George Washington’s aggressive response to epidemic disease during the Revolutionary War offers lessons for today. That war was fought not just against British forces, but against an enemy far more dangerous—smallpox.

Smallpox was one of the most dreaded diseases of the eighteenth century. A viral illness, smallpox caused high fever, severe headaches, vomiting, pains in the loins and back, and the eruptions that gave the disease its name. Smallpox was extraordinarily virulent; individuals exposed to the virus, which passed by contact, were almost certain to be infected. One attack usually conferred immunity to future infection. Smallpox was endemic in eighteenth-century Britain; the island was rarely free of the disease. It was almost constantly present in London and often ravaged the countryside. In Britain death seems to have claimed between fifteen and twenty percent of those infected. Smallpox was among the most common causes of death in eighteenth-century London. Ten percent of deaths in the city between 1731 and 1765 (which averaged about 23,300 total each year) were attributed to the disease. The number reached an all-time high in 1751, when some 3,538 Londoners died from smallpox—most of them children under five.

Smallpox was far less common in North America. It passed through the colonies in epidemic waves that typically began in the port cities and spread outward. The disease appeared sporadically in Boston, New York, Philadelphia and Charleston, and passed into the surrounding areas before gradually fading. Smallpox was no less virulent in North America, but the low density of the population—early America’s version of “social distancing”—discouraged its transmission. Smallpox was consequently less likely to reach epidemic proportions in the Chesapeake, the Carolinas or Georgia, where the population was dispersed and towns were few and small. Ships trading along the tidewater rivers sometimes transmitted the illness to particular plantations, but such outbreaks tended to be localized. Annapolis and Williamsburg were infected occasionally, but even in those towns epidemics were typically short.

Smallpox infection in Britain’s mainland colonies in North America seems to have been distributed more or less evenly across the age spectrum, because the North American population contained a much larger percentage of non-immune adults. Adults were better able to endure the ravages of the disease than children, so the mortality rate among colonists was lower than in Britain. About ten percent of infected colonials seem to have died. But American epidemics seemed particularly bad to contemporaries, because the large percentage of non-immunes meant that outbreaks tended to involve a much higher percentage of the people in any community than would be infected in a comparable English population. This fact led some to speculate that Americans were somehow intrinsically more susceptible to the disease.

The Revolutionary War occurred during one of the worst smallpox epidemics in American history, which ultimately reached from maritime Canada to Central America (and brilliantly documented by Elizabeth Fenn in her book, Pox Americana—winner of the 2004 Society of the Cincinnati Prize). Its spread has been traced from colonies on the Atlantic seaboard all the way to the Indians living on the Pacific coast. Unlike today’s virus, which spread from continent to continent in days and weeks, and infected people around the world within a few months, the smallpox epidemic that paralleled our Revolution took years to reach the farthest parts of the continent, passing from traders to Indians and from Indian to Indian across the West. This was possible because the smallpox virus, unlike SARS-CoV-2 (the virus that causes COVID-19), remains stable and capable of infecting victims for long periods outside a human host. The coronavirus needs a host, and dies within hours on most surfaces.

When the Revolutionary War began, most of the young men who would serve in the Continental Army and the militia had never been exposed to smallpox. A much larger proportion of the British and Hessian soldiers who came to America had been exposed to it, and were immune. This put the Continental Army, which was always short of manpower, at a considerable disadvantage.

Eighteenth-century people had very little understanding of disease transmission, and incorrectly attributed many diseases caused by pathogens to environmental conditions like bad air, foul smells and damp weather. But they understood that smallpox passed from one person to another and that contact with the sores and scabs of an infected person was almost certain to infect a non-immune. The close quarters of an army camp was ideal for spreading the disease.

George Washington understood how debilitating smallpox could be to a young man. The disease had barely touched Virginia in his youth, but he contracted it in 1751 when he went to Barbados with his brother Lawrence. Smallpox was endemic to Barbados, kept alive there by the constant arrival of non-immune, recently enslaved Africans. The Washington brothers undoubtedly encountered the virus shortly after they arrived, at the home of one of their hosts, where the children were sick with the disease. Lawrence, who had been to boarding school in England, was undoubtedly immune. Nineteen-year-old George was not.

Young George might have encountered an infected child face-to-face, inhaling small infectious droplets or carrying the virus to his mouth or nose on his hands. But since the infectious nature of smallpox was understood, it seems unlikely that George risked direct personal contact with an infected person. He probably kept his distance, but he could have picked up the virus in another way. The virus can be present in scabs and dried-out bodily secretions, and desiccated but still dangerous particles can circulate in the air or be carried to a new host on inanimate objects. Someone changing bed linen, sweeping floors or even opening the window in a sickroom might have swirled infectious material into the air and ultimately into George Washington’s lungs.

That was on November 4. The disease has a two-week incubation period, and like clockwork George fell ill on November 17, later recording in his diary that on that day he had been “strongly attacked with the small Pox.” He was confined to the brothers’ rented house until December 12. He suffered, but that suffering conveyed immunity that protected him during the Revolutionary War.

Smallpox was already present in Massachusetts when Washington arrived to take command of the Continental Army in the summer of 1775. He took steps to isolate the soldiers from infected townspeople and contain the unfortunates who had already contracted the disease. Daily inspections were instituted to check men for symptoms, and immune troops were placed on the front lines. Washington established a dedicated smallpox hospital. These steps undoubtedly flattened the curve of infection, slowing the spread of the disease, but could not stop it. New recruits, many of whom came from areas where smallpox was rare, contracted the disease after arriving at the crowded camps. Washington knew that nothing would kill the patriotic spirit of the new recruits converging in Cambridge faster than a smallpox epidemic in the army.

While Washington’s precautions—similar to the self-quarantines and social-distancing policies of the moment—were based on the best science of his time, there was only one proven solution: inoculation. Vaccination was unknown. Inoculation had been introduced to Boston by Cotton Mather during the 1721 smallpox outbreak. This risky procedure involved making a cut in the skin of a healthy person and inserting the virus, usually in the form of pus from the skin eruptions of an infected person. Inoculation, in most cases, conveyed a mild case of the dreaded sickness. The pox were typically limited to the area around the incision, and the associated fever and other symptoms less severe than those originating from an infection that began in the lungs.

The procedure was dangerous. Patients under inoculation could develop a full blown case of the disease and die, and they were as contagious as other smallpox sufferers and had to be isolated until recovery. The risk of inoculation accidentally spreading the disease made it a highly controversial procedure. Without proper regulation and supervision, inoculation might destroy the army and spread the disease to civilians.

The cost of failing to act became clear during the invasion of Canada in the winter of 1775-1776. American forces were devastated by smallpox during the Siege of Quebec. After interacting with infected locals (purportedly sent into American lines by the British army), the pestilence spread quickly through the American army. Disorganized attempts at inoculation left the whole army contagious and suffering. The spread of the virus and lack of supplies made their position untenable. The army withdrew from Canada in defeat. Everyone knew—the British, Congress, even deserters—that sickness had been the invading army’s downfall.

Washington decided that inoculation was a risk he had to take to build up the army’s immunity. Washington listened to the advice of doctors and became convinced that inoculating troops before they entered active duty was the most effective strategy. By January 1777, this became army policy. “The Small Pox by inoculation,” the commander-in-chief wrote to his brother John Augustine, “appears to me to be nothing.” He ordered all of his slaves inoculated and reported that they “are likely to get well through the disorder.” If he were a member of the House of Burgesses, Washington wrote, he would “move for a Law to compel the Masters of Families to inoculate every Child born within a certain limited time under severe Penalties.”

Ensuring the health of the troops was a key to a successful Revolution. The Board of War asked Dr. Benjamin Rush to write a pamphlet about keeping soldiers healthy for the use of the Continental Army officers. “Fatal experience,” Rush wrote, “has taught the people of America that a greater proportion of men have perished with sickness in our armies than have fallen by the sword.” Rush prescribed proper dress and diet as well as exercise, personal hygiene and orderly, clean encampments providing proper sanitation and access to good water. Lack of uniforms, tents and adequate food often made following Rush’s guidelines impossible for the young officers responsible for carrying them out. They did their best, which blunted the force of disease and helped keep the Continental Army in the field. Their best efforts, and the best efforts of the officers of the Continental Navy and of the French army and navy, could not stop the ravages of epidemic disease. Contagious illnesses claimed thousands more lives than battle.

There was no glory in it. Artists celebrated men giving their lives in battle rather than those who suffered and died in a struggle with one of the war’s more dangerous enemies—smallpox, dysentery, measles, influenza and typhus among them. Only once, it seems, did a contemporary artist grasp the deadly importance of disease to the war and depict it on canvas.

The subject of the painting, which is among the treasures in our collections, is Thomas François Lenormand de Victot, a French naval officer who served under Admiral d’Estaing and later, Admiral de Grasse. Wounded at Grenada in 1779, he was denied a glorious death in battle. He died at Martinique in 1782 from a fever that swept through the French fleet. In the painting—undoubtedly commissioned by his family—Lenormand is dead in the foreground, but his risen spirit confronts Death, protecting his stricken sailors, facing the war’s great killer with courage and dignity.

Disease wracked the armies and navies of the Revolution, but Washington’s energetic, proactive response flattened the curve—it slowed the spread of disease and helped the Continental Army prevail in a war that demanded much more than tactical skill or courage in battle. After the disaster at Quebec, smallpox never overcame an American army. Washington and his senior officers worked ceaselessly to prevent the spread of disease among their troops. There was no glory in it, but it saved lives, and ultimately saved the Revolution.

Our republic was founded by people who committed themselves to the greater good. We are called to do the same. Washington protected his troops and we are called to protect ours. The soldiers on our front lines include grocery clerks, medical professionals, delivery men on scooters, sanitation workers and the thousands of others risking exposure while working to maintain essential services. We are protecting the republic Washington and his generation fought to create. Like Washington, we need to act before the disease decimates us. Washington learned from experience. We should learn from his example.

Kathleen Higgins