The complex relationship between the history of infectious diseases and social inequalities has recently attracted renewed attention. Smallpox has so far largely escaped this revived scholarly scrutiny, in spite of its special place in the history of medicine. After a century-long status as one of the deadliest and widespread of all infectious diseases, it was the first disease in history to be effectively eradicated through widespread immunization. Still, despite claims that the disease made victims in lower and higher social classes alike, there are ample reasons to assume that the burden of death was not shared equally across society. Literature has already demonstrated important differences between urban and rural communities, but has so far failed to address intra-urban disparities due to varying living conditions, disease environments and uptake of health measures.
In this paper, we examine the last nationwide upsurge of smallpox in the Netherlands through the lens of Amsterdam’s fifty neighbourhoods in the period 1870-1872. We examine how this epidemic evolved over time, how it spread geographically across a city, and whether certain neighbourhoods bore a larger burden of death than others. We use a mixed methods approach combining qualitative spatial analysis and OLS regression to investigate which part of the population was affected most by this epidemic in terms of age and sex, geographic distribution across the city, and underlying socio-demographic neighbourhood characteristics such as relative wealth, house density, crude death rate, and birth rate.
Our analyses reveal a significant spatial patterning of smallpox mortality that can largely be explained by existing socio-demographic neighbourhood characteristics. The regression analysis confirms that neighbourhood wealth and house density are important factors in explaining variation in the impact of smallpox within the city. Moreover, qualitative sources point out that various other socio-demographic aspects such as living conditions and vaccination uptake may further explain the differences in smallpox rates between neighbourhoods. We therefore argue that the smallpox epidemic was not socially neutral, but that it lays bare some of the deep-seated social and health inequalities across the city.