How New York City vaccinated 6 million people in less than a month

What the public didn’t know was that smallpox, the scourge of civilizations, had improbably reemerged in the city five weeks earlier.

On March 1, a 47-year-old American businessman, Eugene Le Bar, arrived in New York after a long bus ride from Mexico City. He was on his way to Maine, but he had been feeling sick and checked into a Midtown hotel with his wife. After sightseeing, he collapsed into bed, exhausted, with a headache and a pain in the back of his neck.

By March 5, Le Bar was in Bellevue Hospital with a 105-degree fever and a peculiar rash on his face and hands. Three days later, he was transferred to Willard Parker, the city’s communicable disease hospital. His doctors considered several diagnoses, none definitive. Because he had a vaccination scar, they ruled out smallpox. On March 10, Le Bar was dead.

Soon, more patients at Willard Parker began exhibiting symptoms similar to Le Bar’s: first, a 22-month-old from the Bronx named Patricia; then a 27-year-old man from Harlem, Ismael Acosta. A 30-month-old toddler, John, followed. The doctors thought they were looking at chickenpox but were flummoxed by the patients’ rashes, which didn’t fit the diagnosis.

On April 4, the results came back from the U.S. Army Medical School Laboratory in Washington. All three were confirmed cases of smallpox, which had not been seen in New York City since before the war. Health officials began connecting the dots, and the dots led back to Le Bar, patient zero.

The city’s health commissioner, Israel Weinstein, had taken the job 10 months earlier. He had been a child on the Lower East Side when a smallpox outbreak brought the city to its knees in the early 1900s, killing 720 New Yorkers in two years. Now he was both a medical doctor and a scientist; he had a doctorate from New York University, along with a doctorate and an M.D. from Columbia.

So when he got the lab results, he knew what he was up against.

Smallpox had plagued humankind for thousands of years. According to the World Health Organization, it claimed the lives of 300 million people in the 20th century alone.

All it takes for smallpox to spread is a cough, a sneeze or a touch. Then, it’s only a matter of days before the virus triggers fever, aches, pains and nausea. A rash appears on the face and soon covers the body, sprouting into fluid-filled pustules. Three out of 10 cases are fatal. Those who survive are often left deeply scarred, blind or both.

“In the pantheon of infectious diseases, smallpox is in the top five,” said Dr. Charles DiMaggio, professor of surgery and population health at NYU Grossman School of Medicine. “It was thoroughly horrifying because it disfigured people it didn’t kill, and it killed indiscriminately.”

Thanks to a vaccine developed in the late 1700s and refined in the decades that followed, smallpox outbreaks had generally been contained.

In 1980, the WHO officially declared smallpox eradicated.

“The smallpox eradication program is absolutely considered one of the crowning achievements of global public health,” DiMaggio said. “And it’s never been duplicated. Just the very idea that a disease was eradicated — a disease that ravaged humankind for millennia — is remarkable. And the reason we were able to do that is because of vaccinations.”

In 1947, most New Yorkers had been inoculated against smallpox. They had been told the inoculation would protect them for life, but there was no guarantee. In some cases, the vaccine didn’t take. In others, the immunity wore off. Le Bar was proof of that.

Weinstein had some tough decisions to make.

The lab results reached him on Good Friday, April 4. In two days, New Yorkers would be gathering for the annual Easter Parade. If only one of them had smallpox, even among a vaccinated population, the resulting outbreak could be devastating.

“Imagine the Easter Parade and all these people crowded together on Fifth Avenue,” said Dr. Howard Markel, director of the Center for the History of Medicine at the University of Michigan. “All of them cheering and chanting and potentially coughing and sneezing, and you have smallpox introduced into that picture. That is a public health nightmare.”

Weinstein wasted no time. Knowing there was only one way to deal with the virus — vaccination — he took action. At 2 p.m. that day, he held a news conference, urging all city dwellers to get vaccinated immediately, even if they had been inoculated as children. Revaccinations were necessary, he said, in case people had lost their immunity.

It was hardly without risk. Not only could the announcement cause mass hysteria, but in 1947, vaccines were not tested the way they are today. The vaccine available at the time could trigger rare but dangerous side effects, especially in people with weakened immune systems or particular skin conditions.

According to Dr. David Oshinsky, professor of medicine at NYU Langone Health, Weinstein acted in line with the scientific knowledge of the era. He made the right move, which was to vaccinate as many people as possible.

Markel agreed. “Weinstein was doing his job as best he could,” he said. “The risk of smallpox spreading and causing disease and death was far, far greater than the tiny risk of getting encephalitis or dying of the vaccine. So I come not to bury Weinstein but to praise him.”

In a series of daily radio addresses, Weinstein focused on transparency and a consistent message. The vaccine, he said, was free, and there was, in his words, “absolutely no excuse for anyone to remain unprotected.” In a calm, clear voice, he promoted the rallying cry that would appear on posters throughout the city: “Be Sure. Be Safe. Get Vaccinated!”

“The first thing he did was level with the public,” Oshinsky said. “He told them that smallpox had arrived in the city and that it was possible there was going to be a spread — and that it was an extremely communicable and dangerous disease. And he said, ‘We will provide enough vials of vaccine to effectively protect the city.’”

But the municipal stockpile contained nowhere near enough to vaccinate all of the city’s 7.8 million residents.

With the full cooperation of Mayor William O’Dwyer, Weinstein secured 250,000 units of vaccine from the naval medical supply depot in Brooklyn. He had 780,000 doses flown in from military bases in California and Missouri. He bought an additional 2 million from private manufacturers, and then he ordered more.

He directed his Bureau of Laboratories to convert its bulk supplies into single-dose units, and he began a tracing program to locate and vaccinate those who had been in contact with the victims.

The vaccine rollout was remarkably swift and uncomplicated, and it’s one that almost certainly couldn’t happen today.

“In 1947, the city was able to act alone, as opposed to navigating a complicated relationship with the governor of New York and the federal government,” said Dr. Irwin Redlener, director of the Pandemic Resource and Response Initiative at Columbia University’s Earth Institute. “The city was able to say, ‘We’re going after this,’ and then make it happen.”

At first, the public’s response was lackluster. Easter Sunday turned out to be surprisingly warm and sunny — the temperature hit a record 79 degrees — and more than 1 million New Yorkers turned out for the parade. That weekend, only 527 people requested vaccines. But days later, when news broke that Ismael Acosta’s wife, Carmen, had died from smallpox and that three more cases had been discovered, people’s minds changed — and, as it happened, so did the weather.

New Yorkers were soon standing for hours, often in chilly rain, outside public and private hospitals, clinics and police stations, waiting to get their inoculations. For them, vaccinations were nothing new. Many had served as soldiers in World War II; they had been vaccinated against a host of viruses and saw the inoculations as a matter of course. Moreover, today’s anti-vaccination movement did not exist.

Oshinsky, who wrote the Pulitzer Prize-winning book “Polio: An American Story,” offers yet another reason. “This was the height of polio in the United States,” he said. “People had a much better sense of the impact of infectious disease. They saw it all the time, and they were rightly fearful. But they were also optimistic that medical science could conquer this. In 1947, there was tremendous faith in the medical community, unlike today.”

In front of news cameras, Weinstein vaccinated O’Dwyer, who had already been inoculated four times in the Army. President Harry Truman also got into the act. His visit to New York on April 21 was accompanied by news reports that he, too, had rolled up his sleeve.

“In today’s vernacular, O’Dwyer and Truman were influencers,” said Lisa Sherman, president of the Ad Council, the nonprofit group working on a campaign for the COVID-19 vaccines. “They could deliver important information that people wanted to hear. They were trusted messengers.”

The response was so great that the city enlisted thousands of civilian volunteers to help deliver inoculations. Armed with vials of vaccine, the volunteers, along with professional health care providers, administered as many as eight doses per minute. Making their way through every school in the city, they inoculated 889,000 students. In the first two weeks, 5 million New Yorkers were vaccinated against smallpox.

By mid-April, the city’s stockpile was nearly depleted. O’Dwyer convened an emergency meeting of drug company representatives, all but threatening them with public scorn if they didn’t ramp up delivery. Within 48 hours, 1 million more doses arrived.

In early May, 10 weeks after Le Bar stepped off a bus in Manhattan, Weinstein announced that the danger had passed.

Later that year, he summed up the case in The American Journal of Public Health. “In a period of less than a month, 6,350,000 people were vaccinated in New York City,” he wrote. “Never before had so many people been vaccinated in such a city and on such short notice.”

The final tally was 12 infections and two deaths.

“What Dr. Weinstein did in 1947 is something we’re still studying and referring to,” Markel said. “The fact that they developed the logistics — the delivery of vaccine, the large public spaces where people could line up to get vaccines, the manpower in the form of nurses and doctors who would give the vaccine — is pretty incredible. Weinstein is to be credited.”

“It stands out as a remarkable achievement by any measure,” DiMaggio said. “It was a public health triumph.”

Weinstein resigned from his post in November 1947, seven months after the smallpox outbreak. He left behind a blueprint for containing an infectious disease in a large, dense city.

But this time, with the coronavirus pandemic, New York faces a logistical hurdle. Experts in infectious disease point to a hollowing out of the public health infrastructure — not just in the city but across the country. Yet they believe the biggest obstacle is not distribution but the public’s distrust of government, science and the media.

“We’re coming out of a train wreck of messaging,” Redlener said. “We’ve learned that politics is poison to a public health initiative, especially during a crisis. Honesty and straightforward, clear messaging are absolutely critical.”

In 1947, Weinstein was the only voice with a megaphone. He spoke, and people listened.

“Back then, there was a much simpler media landscape,” Sherman said as she laid out the Ad Council’s campaign, which is due to kick off early next year. “In today’s environment, we’re dealing with a highly, highly fragmented media. We’ll be relying on microinfluencers who are the trusted voices.”

So, as the COVID-19 vaccine rollout in New York City began this past week, a major question remains: Can the city come close to what it accomplished 73 years ago?

Redlener, who serves as an adviser to Mayor Bill de Blasio on emergency response, said he believes that New York will meet the challenge again. But, he added, “It’s almost inconceivable that we’re going to be able to do something similar as rapidly and as effectively.”