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The history of smallpox extends into pre-history, with the disease probably emerging in human populations about 10,000 BC.[1] The earliest credible evidence of smallpox is found in the Egyptian mummies of people who died some 3,000 years ago.[2] Smallpox has had a major impact on world history, not least because indigenous populations of regions where smallpox was non-native, such as the Americas and Australia, were rapidly and greatly reduced by smallpox (along with other introduced diseases) during periods of initial foreign contact, which helped pave the way for conquest and colonization. During the 18th century the disease killed an estimated 400,000 Europeans each year, including five reigning monarchs, and was responsible for a third of all blindness.[3] Between 20 and 60% of all those infected—and over 80% of infected children—died from the disease.[4]

During the 20th century, it is estimated that smallpox was responsible for 300–500 million deaths.[5][6][7] In the early 1950s an estimated 50 million cases of smallpox occurred in the world each year.[8] As recently as 1967, the World Health Organization estimated that 15 million people contracted the disease and that two million died in that year.[8] After successful vaccination campaigns throughout the 19th and 20th centuries, the WHO certified the global eradication of smallpox in December 1979.[8] Smallpox is one of two infectious diseases to have been eradicated, the other being rinderpest, which was declared eradicated in 2011.[9][10][11]

Eurasian epidemics

It has been suggested that smallpox was a major component of the Plague of Athens that occurred in 430 BCE, during the Peloponnesian Wars, and was described by Thucydides. Galen's description of the Antonine Plague, which swept through the Roman Empire in 165–180 CE, indicates that it was probably caused by smallpox.[12] Returning soldiers brought the disease home with them to Syria and Italy, where it raged for fifteen years and greatly weakened the Roman empire, killing up to one-third of the population in some areas.[13] Total deaths have been estimated at 5 million.[14] A seco

During the 20th century, it is estimated that smallpox was responsible for 300–500 million deaths.[5][6][7] In the early 1950s an estimated 50 million cases of smallpox occurred in the world each year.[8] As recently as 1967, the World Health Organization estimated that 15 million people contracted the disease and that two million died in that year.[8] After successful vaccination campaigns throughout the 19th and 20th centuries, the WHO certified the global eradication of smallpox in December 1979.[8] Smallpox is one of two infectious diseases to have been eradicated, the other being rinderpest, which was declared eradicated in 2011.[9][10][11]

It has been suggested that smallpox was a major component of the Plague of Athens that occurred in 430 BCE, during the Peloponnesian Wars, and was described by Thucydides. Galen's description of the Antonine Plague, which swept through the Roman Empire in 165–180 CE, indicates that it was probably caused by smallpox.[12] Returning soldiers brought the disease home with them to Syria and Italy, where it raged for fifteen years and greatly weakened the Roman empire, killing up to one-third of the population in some areas.[13] Total deaths have been estimated at 5 million.[14] A second major outbreak of disease in the Roman Empire, known as the Plague of Cyprian (251–266 CE), was also either smallpox or measles. The Roman empire stopped to grow as a consequence on these two plagues, according to historians like Theodore Mommsen. Although some historians believe that many historical epidemics and pandemics were early outbreaks of smallpox, contemporary records are not detailed enough to make a definite diagnosis.[1][15]

Around 400 CE, an Indian medical book[which?] recorded a disease marked by pustules and boils, saying "the pustules are red, yellow, and white and they are accompanied by burning pain … the skin seems studded with grains of rice." The Indian epidemic was thought to be punishment from a god, and the survivors created a goddess, Sitala, as the anthropomorphic personification of the disease.[16][17][18] Smallpox was thus regarded as possession by Sitala. In Hinduism the goddess Sitala both causes and cures high fever, rashes, hot flashes and pustules. All of these are symptoms of smallpox.

Most of the details about the epidemics are lost, probably due to the scarcity of surviving written records from the Early Middle Ages. The first incontrovertible description of smallpox in Western Europe occurred in 581 CE, when Bishop Gregory of Tours provided an eyewitness account describing the characteristic symptoms of smallpox.[15] Waves of epidemics wiped out large rural populations.[19] The establishment of the disease in Europe was of special importance, for this served as the endemic reservoir from which smallpox spread to other parts of the world, as an accompaniment of successive waves of European exploration and colonization.

In 710 CE, smallpox was re-introduced into Europe via the Iberia by the Umayyad conquest of Hispania.[20]

The Japanese smallpox epidemic of 735–737 is believed to have killed as much as one-third of Japan's population.[21][22]

The clearest description of smallpox from pre-modern times was given in the 9th century by the Persian physician, Muhammad ibn Zakariya ar-Razi, known in the West as "Rh

Around 400 CE, an Indian medical book[which?] recorded a disease marked by pustules and boils, saying "the pustules are red, yellow, and white and they are accompanied by burning pain … the skin seems studded with grains of rice." The Indian epidemic was thought to be punishment from a god, and the survivors created a goddess, Sitala, as the anthropomorphic personification of the disease.[16][17][18] Smallpox was thus regarded as possession by Sitala. In Hinduism the goddess Sitala both causes and cures high fever, rashes, hot flashes and pustules. All of these are symptoms of smallpox.

Most of the details about the epidemics are lost, probably due to the scarcity of surviving written records from the Early Middle Ages. The first incontrovertible description of smallpox in Western Europe occurred in 581 CE, when Bishop Gregory of Tours provided an eyewitness account describing the characteristic symptoms of smallpox.[15] Waves of epidemics wiped out large rural populations.[19] The establishment of the disease in Europe was of special importance, for this served as the endemic reservoir from which smallpox spread to other parts of the world, as an accompaniment of successive waves of European exploration and colonization.

In 710 CE, smallpox was re-introduced into Europe via the Iberia by the Umayyad conquest of Hispania.[20]

The Japanese smallpox epidemic of 735–737 is believed to have killed as much as one-third of Japan's population.[21][22]

The clearest description of smallpox from pre-modern times was given in the 9th century by the Persian physician, Muhammad ibn Zakariya ar-Razi, known in the West as "Rhazes", who was the first to differentiate smallpox from measles and chickenpox in his Kitab fi al-jadari wa-al-hasbah (The Book of Smallpox and Measles).[23]

Smallpox was a leading cause of death in the 18th century. Every seventh child born in Russia died from smallpox.[8] It killed an estimated 400,000 Europeans each year in the 18th century, including five reigning European monarchs.[24] Most people became infected during their lifetimes, and about 30% of people infected with smallpox died from the disease, presenting a severe selection pressure on the resistant survivors.[25]

In northern Japan, Ainu population decreased drastically in the 19th century, due in large part to infectious diseases like smallpox brought by Japanese settlers pouring into Hokkaido.[26]

The Franco-Prussian War triggered a smallpox pandemic of 1870–1875 that claimed 500,000 lives; while vaccination was mandatory in the Prussian army, many French soldiers were not vaccinated. Smallpox outbreaks among French prisoners of war spread to the German civilian population and other parts of Europe. Ultimately, this public health disaster inspired stricter legislation in Germany and England, though not in France[27]

In 1849 nearly 13% of all Calcutta deaths were due to smallpox.[28] Between 1868 and 1907, there were approximately 4.7 million deaths from smallpox in India. Between 1926 and 1930, there were 979,738 cases of smallpox with a mortality of 42.3%.[29]

Smallpox is exogenous to Africa. One of the oldest records of what may have been an encounter with smallpox in Africa is associated with the elephant war circa AD 568 CE, when after fighting a siege in Mecca, Ethiopian troops contracted the disease which they carried with them back to Africa.

Arab ports in Coastal towns in Africa likely contributed to the importation of smallpox into Africa, as early as the 13th century, though no records exist until the 16th century. Upon invasion of these towns by tribes in the interior of Africa, a severe epidemic affected all African inhabitants while sparing the Portuguese. Densely populated areas of Africa connected to the Mediterranean, Nubia and Ethiopia by caravan route likely were affected by smallpox since the 11th century, though written records do not appear until the introduction of the slave trade in the 16th century.[2]

The enslavement of Africans continued to spread smallpox to the entire continent, with raiders pushing farther inland along caravan routes in search of people to enslave. The effects of smallpox could be seen along caravan routes, and those who were not affected along the routes were still likely to become infected either waiting to be put onboard or on board ships.[2]

The enslavement of Africans continued to spread smallpox to the entire continent, with raiders pushing farther inland along caravan routes in search of people to enslave. The effects of smallpox could be seen along caravan routes, and those who were not affected along the routes were still likely to become infected either waiting to be put onboard or on board ships.[2]

Smallpox in Angola was likely introduced shortly after Portuguese settlement of the area in 1484. The 1864 epidemic killed 25,000 inhabitants, one third of the total population in that same area. In 1713, an outbreak occurred in South Africa after a ship from India docked at Cape Town, bringing infected laundry ashore. Many of the settler European population suffered, and whole clans of the Khoisan people were wiped out. A second outbreak occurred in 1755, again affecting both the white population and the Khoisan. The disease spread further, completely eradicating several Khosian clans, all the way to the Kalahari desert. A third outbreak in 1767 similarly affected the Khoisan and Bantu peoples. But the European colonial settlers were not affected nearly to the extent that they were in the first two outbreaks, it has been speculated this is because of variolation. Continued enslavement operations brought smallpox to Cape Town again in 1840, taking the lives of 2500 people, and then to Uganda in the 1840s. It is estimated that up to eighty percent of the Griqua tribe was exterminated by smallpox in 1831, and whole tribes were being wiped out in Kenya up until 1899. Along the Zaire river basin were areas where no one survived the epidemics, leaving the land devoid of human life. In Ethiopia and the Sudan, six epidemics are recorded for the 19th century: 1811–1813, 1838–1839, 1865–1866, 1878–1879, 1885–1887, and 1889–1890.[30]

After first contacts with Europeans and Africans, some believe that the death of 90–95% of the native population of the New World was caused by Old World diseases.[43] It is suspected that smallpox was the chief culprit and responsible for killing nearly all of the native inhabitants of the Americas. For more than 200 years, this disease affected all new world populations, mostly without intentional European transmission, from contact in the early 16th century until possibly as late as the French and Indian Wars (1754–1767).[44]

In 1519 Hernán Cortés landed on the shores of what is now Mexico and what was then the Aztec Empire. In 1520 another group of Spanish arrived in Mexico from Hispaniola, bringing with them the smallpox which had already been ravaging that island for two years. When Cortés heard about the other group, he went and defeated them. In this contact, one of Cortés's men contracted the disease. When Cortés returned to Tenochtitlan, he brought the disease with him.

Soon, the Aztecs rose up in rebellion against Cortés and his men. Outnumbered, the Spanish were forced to flee. In the fighting, the Spanish soldier carrying smallpox died. Cortés would not return to the capital until August 1521. In the meantime smallpox devastated the Aztec population. It killed most of the Aztec army and 25% of the overall population.[45] The Spanish Franciscan Motolinia left this description: "As the Indians did not know the remedy of the disease…they died in heaps, like bedbugs. In many places it happened that everyone in a house died and, as it was impossible to bury the great number of dead, they pulled down the houses over them so that their homes become their tombs."[46] On Cortés's return, he found the Aztec army’s chain of command in ruins. The soldiers who still lived were weak from the disease. Cortés then easily defeated the Aztecs and entered Tenochtitlán.[47] The Spaniards said that they could not walk through the streets without stepping on the bodies of smallpox victims.[48]

The effects of smallpox on Tahuantinsuyu (or the Inca empire) were even more devastating. Beginning in Colombia, smallpox spread rapidly before the Spanish invaders first arrived in the empire. The spread was probably aided by the efficient Inca road system. Within months, the disease had killed the Incan Emperor Huayna Capac, his successor, and most of the other leaders. Two of his surviving sons warred for power and, after a bloody and costly war, Atahualpa become the new emperor. As Atahualpa was returning to the capital Cuzco, Francisco Pizarro arrived and through a series of deceits captured the young leader and his best general. Within a few years smallpox claimed between 60% and 90% of the Inca population,[49] with other waves of European disease weakening them further. A handful of historians argue that a disease called Bartonellosis might have been responsible for some outbreaks of illness, but this opinion is in the scholarly minority.[50] The effects of Bartonellosis were depicted in the ceramics of the Moche people of ancient Peru.[51]

Even after the two largest empires of the Americas were defeated by the virus and disease, smallpox continued its march of death. In 1561, smallpox reached Chile by sea, when a ship carrying the new governor Francisco de Villagra landed at La Serena. Chile had previously been isolated by the Atacama Desert and Andes Mountains from Peru, but at the end of 1561 and in early 1562, it ravaged the Chilean native population. Chronicles and records of the time left no accurate data on mortality but more recent estimates are that the natives lost 20 to 25 percent of their population. The Spanish historian Marmolejo said that gold mines had to shut down when all their Indian labor died.[52] Mapuche fighting Spain in Araucanía regarded the epidemic as a magical attempt by Francisco de Villagra to exterminate them because he could not defeat them in the Arauco War.[32]

In 1633 in Plymouth, Massachusetts, the Native Americans were struck by the virus. As it had done elsewhere, the virus wiped out entire population groups of Native Americans. It reached Mohawks in 1634,[53] the Lake Ontario area in 1636, and the lands of the Iroquois by 1679.[54]

A particularly virulent sequence of smallpox outbreaks took place in Boston, Massachusetts. From 1636 to 1698, Boston endured six epidemics. In 1721, the most severe epidemic occurred. The entire population fled the city, bringing the virus to the rest of the Thirteen Colonies.[55][56]

During the siege of Fort Pitt, as recorded in his journal by sundries trader and militia Captain, William Trent, on June 24, 1763, dignitaries from the Delaware tribe met with Fort Pitt officials, warned them of "great numbers of Indians" coming to attack the fort, and pleaded with them to leave the fort while there was still time. The commander of the fort refused to abandon the fort. Instead, the British gave as gifts two blankets, one silk handkerchief and one linen from the smallpox hospital, to two Delaware Indian delegates.[57][58][59] The dignitaries were met again later and they seemingly hadn't contracted smallpox.Hernán Cortés landed on the shores of what is now Mexico and what was then the Aztec Empire. In 1520 another group of Spanish arrived in Mexico from Hispaniola, bringing with them the smallpox which had already been ravaging that island for two years. When Cortés heard about the other group, he went and defeated them. In this contact, one of Cortés's men contracted the disease. When Cortés returned to Tenochtitlan, he brought the disease with him.

Soon, the Aztecs rose up in rebellion against Cortés and his men. Outnumbered, the Spanish were forced to flee. In the fighting, the Spanish soldier carrying smallpox died. Cortés would not return to the capital until August 1521. In the meantime smallpox devastated the Aztec population. It killed most of the Aztec army and 25% of the overall population.[45] The Spanish Franciscan Motolinia left this description: "As the Indians did not know the remedy of the disease…they died in heaps, like bedbugs. In many places it happened that everyone in a house died and, as it was impossible to bury the great number of dead, they pulled down the houses over them so that their homes become their tombs."[46] On Cortés's return, he found the Aztec army’s chain of command in ruins. The soldiers who still lived were weak from the disease. Cortés then easily defeated the Aztecs and entered Tenochtitlán.[47] The Spaniards said that they could not walk through the streets without stepping on the bodies of smallpox victims.[48]

The effects of smallpox on Tahuantinsuyu (or the Inca empire) were even more devastating. Beginning in Colombia, smallpox spread rapidly before the Spanish invaders first arrived in the empire. The spread was probably aided by the efficient Inca road system. Within months, the disease had killed the Incan Emperor Huayna Capac, his successor, and most of the other leaders. Two of his surviving sons warred for power and, after a bloody and costly war, Atahualpa become the new emperor. As Atahualpa was returning to the capital Cuzco, Francisco Pizarro arrived and through a series of deceits captured the young leader and his best general. Within a few years smallpox claimed between 60% and 90% of the Inca population,[49] with other waves of European disease weakening them further. A handful of historians argue that a disease called Bartonellosis might have been responsible for some outbreaks of illness, but this opinion is in the scholarly minority.[50] The effects of Bartonellosis were depicted in the ceramics of the Moche people of ancient Peru.[51]

Even after the two largest empires of the Americas were defeated by the virus and disease, smallpox continued its march of death. In 1561, smallpox reached Chile by sea, when a ship carrying the new governor Francisco de Villagra landed at La Serena. Chile had previously been isolated by the Atacama Desert and Andes Mountains from Peru, but at the end of 1561 and in early 1562, it ravaged the Chilean native population. Chronicles and records of the time left no accurate data on mortality but more recent estimates are that the natives lost 20 to 25 percent of their population. The Spanish historian Marmolejo said that gold mines had to shut down when all their Indian labor died.[52] Mapuche fighting Spain in Araucanía regarded the epidemic as a magical attempt by Francisco de Villagra to exterminate them because he could not defeat them in the Arauco War.[32]

In 1633 in Plymouth, Massachusetts, the Native Americans were struck by the virus. As it had done elsewhere, the virus wiped out entire population groups of Native Americans. It reached Mohawks in 1634,[53] the Lake Ontario area in 1636, and the lands of the Iroquois by 1679.[54]

A particularly virulent sequence of smallpox outbreaks took place in Boston, Massachusetts. From 1636 to 1698, Boston endured six epidemics. In 1721, the most severe epidemic occurred. The entire population fled the city, bringing the virus to the rest of the Thirteen Colonies.[55][56]

During the siege of Fort Pitt, as recorded in his journal by sundries trader and militia Captain, William Trent, on June 24, 1763, dignitaries from the Delaware tribe met with Fort Pitt officials, warned them of "great numbers of Indians" coming to attack the fort, and pleaded with them to leave the fort while there was still time. The commander of the fort refused to abandon the fort. Instead, the British gave as gifts two blankets, one silk handkerchief and one linen from the smallpox hospital, to two Delaware Indian delegates.[57][58][59] The dignitaries were met again later and they seemingly hadn't contracted smallpox.[60] A relatively small outbreak of smallpox had begun spreading earlier that spring, with a hundred dying from it among Native American tribes in the Ohio Valley and Great Lakes area through 1763 and 1764.[60] The effectiveness of the biological warfare itself remains unknown, and the method used is inefficient compared to respiratory transmission and these attempts to spread the disease are difficult to differentiate from epidemics occurring from previous contacts with colonists,[61] as smallpox outbreaks happened every dozen or so years.[62]

In the late 1770s, during the American Revolutionary War, smallpox returned once more and killed thousands.[63][64][65] Peter Kalm in his Travels in North America, described how in that period, the dying Indian villages became overrun with wolves feasting on the corpses and weakened survivors.[66] During the 1770s, smallpox killed at least 30% of the Northwestern Native Americans, killing tens of thousands.[67][68] The smallpox epidemic of 1780–1782 brought devastation and drastic depopulation among the Plains Indians.[69] This epidemic is a classic instance of European immunity and non-European vulnerability. It is probable that the Indians contracted the disease from the ‘Snake Indians’ on the Mississippi. From there it spread eastward and northward to the Saskatchewan River. According to David Thompson’s account, the first to hear of the disease were fur traders from the Hudson’s House on October 15, 1781.[70] A week later, reports were made to William Walker and William Tomison, who were in charge of the Hudson and Cumberland Hudson’s Bay Company posts. By February, the disease spread as far as the Basquia Tribe. Smallpox attacked whole tribes and left few survivors. E. E. Rich described the epidemic by saying that “Families lay unburied in their tents while the few survivors fled, to spread the disease.”[71] After reading Tomison’s journals, Houston and Houston calculated that, of the Indians who traded at the Hudson and Cumberland houses, 95% died of smallpox.[69] Paul Hackett adds to the mortality numbers suggesting that perhaps up to one half to three quarters of the Ojibway situated west of the Grand Portage died from the disease. The Cree also suffered a casualty rate of approximately 75% with similar effects found in the Lowland Cree.[72] By 1785 the Sioux Indians of the great plains had also been affected.[30] Not only did smallpox devastate the Indian population, it did so in an unforgiving way. William Walker described the epidemic stating that “the Indians [are] all Dying by this Distemper … lying Dead about the Barren Ground like a rotten sheep, their Tents left standing & the Wild beast Devouring them.”[70]

In 1799, the physician Valentine Seaman administered the first smallpox vaccine in the United States. He gave his children a smallpox vaccination using a serum acquired from Edward Jenner, the British physician who invented the vaccine from fluid taken from cowpox lesions. Though vaccines were misunderstood and mistrusted at the time, Seaman advocated their use and, in 1802, coordinated a free vaccination program for the poor in New York City.[73][74]

By 1832, the federal government of the United States established a smallpox vaccination program for Native Americans.[75]

In 1900 starting in New York City, smallpox reared its head once again and started a sociopolitical battle with lines drawn between the rich and poor, white and black. In populations of railroad and migrant workers who traveled from city to city the disease had reached an endemic low boil. This fact did not bother the government at the time, nor did it spur them to action. Despite the general acceptance of the germ theory of disease, pioneered by John Snow in 1849, smallpox was still thought to be mostly a malady that followed the less-distinct guidelines of a "filth" disease, and therefore would only affect the "lower classes".[76]

The last major smallpox epidemic in the United States occurred in Boston, Massachusetts throughout a three-year period, between 1901–1903. During this three-year period, 1596 cases of the disease occurred throughout the city. Of those cases, nearly 300 people died. As a whole, the epidemic had a 17% fatality rate.[77]

Those who were infected with the disease were detained in quarantine facilities in the hopes of protecting others from getting sick. These quarantine facilities, or pesthouses, were mostly located on Southampton Street. As the outbreak worsened, men were also moved to hospitals on Gallop’s Island. Women and children were primarily sent to Southampton Street. Smallpox patients were not allowed in regular hospital facilities throughout the city, for fear the sickness would spread among the already sick.[78]

A reflection of the previous outbreak that occurred in New York, the poor and homeless were blamed for the sickness's spread. In response to this belief, the city instructed teams of physicians to vaccinate anyone living in inexpensive housing.

In an effort to control the outbreak, the Boston Board of Health began voluntary vaccination programs. Individuals could receive free vaccines at their work places or at different stations set up throughout the city. By the end 1901, some 40,000 of the city’s residents had received a smallpox vaccine. However, despite the city's efforts, the epidemic continued to grow. In January 1902, a door-to-door vaccination program was initiated. Health officials were instructed to compel individuals to receive vaccination, pay a $5 fine, or be faced with 15 days in prison. This door-to-door program was met by some resistance as some individuals feared the vaccines to be unsafe and ineffective. Others felt compulsory vaccination in itself was a problem that violated an individual's civil liberties.

This program of compulsory vaccination eventually led to the famous Jacobson v. Massachusetts case. The case was the result of a Cambridge resident's refusal to be vaccinated. Henning Jacobsen, a Swedish immigrant, refused vaccination out of fear it would cause him illness. He claimed a previous smallpox vaccine had made him sick as a child. Rather than pay the five dollar fine, he challenged the state's authority on forcing people to receive vaccination. His case was lost at the state level, but Jacobson appealed the ruling, and so, the case was taken up by the Supreme Court. In 1905 the Supreme Court upheld the Massachusetts law: it was ruled Jacobson could not refuse the mandatory vaccination.[77]

In Canada, between 1702 and 1703, nearly a quarter of the population of Quebec city died due to a smallpox epidemic.[30]

There is evidence that smallpox reached the Philippine islands from the 4th century onwards – linked possibly to contact between South East Asians and Indian traders.[79]

During the 18th century, there were many major outbreaks of smallpox, driven possibly by increasing contact with European colonists and traders. There were epidemics, for instance, in the Sultanate of Banjar (South Kalimantan), in 1734, 1750–51, 1764–65 and 1778–79; in the Sultanate of Tidore (Moluccas ) during the 1720s, and in southern Sumatra during the 1750s, the 1770s and in 1786.[79]Sultanate of Banjar (South Kalimantan), in 1734, 1750–51, 1764–65 and 1778–79; in the Sultanate of Tidore (Moluccas ) during the 1720s, and in southern Sumatra during the 1750s, the 1770s and in 1786.[79][80][81]

Smallpox was externally brought to Australia. The first recorded outbreak, in 1789, devastated the Aboriginal population; while the extent of this outbreak is disputed, some sources claim that it killed about 50% of coastal Aboriginal populations on the east coast.[82] There is an ongoing historical debate concerning two rival and irreconcilable theories about how the disease first entered the continent. The central hypotheses of these theories suggest that smallpox was transmitted to indigenous Australians by either: