engine.
A new economic model emerged as a result of the recurring yellow fever epidemics: immunocapitalism, which found many ways to insert privilege and division into the social structure. Newcomers were not considered acclimated and had limited opportunities for advancement, Olivarius said. People with immunity had more value because they wouldn't get the disease again and wouldn't disrupt the economy.
Being "acclimated" meant access to jobs, credit, housing and improved social status. To be unacclimated meant lower status and stagnation. Merchants wouldn't enter into contracts with someone who couldn't prove acclimation, she said. Immunity conferred privileges.
"In job ads at the time, the first thing you list is 'I'm acclimated.' It was a sign that someone is permanent," she said.
"People stayed behind on purpose to get the disease. If you get sick and you survive, you go up the ladder of society," Olivarius said.
Immunity granted other advantages. Wealthy people rarely purchased life insurance on themselves, but they did take out insurance on their slaves as property. Insurance companies targeted middle-class men for policies on themselves as a "smart move" to protect their families if the head of the household died. These policies charged "climate premiums" based on immunity to yellow fever, however, Olivarius said.
"If you were unacclimated, you could be flatly not approved for a policy or charged a very high premium," she said.
Proving one had yellow fever was another matter. Many of its symptoms, including fever, delirium and nausea, were vague and similar to other diseases found in the region — unless a patient vomited blood, a telltale symptom.
"Yellow fever doesn't leave visual scars. You have to perform your immunity to this disease," she said.
Affidavits from physicians and letters from witnesses and business associates to insurance agents attested to the policy applicant's acclimation: "I cared for him in 1833" or "I've never known him to be sick in 12 years" were ways to prove immunity, Olivarius said.
Survival and immunity also conferred a certain sense of moral superiority. It was part of the genesis stories of much of the city's political and economic elite. Triumph over yellow fever was God's will, manliness, morality, sobriety and honor. Those who died were judged dissipated or alcoholic, getting what they deserved, she said.
Olivarius acknowledges there are limits to comparing the COVID-19 pandemic to yellow fever epidemics in 19th-century New Orleans. For one thing, theirs was a culture of mass mortality, a highly destructive society that was exacerbated by risk taking and gambling, with betting on the future and on the next cotton price. The city also had a nearly nonexistent public health policy to begin with, she said.
Where antebellum New Orleans had a high mortality rate and no medical way to treat the disease, COVID-19 is far less lethal, at about 2% mortality or less.
"We can make decisions that can slow the infection from COVID-19 (to prevent) the worst epidemiological effects of this disease," she said.
Still, Olivarius has some concerns about the push to reignite the economy too soon by lifting the sequester-at-home orders.
"You can see a mercenary attitude. It has icy echoes of the past about the greater good. There's rhetorical talk about public health versus economic crisis as separate, but they aren't," she said.
People in the past also thought "we can't let the cure be worse than the disease," she added.
She thinks that while yellow fever was a persistent and inescapable part of life in the 19th century, "We don't have to make those choices" under COVID-19.
The haves and the have nots
Olivarius finds disturbing certain parallels between attitudes toward yellow fever and those emerging toward COVID-19: ideas about building herd immunity and valuing certain lives over others.
A March 25 article in the conservative online magazine The Federalist titled "How Medical 'Chickenpox Parties' Could Turn The Tide Of The Wuhan Virus" touted the idea of "controlled voluntary infection." People at low risk for severe complications deliberately contract the coronavirus so they become immune. (Researchers are not yet sure to what degree if any getting COVID-19 will confer immunity.)
The author claims voluntary controlled infections would model "chickenpox parties" that took place before immunizations of childhood diseases such as chickenpox and German measles. Neighborhood children were invited to play with an infected child so "the entire community would get the disease out of the way in one little local epidemic," according to the article. Immunity obtained at a young age would also prevent people from getting the disease later in life when it would be more dangerous, the article said.
"It so enraged me that I wrote a New York Times op-ed about it," Olivarius said, noting the suffering and lives lost in New Orleans when people deliberately tried to get yellow fever.
The potential segmenting of the population according to those who have had COVID-19 and those who have not worries Olivarius.
"The problem in the U.S. Is we don't have widespread immunity. We might end up with an immune elite to COVID who can go out to work, restaurants, the movies and parks and the non-immunes without antibodies would be stuck at home," she said.
That could lead to people deliberately trying to get sick to get back to work again. She pointed to serious talk about issuing "immunity passports," which would allow people who have had COVID-19 to travel freely while the movement of the "have nots" would be restricted.
The COVID-19 pandemic also could create a growing justification for racism, she said.
Antebellum society used yellow fever as a justification for slavery. A persistent myth claimed that since yellow fever was known in Africa, black people had a natural resistance to yellow fever. There is no such thing as inherited immunity, however, and slaves who had not contracted the disease in Africa had no immunity when they boarded slave ships and were sent in chains to Louisiana, Olivarius said. Slavers, however, used the mythology to justify having black people work in places where the chances of contracting the disease were the highest. Many deaths soon followed.
Slaves who had survived yellow fever were worth more. Advertisements showed that an "acclimated" slave could fetch 25% to 50% more, Olivarius said.
Olivarius also sees the United States' poor people and people of color being the greater victims of the COVID-19 epidemic. There are already racial and geographical disparities in testing and exposure to the virus, she said. Those who are in service jobs come into contact with the public and have a greater likelihood of contracting the disease: grocery store employees, transportation workers and others. White-collar workers stay protected at home and work remotely from their laptops.
"Pandemics and epidemics … lay bare the existing inequality and demonstrate fast and painfully who belongs in society and who does not," she said.
"I'm scared. I worry that with COVID-19 we will radically increase racism. Already, there is huge discrimination against Chinese individuals who are being blamed" for the disease, which originated in Wuhan, China, she said. "Those are bad signs. What's going to come in the months and years with this epidemic?"
If there is one lesson from history that is important during this pandemic, Olivarius said, it's that the public must have information that is accurate and truthful.
In 1847, there were many suspected cases of yellow fever earlier than expected, in June. Doctors were hesitant to diagnose the disease and made a huge effort not to declare an early case that year. A diagnosis brought fear and upended the economy, she said. When a young Irish immigrant showed symptoms, one doctor first suspected the disease, but he would not issue a definitive diagnosis and sought a second opinion. The second doctor, although noting the symptoms were clearly yellow fever, was also hesitant to label it.
"Both didn't want to be wrong. The boy died, and many thousands of people died. If they had declared it was yellow fever, it would've saved many lives," Olivarius said.
On a larger scale, misinformation in New Orleans was propagated by a board of health, which was responsible for collecting mortality data on a weekly basis.
"Everyone knew the board was a propaganda arm for business," she said, and the board made a concerted effort to keep the numbers low.
"People knew they were lying to them," she said.
"When people live in an epidemic and the information is not reliable, it erodes trust in many things, and people take things into their own hands," she said.
"This is hugely disruptive," she said of the COVID-19 pandemic. "Having trust matters."
To reduce disruption, a central message from government leaders must be "we're in this together," she said.
Find comprehensive coverage on the Midpeninsula's response to the new coronavirus by Palo Alto Online, the Mountain View Voice and the Almanac here.
Most PopularHistorical Guide To Yellow Fever
In the summer of 1693, a strange disease spread through Boston. Victims suffered from jaundice, high fever and black vomit. For more than two hundred years, yellow fever — as the disease became known — attacked numerous American cities, usually in severe summer outbreaks.
At the dawn of the 20th century, a U.S. Army Yellow Fever Board stationed in Cuba, headed by Major Walter Reed, confirmed a theory of Cuban doctor Carlos Finlay about the role of mosquitoes in the transmission of the disease. This theory was put to the test a few years later during a massive yellow fever outbreak in New Orleans.
HistoryYellow fever was a constant blight for eastern American cities — especially southeastern cities — in the 18th and 19th centuries. Most outbreaks occurred in the summer months, but some summers would pass without incident. Severe outbreaks occurred mostly in the south, especially along the Gulf Coast.
But increased mobility in the period after the Civil War enabled the disease — through infected carriers — to travel farther inland. Health officials offered different theories about the nature of the disease and its transmission, but it wasn't until a Cuban doctor presented his observations on the transmission of the disease by mosquitoes to a board of American Army doctors that an understanding of the disease was mastered.
SymptomsThe first stages of yellow fever are similar to the common flu: headache, fever and muscle aches. This lasts for two to three days and then the victim feels better, even to the point of thinking that their flu has passed.
The second "toxic" phase begins one or two days later, as the virus attacks the internal organs such as the kidneys and liver. Victims become jaundiced and yellowed, hence the name yellow fever. Excessive internal bleeding can cause the victim to vomit blood, which was called the "black vomit."
Death occurs from internal hemorrhaging, usually five to ten days into the second phase.
TransmissionYellow fever is a virus that is transmitted to humans by particular species of mosquitoes — in North American outbreaks, the Aegis Egyptae.
Female mosquitoes with infected parents can be born with the disease, or they can feed on infected humans, acquiring the disease along with the human blood.
The virus replicates in the mosquito's digestive tract, and is then carried through the bloodstream to the salivary glands. This cycle takes between seven and seventeen days, during which the mosquito can not transmit the virus.
After the virus has spread to the salivary glands of the insect, the next time the mosquito feeds, she will transmit the virus into the human skin. From the skin, the virus multiplies and is carried into the lymph nodes, which carries it into the bloodstream. Then symptoms appear.
Patients who survive yellow fever develop immunity from further infections.
Mosquitoes will not survive a frost. However, infected female mosquitoes pass yellow fever to their eggs. These eggs can lie dormant through dry, winter conditions, hatching the next year, releasing new infected mosquitoes; this is the reason the disease returned annually. Areas of standing water are prime breeding grounds and are emblematic of outbreak areas.
Treatment and Prevention"If you get yellow fever today your chances of survival are probably not much different than they were in the 1700s or the 1800. It's still going to be 1 out of every 5 or so who are going to die. There is no treatment, you can prevent it but you can't treat yellow fever." — Jim Writer, author, Yellow Jack: How Yellow Fever Ravaged America and Walter Reed Discovered Its Deadly Scourge
There is no cure for yellow fever.
Before the transmission of yellow fever was understood, yellow fever was thought to be airborne or spread through infected clothing. Urban areas burned tar, blanketing cities in choking smoke, in an effort to purify the air. Infected victims were also subject to strict quarantines in an effort to stop the spread of the disease. Quarantine and isolation, combined with choking smoke, reduced outbreak sites to virtual ghost towns.
Once mosquitoes were known to transmit the virus, public health officials targeted the insects in their preventive measures. A 1905 yellow fever outbreak in New Orleans was the first large scale test of mosquito control as a means of thwarting yellow fever. Workmen covered cisterns with screens and treated standing water with kerosene. Informed residents burned an estimated three hundred tons of sulphur to fumigate their premises. That year 452 victims died from yellow fever, but the further spread was prevented and future outbreaks did not occur.
In the 1930s, French and American scientists independently developed vaccines against yellow fever. The vaccines are not entirely without risk and are only administered to individuals living or traveling through areas known to be infected with yellow fever.
Vaccination, mosquito control and surveillance for outbreak in high risk areas remain the most effective means of controlling yellow fever.
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