The Washington PostDemocracy Dies in Darkness

Two opposing approaches to public health may be on the ballot in 2024

Governors DeSantis and Whitmer took opposite approaches to covid in swing states — but each sailed to reelection

Michigan Gov. Gretchen Whitmer (D) and Florida Gov. Ron DeSantis (R). (Bill Pugliano/Getty Images; Jabin Botsford/The Washington Post)
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Two governors scored smashing reelection victories by double-digit margins in swing states in the midterm elections, igniting presidential buzz. Their opposite approaches to handling covid-19 tells us of the very different approaches to public health and social services that they would deliver as national leaders.

Perhaps more than any other governor, Florida’s Ron DeSantis (R) openly derided public efforts to slow the spread of the coronavirus and called vaccination a “personal choice.” Michigan’s Gretchen Whitmer (D) did the opposite, enacting strict public health measures and imploring Michiganders to “get through this together” to slow the virus’s spread.

The divide between Whitmer and DeSantis is nothing new. Instead, they are continuing a debate about public health and private freedoms that goes back to the founding era. Their responses reflect long-standing regional differences in Americans’ desire for government interventions in times of crisis. The South, in particular, has long been hostile to strong public health measures, just as DeSantis is.

Like leaders today, the founders also dealt with a pandemic: smallpox. Like covid, the smallpox pandemic of the 1770s affected all 13 colonies during the American Revolution. But the responses from political leaders in New England to control the pandemic and satisfy their angry and fearful fellow citizens differed dramatically from those in Virginia.

Smallpox was a not a new disease to Americans in 1776. The distinctive pockmarks it inflicted on victims and its high mortality rate — before the discovery of germ theory, antibiotics and IV fluids — were enough to convince Americans that no one should want to experience smallpox.

Whereas smallpox was endemic in large European cities, the colonists were adamant that smallpox not be allowed to gain a permanent foothold here. They used strict quarantines to stop the spread of the disease and enacted harsh penalties for anyone who violated them. Many communities required anyone with smallpox symptoms to report them to authorities so that they could be isolated, with stiff fines for violating such orders.

By the American Revolution, the surest way to prevent smallpox was by inoculation — the purposeful insertion of matter taken from a smallpox pustule and inserted into a small incision on a patient’s arm. The patient would usually develop a mild, survivable case of smallpox yielding them lifetime immunity but would remain infectious for several weeks. This required strict isolation to prevent spreading smallpox to others. When smallpox broke out again during the Revolutionary War, the colonies understandably pushed to expand inoculation.

Rhode Island reacted first in June 1776 by authorizing the construction of a public inoculation hospital in each county. The Rhode Island General Assembly instructed its delegates to the Continental Congress to propose “a general system of inoculation in the army and navy.”

Writing from the Second Continental Congress in Philadelphia to his wife, Abigail, in Massachusetts, John Adams mused, “I could almost wish that an inoculating Hospital was opened, in every Town in New England.” About a week later, on July 3, 1776, the Massachusetts legislature authorized a “general inoculation” in Boston, a complete shutdown of the city while susceptible individuals were inoculated en masse. About 5,000 Bostonians were inoculated together, about one-third of the city’s population, including Abigail Adams and their children.

New Englanders argued that securing the health of citizens was a foremost duty of the government as they attempted to provide inoculation to as many people as possible.

In the South, however, public inoculation hospitals and mass inoculations were less common. Smallpox was less prevalent in the more rural region, and while Southerners understood inoculation to be effective, many worried that large-scale public inoculations in cities and towns would not only halt commerce but also could spark epidemics among the enslaved if there were quarantine lapses. Enslaved people were often left uninoculated because of the expense of the procedure and the loss of labor during their convalescence. Enslavers also sometimes justified their inaction with the false belief that smallpox was less dangerous for Black people.

After George Washington’s order in February 1777 to inoculate the Continental Army, Southerners began to demand changes to their own public health laws. But rather than calling for more government regulations and public hospitals, wealthy Southerners pushed to be allowed to self-regulate and inoculate privately in their homes.

Despite the push for public inoculation from Washington, other leading Virginians reacted to mass inoculation efforts with annoyance. George Mason complained that all the soldiers inoculating at once in Alexandria — and therefore unable to engage in commerce — made trade difficult. After recovering from his inoculation, Mason set out to change Virginia’s smallpox laws. At the time, the law allowed communities to vote on and to regulate public inoculation campaigns but did not allow people to inoculate privately without permission from local authorities. Mason also thought some of Virginia’s quarantine rules and penalties for inadvertently spreading smallpox were too harsh.

The committee that Mason assembled in the Virginia General Assembly included three signers of the Declaration of Independence: Benjamin Harrison, Thomas Nelson Jr. and its author, Thomas Jefferson. The committee concluded that general inoculation campaigns disrupted commerce, but elective private inoculations done at home did not. And so, it passed a law in 1778 that allowed anyone to inoculate privately if they wished with no public debate and at no cost to the taxpayer.

Thus, the nation was founded with two different visions of public health: elective private inoculations in much of the South, and publicly funded hospitals and general inoculation campaigns in the North. The two systems reflected regional cultural values and power structures embedded in which were different conceptions of liberty: a liberty to be safe from disease through the actions of an elective government, and a liberty for the head of a household to act in his interest.

But the story doesn’t end there. We can assess what governing approach worked best. In New England, mass inoculation efforts and strict quarantines halted the spread of smallpox. Boston launched another general inoculation campaign in 1778, once again shutting down the city while thousands were inoculated. Smallpox was gone from New England by the beginning of 1779, with military hospitals no longer reporting any soldiers or civilians with active cases.

In Virginia, however, smallpox spread rapidly across the state as British Gen. Charles Cornwallis advanced toward Yorktown in 1781. Although Virginians had been permitted to make the private choice to inoculate after the law was enacted in 1778, not enough people did. Even fewer elected to inoculate their enslaved people, despite understanding the risks of leaving enslaved people susceptible.

Virginians like Jefferson blamed the British for spreading smallpox rather than blaming themselves for failing to conduct mass inoculations as happened in New England, leaving poor families — Black and White — susceptible to a preventable disease.

Regional differences in public health laws remained long after the war. As president, Adams passed the first federal health law in 1798 creating the marine hospital system, which provided the foundation for the later U.S. Public Health Service and Centers for Disease Control and Prevention. However, when Jefferson won the contentious 1800 election, the Virginian’s desire for private health-care decisions also went to the White House.

Benjamin Waterhouse, the Boston doctor and Harvard professor who introduced vaccination in the United States in 1800, became frustrated by the unwillingness of Jefferson, and later his fellow Virginians James Madison and James Monroe, to publicly endorse and fund public health campaigns to facilitate vaccination. He hoped that a Massachusetts president, John Quincy Adams, who had been inoculated as a child in Boston’s 1776 general inoculation, might do more. Indeed, he pushed Adams to create a Cabinet department dedicated to the “preservation of human life — something that may apply the Jennerian discovery to its best purpose.” (“Jennerian” refers to Edward Jenner, a British physician who pioneered the smallpox vaccine.)

But Adams did not have public support to do so amid a growing mistrust of experts with the political rise of his Southern rival and eventual successor, Andrew Jackson. It didn’t help that there was no vaccination for and no clear understanding of how best to prevent the new disease threatening Americans: cholera.

The United States has never given the federal government, let alone the president, full control over its public health policy. When President Biden attempted to enforce a vaccine-or-testing mandate on large employers to protect against covid, the Supreme Court struck it down but allowed a more limited mandate for health-care workers.

Public health policy remains a patchwork of regulations between and among local, state and federal governments. With the federal government often subordinate to the states on matters of public health, it’s not surprising that two popular governors from different regions of the United States have opposite views. Most American voters — and most viruses — seem to like it that way.