The Washington PostDemocracy Dies in Darkness

Early Americans knew better than President Trump how to prioritize health

A public uprising forced Boston to prioritize fighting smallpox over the economy in 1792

The USS Constitution glides through Boston Harbor on a cruise to honor Vietnam veterans in May 2018. (Bill Sikes/AP)

As the number of coronavirus cases continues to rise across the United States, Americans once again face the question of how we balance the economy with public health. The president’s reported goal is to persuade Americans to “live with the virus being a threat” to keep the economy humming.

Early Americans, who were more familiar with epidemics than we are, also faced such debates about economic well-being in the face of public health crises. They knew then what we must remember now: Governments have a duty to secure the lives of the people first, and only by taking broad, decisive and research-based action with the support of the public can epidemics be overcome.

In 18th-century Boston, city officials routinely quarantined the infected, isolated them and kept close watch over their family, friends and neighbors — an earlier version of contact tracing. With smallpox, the symptoms were obvious and didn’t require testing — backache, high fever and the pustules. When 20 households became infected, the city would hold a town meeting and vote to declare an epidemic, shutting down the whole city for months at a time.

Americans would not learn of Edward Jenner’s discovery of the vaccine until 1798, but another preventive technique that is specific to smallpox, known as inoculation, offered the promise of immunity. Inoculation required the purposeful implanting of the pus from a smallpox pustule into an incision made on a healthy person’s arm. It usually produced only mild symptoms but conferred a lifetime immunity to smallpox. It was first practiced in Boston in 1721 after Onesimus, an enslaved African man revealed the technique to his enslaver, the Rev. Cotton Mather. During the 18th century, inoculation’s success was proved effective again and again by experience and statistics.

Inoculation, however, had serious risks. Between 1 and 2 percent of all people receiving inoculation died. Although it is a significantly better result than death from natural smallpox, in which about 15 percent to 30 percent died, it nevertheless showed the potential for fatal consequences. Second, inoculated patients remained infectious for several weeks and had to be quarantined or else could spread the natural disease to others and spark a prolonged epidemic with a high number of deaths.

While the wealthy could afford to inoculate privately, for the poor, the cost of inoculation and time spent in quarantine was much too expensive. The solution? A total shutdown so that everyone could inoculate at once during what was termed a “general inoculation.” Boston pioneered the concept of the “general inoculation,” in 1752 and 1764, and even reimbursed doctors who inoculated the poor so that they could gain immunity at no cost to themselves.

In 1792, the city seemed ripe for another outbreak and the people clamored for a general inoculation, but the city’s merchants and businessmen, including heroes of the revolution such as Gov. John Hancock, consistently opposed such expensive shutdowns as “inconveniencies” that could last for months and damage the economy.

The newspapers estimated that at least 10,000 people in Boston, about half its population, were vulnerable. As new cases started breaking out in August, a town meeting was called. Speakers opposed to closing the city for a general inoculation argued that it would interrupt the fall trading season. Among those opposed were prominent Bostonians such as Robert Treat Paine, a state Supreme Court justice and signer of the Declaration of Independence, and William Cooper, the town clerk. They emphasized, as a writer in the newspaper summarized, that shutting down the city “three weeks to the opening of the Fall Trade, of such vast importance to us — would be making a sacrifice beyond my power to state.”

These ideas to prioritize the economy initially won out. But that was because women and the poorest men could not vote in the town meeting, which was dominated by Boston’s elite. Boston’s working class responded by writing angry letters to the local newspapers. Some began doubting the official numbers of cases being reported by Cooper, as he had spoken out against shutting down the city. A writer calling himself “No Physician” wrote that Cooper’s counting method was “a curious struggle against nature and the established order of things.” He asked sarcastically, “For what purpose are we struggling? Why lest the fall business should be hurt.”

Several others pointed out the self-serving hypocrisy of the men who spoke against general inoculation. Paine’s family had all been inoculated previously, but now he was arguing that the poor should not be. Hancock had his family inoculated in 1783. Drawing the most anger was Capt. James Prince, who, while arguing against a citywide shutdown, had sent his family to be inoculated privately. One writer, recalling the violence of the revolution, threatened to begin rioting if ordinary Bostonians could not “defend their little ones from assassination.”

At the core of these debates were issues about the government’s responsibility to act on behalf of all of its people during a crisis. Calling upon the new federal government was out of the question, as it would take weeks for the Washington administration to learn that Boston had a problem and even longer to implement a solution. Average Bostonians referred to health as less a right belonging to the people than as a required duty of government to defend, and in this debate they had one powerful founder on their side.

Thomas Paine, who had helped shift public opinion with “Common Sense” in the spring of 1776, wrote a new book weighing in on the French Revolution from London, titled “The Rights of Man.” It was published in serial form on the front page of the Boston newspaper, the Independent Chronicle, and excerpts and reviews commanded tremendous public attention across other local newspapers, too. Supporters of shutting down the city during the epidemic used Thomas Paine’s words and reasoning to support their position.

He argued that government was “a trust. … It has of itself no rights; they are altogether duties.” He also urged the adoption of a system of “progressive taxation” to support a comprehensive program for the poor “to provide against the misfortunes to which all human life is subject.” The government needed to care for the “laboring man,” who paid all his taxes honestly but still could not afford it “if himself, or [his family] are afflicted with sickness,” Thomas Paine argued.

As the outbreak intensified and the pressure to shut down grew, city leaders announced on Aug. 28, 1792, that the city would close for a general inoculation. The people rushed to inoculate, quarantine and support the poor. On Oct. 8, Cooper declared that the city was free of infection. In all, 9,152 people had inoculated and 165 had died, a mortality rate of 1.8 percent. An additional 232 people caught the disease naturally, and of those, 33 died, a mortality rate of 14 percent. Closing down the city saved thousands of lives. Trade resumed and lives continued, but because the public health efforts were successful, they were largely forgotten.

Today’s leaders should heed the advice of one correspondent writing under the name “Centinel” in 1792. Centinel warned that politicians showed their “highest indignation” to the people by refusing to shut down to halt an epidemic. He argued that government ought to follow “the loud hints of the law, and the broad hints of the people.” He warned that when the public is kept from removing small pests like germs from their society, they will turn their anger on larger pests, like politicians.