The Washington PostDemocracy Dies in Darkness

Covid-19 showed the urgency of investing in public health. Will we listen?

After the coronavirus pandemic, let’s not make the same mistake Americans made in 1822.

People to receive a coronavirus vaccine at a FEMA vaccination center at Miami Dade College in Miami on April 5. (Lynne Sladky/AP)

Two hundred years ago, America made a bad decision about infectious diseases and national priorities.

In 1798, the English physician Edward Jenner had shown that an injection of cowpox — variolae vaccinae — protected people from the horrors of smallpox. The good doctor wanted to share the liberating power of vaccination with the entire world. An overjoyed Thomas Jefferson put aside his fear and loathing of England to thank Jenner on behalf of “the whole human family.”

And yet, in 1822, Congress sank a promising effort to vaccinate Americans nationally. What went wrong? And how can we avoid a similar mistake today, as the shadow of the coronavirus pandemic appears poised to recede?

Despite Jenner’s benevolent vision, vaccination was mostly limited to elite clients and private institutes in the early United States. The conservative Federalists were fine with this, but the more democratic Jeffersonians were not. Asphysician James Smith of Baltimore argued, “every citizen should have the right secured to him of a free access” to Jenner’s breakthrough. His idea was to provide both vaccine matter and vaccine information to concerned citizens, enabling them to understand and popularize this “wonderful Prophylactic.”

As the historian Rebecca Fields Green notes, Smith was one of many Jeffersonian reformers who trusted the general population to make good decisions. The key, they argued, was to treat ordinary people as equal members of society and equal partners in progress.

Congress agreed insofar as the Constitution pledged to “promote the general Welfare.” Fighting smallpox surely fit that category, so in 1813, Congress gave Smith’s new National Vaccine Institute the right to distribute vaccinae through the U.S. postal system.

However, the Jeffersonians in Congress also feared federal overreach, and money was tight during the War of 1812. The institute thus ran on a shoestring budget. Basically, it amounted to the doctor’s own cluttered office, from which he sent printed instructions and vaccine matter — carefully dried on small panes of glass — around the country. Among the beneficiaries were a group of children in Columbia, S.C., and the small village of Hallowell, Maine.

Alas, the overwhelmed Smith mistakenly sent live smallpox to North Carolina in 1822, causing a small outbreak and a political firestorm.

At this historical moment, Congress might have recognized the cause of the mistake and opted to increase funding and support for the institute. After all, the War of 1812 had shown how feeble the Union really was, inspiring all kinds of plans for national “improvement” in military preparedness, transportation and education.

However, a new generation of anti-government Southerners now rejected the very concept of the “general Welfare.” Most of the people on their cotton plantations were enslaved; as such, they had little sense of living in a cohesive society, to say nothing of a democratic one. They disliked any government they did not completely control and recoiled at the idea of a national state that was robust and responsive enough to promote the health of the entire population.

During the debate, one Southerner likened the institute to something out of the despotic monarchies and huge governments of the Old Continent. (One can only imagine how Smith, who had unsuccessfully asked for a salary six years earlier, would have responded to this.) America, the congressman continued, was instead a free country where people should “take care of themselves.”

To be sure, many delegates from the Western and Northern states still called for public investments in canals and turnpikes. Yet they, too, showed little interest in vaccines or medical research, perhaps because the United States hadn’t had a big smallpox outbreak in years. It never occurred to them that National Vaccine Institute had contributed to that happy fact.

In any case, instead of boosting funding for the institute, Congress shuttered it. This decision signaled a larger turn away from public health as a national priority. For most of the next century, the federal government left local and state officials to deal with smallpox, yellow fever and cholera, not to mention the lethal 1918 flu pandemic. Only the wealthy had doctors, so most people distrusted medical expertise. The major breakthroughs in vaccines and treatments continued to come from Europe, and smallpox lingered in America until 1949.

Fast forward to our own moment in history.

Devastated by covid-19, America has made a remarkable comeback. Health-care workers are now vaccinating over 3 million people per day, putting the United States near the top of the world in this vital category.

But many Republican leaders do not want to dwell on these successes, nor to mention the more than 550,000 dead from covid-19. They reject the very idea of public health.

Although Democrats show more interest in keeping Americans out of hospitals and morgues, their focus is already moving on to President Biden’s $2 trillion American Jobs Plan, which mostly centers on new roads, bridges and electrical grids. Once again, economic projects may soon overshadow public health measures, especially as our covid-19 memories fade.

This time, however, we could choose another path.

We could make preparing for the next pandemic — more viruses are surely coming — a core part of national defense, strengthening global warning systems and increasing investments in basic research on emerging pathogens, including antibiotic-resistant bacteria. And we could take a lesson from the long-forgotten Dr. Smith by involving the public in medical and scientific progress rather than simply expecting people to embrace it.

We might begin by building more hospitals, especially in the rural areas that have lost more than 120 hospitals over the past decade, or by creating a medical reserve of health workers in communities around the country. Or we could push for medical literacy in public schools.

Whatever our tactics, getting ready for the next pandemic might help us become a healthier society in every sense — a kind of medical democracy where each of us is ready and willing to protect all of us.