A pox on you

On the surface, such an attack might seem inhuman, or at best ignorant. But the act was the calculated result of long-simmering anger over the cost and politics of smallpox inoculations in one of the largest and most prosperous towns in the Colonies. Their anger would be familiar to anyone today who has faced ballooning insurance premiums, or who was moved to stand up and shout at this summer’s town hall debates on health care.

Watching the current debate in Washington, it’s tempting to think of health care reform as something radical and new - an issue that could force a profound shift in national identity. But America has been through this already. More than 200 years prior to this year’s push for a new national health policy, Americans were already becoming incensed about how they paid for health care, and who got access to it.

Health care in Colonial America looked nothing like what we’d consider medicine today, but the debates it triggered were similar. The danger of smallpox and the high cost of its prevention led to divisive questions about who should pay, whether everyone deserved equal access, and if responsibility lay at the feet of the individual, the state, or the nation. Epidemics forced the early republic to wrestle with the question of the federal government’s proper role in regulating the nation’s health.

Colonial leaders and ordinary people alike possessed a similar sense that a proper solution to these issues would determine the brightness and shape of America’s future. At times conflicts over public health threatened the social and political fabric of communities. Did these rowdy Colonials, with the aid of the Founding Fathers, solve these dilemmas? Hardly. But their observations, questions, and compromises offer a useful lesson for what we can expect as we find ourselves again with health care in the forefront of the national conversation.

In the late 1700s, the majority of Americans had never seen a general hospital, nor ever received advice or treatment from a person with a medical degree. They did not know that germs caused disease. Surgeons had little social standing and worked without antiseptics or anesthetics.

But Colonial Americans took pride in their health, and like Americans today, they were energized by the idea that science could improve it. The Enlightenment ideals that shaped the founders’ political philosophy shaped views on health as well; Colonials devoured new books on medicine and imagined a future in which the triumph of reason based on natural law would lead to the pinnacle of human achievement, both in politics and the body.

Americans reveled in the fact that they were at least as healthy as people back in the Old World, and they demanded that their leaders keep it that way. Beginning in the 1650s, Boston voters empowered the city’s selectmen to ensure that outhouses were dug deep enough and far enough away from roads or private houses. They paid a scavenger to remove dead animals from the streets. The people of Massachusetts adopted the English system that held local communities responsible for the care of the poor. Massachusetts selectmen were allowed to fence off homes and quarantine anyone who had an infectious disease. During epidemics, towns often created guard stations and required all visitors from slaves to wealthy merchants to be “smoked” with sulfur before entering.

By modern standards, these practices would hardly qualify as preventative medicine. An important exception, however, was the approach to smallpox, the fierce viral disease that had killed millions of people and disfigured even more. By the 18th century, the fight against smallpox resembled modern medicine in one crucial respect: It was a disease that people could do something about. Inoculation, known in parts of Asia and Africa for centuries, had been introduced to Boston minister Cotton Mather by his African slave Onesimus in 1706, and had slowly gained popularity in Europe and America. But inoculation was expensive, as was quarantine, and it was not at all clear what share of this - if any - should be borne by the government.

In the 1760s when tensions between Colonials and the British over taxation and representation were on the rise, so too were concerns over smallpox inoculations. As demand grew, the price of inoculations increased, leaving most Americans unable to afford them. During an epidemic in Boston in 1764, concerned voters called for a general inoculation of all willing citizens. Many simply fled the town to avoid the pox, but nearly 5,000 people (a third of the town’s population) were inoculated. More than 1,000 of them were poor and were inoculated for free or reduced cost.

However, mass inoculation was not always practical for smaller towns, and across the Colonies, leaders struggled to find ways to inoculate everyone who sought the procedure. Part of the problem was the nature of inoculation: Unlike with a vaccination, which would be introduced by Edward Jenner in 1798, inoculated patients could infect others with smallpox for weeks after the procedure, and they were safest if housed in a special hospital.

Several towns began building hospitals specifically for smallpox inoculation. At a town meeting in Salem, voters decided that private inoculation hospitals - the type that Marblehead sailors rebelled against - unfairly shut out the poor. Building a public hospital, however, might also burden them with heavy taxes. Salem’s solution, supported by Timothy Pickering, a future secretary of state, was a public-private compromise. The town collected private donations for the building of a new hospital, but left its operation to the town government, which assured access for the poor. In Marblehead, three years after the destruction of the private hospital, the people voted to inoculate the poor at the town’s expense.

Prominent Americans began to articulate opinions on the proper role of government in matters of health. Benjamin Franklin supported public hospitals and inoculations; in 1774 he helped found an organization in Philadelphia called “The Society for Inoculating the Poor Gratis,” which encouraged doctors to give free inoculations. Although John Adams did not take a public stance at this time, in 1776 he sent a letter to his wife Abigail, who was contemplating having their family inoculated, expressing his hope that smallpox would spread so more people would recognize the need for inoculation. He hoped that the Massachusetts Legislature would license an inoculation hospital “in every County, if not in every Town.” With the Continental army struggling to win a war on two fronts - against the British and against epidemic smallpox ravaging the troops - General George Washington, in January of 1777, authorized the mass inoculation of the Continental Army.

Although smallpox never completely disappeared, the political debate died down as Americans turned their attention to rebuilding communities ravaged by eight years of war. But in 1793, America was again confronted with a health crisis, its first as an independent nation, and a new debate emerged.

An outbreak of yellow fever ravaged Philadelphia, then the nation’s capital, and virtually every major city on the East Coast. No one could agree on what caused yellow fever, nor how to stop it (it would be another 100 years before Walter Reed determined mosquitoes to be the carriers). Frantic port cities embargoed ships coming from the capital, which in turn closed its doors to any trading partner of suspect health. Because the disease ignored state borders, it became a national problem, and many Americans looked to the new federal government for answers.

The phrase in the Preamble to the Constitution that the new government should “promote the general welfare” left the matter unclear - did the federal government have authority over health care, or just a responsibility to help? While Americans expected government to provide health services, these had been previously provided on the local, colony, or state level prior to the Constitution, and the Framers did not anticipate the need for federal intervention. The congressional debate in response to the yellow fever epidemic quickly turned into an early turf war over states’ rights and the power of the federal government.

Some wanted the government to wield broad authority - and in another impulse we’d recognize today, looked to Europe for examples. A Philadelphia editorial suggested that the United States adopt a national “board of commissioners” to regulate “every practice and every kind of medicine,” as was done in Sweden. Representative Samuel Smith of Maryland introduced the National Quarantine Bill in 1796, authorizing the president to regulate quarantines nationwide. South Carolina’s William Smith supported the bill, arguing that it was the job of the “General Government” to “protect the health of their fellow-citizens, as well as their property.”

The opposition dug in. James Holland of North Carolina argued, “To preserve one’s health was an article of self-defense. Every individual should take his own measures to preserve his own health, and each State should judge the best way of doing it for its own district.” William Lyman of Massachusetts, which already had strict quarantine laws, agreed that states should be in charge of health matters; Virginia’s John Page sounded a note that might have been ripped from today’s headlines, warning that this measure “had only a tendency to extend the power of the President.”

Ultimately, members of Congress compromised with a remedy but not a cure. Congress gave the president the power to send federal officials to help states enforce quarantines, and also to help with “the execution of health laws of the states, respectively, in such a manner as may appear necessary.” The 1796 act was revised with more specific terms in 1799, specifying that the federal government must cooperate with state authorities. Signed into law by John Adams, these acts created a hybrid system that forced captains, crews, and federal customs officers to comply with state quarantine and health laws but, in emergencies, allowed the secretary of the treasury or the president to direct the execution of those laws. As for determining whether health care was ultimately a federal responsibility, Congress left that to posterity.

Since that time, our medicine has changed far more than our politics. Inoculation for smallpox was a cutting edge procedure in early America - trendy, expensive, and remarkably effective. For average workers, like those who burned the private hospital in Marblehead, the cost of inoculating themselves and their families may have cost more than they earned in a year. Today hundreds of medical treatments fall into that category, from heart transplants to exotic cancer drugs. And health care, which wouldn’t have been considered an industry at all in 1776, is now one of the largest sectors of the American economy.

The key elements of the political debates, however, remain much the same. How do we balance public and private interests? Is health a personal, state, or federal issue? And who should pay for it? Benjamin Franklin’s Enlightenment philosophy prompted his maxim “Public health is public wealth,” and Americans have long differed on the ways to deliver each. William Lyman, the same representative who advocated against the Federal Quarantine Act, also asserted “the right to preserve health and life was inalienable.”

Early Americans avoided making any grand determination on the government’s constitutional role in preserving health. They muddled through by compromising on the best fixes available. And even so, their decisions had consequences they couldn’t foresee. Although the federal quarantine debates of 1796 and 1799 seemed to put the federal government in the back seat to state medical authorities, in 1799 Congress also authorized the building and funding of marine hospitals for sick or disabled merchant sailors in most American port cities. That system grew into the Public Health Service, the Office of the Surgeon General, and other federal divisions, including the National Institutes of Health and the Centers for Disease Control and Prevention. By leaving an open framework, early Americans may not have provided us with a governing philosophy of health care, but they bequeathed a range of possibilities.

Andrew M. Wehrman is a doctoral candidate in the Department of History at Northwestern University. His article on the 1774 Marblehead hospital attack is featured in the September issue of the New England Quarterly.