Lessons Rising from the Ruins of a Smallpox Hospital

My modern high-rise apartment overlooks one of the few historical ruins in New York City. The remains of New York’s smallpox hospital, opened in 1856, sit on Roosevelt Island, surrounded by green space and the East River. The building served as a hospital for 19 years, becoming a school of nursing until the mid-1950s. Then it was abandoned, a relic of a disease that disabled, disfigured, and killed millions for all of human history—until it was extinguished.

As a long-time public health professional and Centers for Disease Control and Prevention (CDC) staffer, I have always been awed by the effort that ended smallpox. As the only human disease ever eradicated, it is a touchstone for public health efforts, a goal to strive for in ending polio, and a vision of what is possible through vaccination.

For years, I carried a bifurcated needle, developed to deliver the smallpox vaccine, in my briefcase. It was one from a pack my boss found in his first desk at CDC in the 1970s. And I have the scar from that type of inoculation, but my children do not. 

Without global eradication of smallpox, my children would still have needed protection. Bill Foege, a giant in public health, devised the strategy that ended this scourge with his partners at CDC and the World Health Organization. His death earlier this year reminded the world of what medical science, sound public policy, and global cooperation can achieve. In The Milbank Quarterly, he is remembered by global public health leaders Larry Gostin and Mark Rosenberg. Bill Foege’s own book, House on Fire: The Fight to Eradicate Smallpox, published by the Milbank Memorial Fund and University of California Press in 2011, tells the story in his words. We are making the first chapters of that book available for free.

And shots are not the whole story — smallpox eradication required more than an effective vaccine with uptake in vulnerable populations. Across the globe, including here in New York City, the effort relied on surveillance, case-finding in partnership with communities, isolation and quarantine, and supportive care. It meant battling stigma and struggling to care for those with and without means, while isolating them to stop transmission. The ruin outside my window represents part of the smallpox response in New York, which stretched the health care system and workforce of the time. It also illuminated the conditions that allowed the disease to spread and thrive: Crowded tenement housing, lack of access to vaccination and other medical care, underlying health conditions that increased risk, and debates about the vaccine’s effectiveness, safety, and use that slowed containment measures.

Our health care system and health policy apparatus are vastly different than they were in the times of the smallpox hospital, or even in 1949, when the last naturally occurring case of smallpox appeared in the United States. Yet we still face some of the same issues, including:

• Social determinants of health, including poverty, housing, education, racism, and rurality that drive health disparities
• Health care systems that are financed in ways that don’t align with community values and needs, with those most at risk often having high barriers to accessing trusted, affordable sources of care
• Inadequate health care workforce levels in many communities, especially for primary care
• Health policymaking challenged by a lack of trust and transparency

Milbank’s work with state policymakers to promote health equity and population health is aimed at addressing these problems, by supporting decisions with evidence and supporting decision-makers with leadership training and camaraderie. The policy tools are many, and though none elegantly solve every problem, determined public servants can engage with their communities to find the right mix of policies to improve health and address unfair health disparities.

A recent example of solutions that work comes from the Centers for Medicare and Medicaid Services evaluation of the Accountable Health Communities (AHC) model, a test of whether screening beneficiaries for social needs and engaging community health workers to meet those needs could reduce health care utilization and costs. The short answer: it does. Medicaid and Medicare expenditures decreased for those receiving navigation services, and those people also had fewer ED visits and inpatient admissions. Those with the most needs saw the largest reductions in cost and the biggest improvements in quality, which is critical to improving equity in health care. 

Of course, the health care system alone can’t address the conditions that affect population health and health equity. Creating the conditions for health and the services needed to address social needs requires public health policies that support health and community well-being, along with social services and community infrastructure, like childcare, housing, and transportation.

Smallpox eradication was a unique generational achievement, yet many health policy solutions can change lives on a population scale, changing systems to improve our lives and the lives of the next generation. Like Bill Foege, policymakers need evidence, creativity, and a moral commitment to health to bring these solutions to scale.