How to Prevent an Epidemic Like the Amercian Colonists Did

Andrew’s research focuses on the intersections between politics and medicine in Colonial and Revolutionary America.

Andrew Wehrman is a historian of early American history and the history of American medicine at Central Michigan University. His research focuses on the intersections between politics and medicine in Colonial and Revolutionary America.

His current book project The Contagion of Liberty argues that popular demand for public inoculation during smallpox epidemics in the 1760s and 1770s infected Revolutionary politics and changed the way Americans understood their health and their government’s responsibility to protect it.

by Andrew Wehrman

We look back to the United States’s founders for guidance on many things, but not usually for medical advice. Medicine in early America seems backward and frightening. Colonists had very few hospitals. They, of course, had none of our modern technology, but they also didn’t know germ theory. They had no antibiotics and no conception of antiseptics. If you were sick in the eighteenth century, a physician would likely bleed you and perhaps offer a strong purgative to induce vomiting or diarrhea. If you survived all that, hopefully you felt better. Colonists who could not afford to see a doctor were often better off. Looking in hindsight at limitations in colonists’ medical knowledge blinds us to the ways in which they kept themselves well.

Colonists suffered from epidemic diseases that are almost entirely unfamiliar to modern Americans thanks to vaccinations and modern medicine. Colonial Americans suffered from smallpox, cholera, yellow fever, typhus, measles, and scarlet fever. For the most part these diseases were epidemical—that is, outbreaks would in a city occur every decade or two. Boston, for instance, had epidemics of smallpox in 1721, 1730, 1752, 1764, 1776, and 1792. We normally think of these as unavoidable natural disasters. But if we focus on the gaps between those outbreaks, we can see that the colonists were quite vigilant about preventing disease and mitigating the human cost when they occurred. They didn’t need modern medicine to stave off diseases for decades at a time.

The ways in which Colonial America prevented outbreaks of disease and then worked to stop epidemics provide lessons for modern Americans battling our own epidemics. Although so far we have no cures for emerging diseases like ebola or for epidemic crises like opioids and gun violence, studying Colonial Americans proves that you don’t need cures or perfect science to prevent or end an epidemic. What you need, and what these early citizens developed, is a set of principles and policies that leads to better community wellness.

Colonists certainly did not always follow these nine rules, but when they did, they almost always generated healthy results:

Beginning in the seventeenth century, colonists in Boston realized that the sporadic efforts of individuals or even groups of colonists reacting to crises was no substitute for sustained public effort and policy. By the beginning of the eighteenth century, Boston’s town meetings became longer and more substantive. They created a host of new positions: overseers of the poor, assessors, inspectors. The city council selectmen were similarly charged with active duties in the city. The Massachusetts General Court in 1699 passed “An Act for the Better Prevention of the Spreading of Infectious Diseases.” The act forbade any ship from coming into Boston that had infectious crew members or that had sailed from a port known to have an outbreak of disease. To enforce this law Boston needed educated inspectors who recognized symptoms and kept up with news of disease outbreaks around the world. Eventually this act led to the creation of quarantine hospitals, or pesthouses, to isolate infectious people from the town. These were built and staffed at the expense of the town, but individuals who wound up there might still have to pay for their care.

In 1704 the Boston News-Letter, the first continuously published newspaper in Colonial British North America, began. The newspaper was a crucial component of public health in Boston. Not only did newspapers print news and rumors of disease outbreaks locally and around the world, but they also printed medical debates and advertisements from doctors and for new medicines. Newspapers allowed readers to discuss policy issues and to hold their government accountable. Officials in Boston would also use the newspapers for official notices to warn the public there was an infectious family on Fish Street, for example, or later on in the century, to publish disease statistics and annual Bills of Mortality specifying and alerting people to the cause of death of residents.

In 1721, despite the regulations in place, smallpox broke out in Boston. Reverend Cotton Mather had read interesting reports from the Royal Society in London about a new technique called inoculation, in which patients were purposefully infected with smallpox via a small incision in their arms rather than allowing it to occur naturally. The patients usually experienced a mild case of the disease and, most importantly, became immune to natural smallpox for life. While inoculation was new to Western medicine and the Royal Society, Mather excitedly wrote that he already knew about it before reading the reports. His African slave Onesimus had already told him of the technique, which had been used in East Africa for generations. Mather wrote in the newspaper encouraging others to inoculate. He was publicly ridiculed and worse. The only doctor in Boston with a medical degree, William Douglass, lambasted Mather in the press. He mocked Mather’s previous association with the Salem Witch Trials and the idea that an African could be in possession of advanced medical knowledge. But Douglass had some valid concerns, too: by inoculating, Mather was undermining medical and political authorities as well as Boston’s regulations against importing disease. The newspaper swelled with bitter debate as newspaper editors, including Benjamin Franklin’s brother James, took sides. It became so tense that one man threw a grenade into Mather’s house. Fortunately, it failed to explode. As the epidemic worsened, only one doctor in Boston, Zabdiel Boylston, was convinced by Mather to experiment with inoculation. Boylston, beginning with his own family, inoculated 242 people.

In February 1722, once the active spread of epidemic had ceased, the selectmen of Boston collected and printed in the newspaper the statistics from the epidemic and from the inoculation efforts. The numbers showed that the inoculated individuals had a much lower mortality rate (2 percent) than those who caught smallpox naturally (15 percent). The city again attempted to control the spread of infection, but a few years later, in 1730, there was another outbreak. The debate raged again, although not as violently, but the statistics again proved the effectiveness of inoculation. Newspaper publishers and the authors of medical guides and pamphlets began using these statistics to prove that inoculation against smallpox was not only effective but was, in fact, humankind’s greatest medical discovery. In 1736, after his son Francis died from natural smallpox, Benjamin Franklin became one of the leading advocates for inoculation in the colonies. He printed statistics from epidemics and inoculation efforts in newspaper and printed articles and guides on inoculation and healthy living generally in his Poor Richard’s Almanac. In 1759, he printed a brief instructional guide on inoculation and had it distributed free to the poor. Even Douglass changed his mind and began advocating for the regulated implementation of inoculation to prevent disease.

The revelation that inoculation could prevent smallpox also helped prove that disease made no distinction among age, class, sex, or religion. Some had argued that inoculation was contrary to God’s will, because only the Lord should decide who becomes ill or well. Mather, Franklin, Douglass, and others argued instead that God gave us this preventative and that they were, in effect, denying God’s will if they failed to use it. By the middle of the eighteenth century, as the evidence for the efficiency of inoculation increased, the religious qualms about the procedure decreased. Colonists also realized they could not stop epidemics by only inoculating the rich. If they did not look out for and treat slaves, for example, they might miss the beginning of a new outbreak. In a time when most medical authorities were men, women were the caretakers in their homes and the first to rush to help a family member or neighbor in need, so it was essential that they too be inoculated and educated in spotting symptoms in others.

Inoculation for smallpox was effective, but a person undergoing inoculation remained infectious for about three weeks and could spread smallpox to others. For this reason Bostonians tightly regulated inoculations. In 1732, the Massachusetts legislature passed a law requiring the head of any family to alert the selectman when anyone came down with smallpox. The selectman then either moved the patient to a pesthouse or, especially if the victim was a child, fenced off the house from the street and placed a red flag in front to warn neighbors that smallpox was present. Newspapers would also inform readers about outbreaks of smallpox in town. In the Boston Town Meeting the threshold was established that if smallpox appeared in twenty households, the town would declare an epidemic and allow residents to inoculate themselves.

When the threshold was met, as it was in 1752, the entire town shut down. The health of the citizens was more important than the momentary economy of the city. About six thousand of the nearly sixteen thousand people living in Boston at the time opted to leave the city. Thanks to the proliferation of arguments and statistics in favor of inoculation, many Bostonians chose to inoculate. In all 2,124 people were inoculated with only 30 deaths for a 1.4 percent mortality rate. Ultimately 5,545 Bostonians acquired natural smallpox and 539 died (9.7 percent). The port of Boston and general commerce were suspended for months as the disease progressed. Many businesses opted to relocate to Cambridge or other nearby communities. Franklin, lauding Boston’s approach, noted that “the trade of the town suffered only a short interruption, compared to what had usual in former times” from a prolonged epidemic. Merchant Joseph Greenleaf boasted that “the Small-pox never was so favorable in Boston before.”

The 1752 epidemic once again proved the efficiency of inoculation, but it also left much room for improvement. Despite having a preventative at the ready, more than five hundred Bostonians died. Many of those were poor residents who could neither afford to flee nor to get inoculated. For the next decades Boston’s citizens, officials, and newspapers were once again vigilant about reporting and containing isolated outbreaks of disease. In early 1764, the number of smallpox cases began to rise, and the town braced for another citywide shutdown. A writer in the Boston News-Letter implored the town: “Let every reasonable Person consider his poor Neighbor.” In March 1764, the threshold was met and the selectmen informed people of Boston in the newspapers that in three days inoculation would commerce. More than twenty physicians teamed up with the overseers of the poor to treat the poor for free. Boston quickly became “one great hospital,” and thousands began inoculating.

Hundreds of people—including John Adams, who delayed his wedding to Abigail for the opportunity— rushed to Boston to be inoculated. General commerce in Boston was shut down for months. Harvard College had to cancel classes for an entire semester and then cancel commencement ceremonies in June as well.

Pulling off Boston’s general inoculation in the spring of 1764 required the total efforts of its residents. The city reimbursed doctors who inoculated the poor but also covered the costs for hundreds of others. The city hired nurses to care for the sick, carpenters to build hospitals and fence off areas under quarantine, and guards to enforce the rules. They paid bakers to feed the poor, landlords to house them, and weavers and launderers for clean linen and clothes, and the city even paid women to act as wet nurses for children who were either under inoculation or whose mothers were. Boston sent out inspectors to survey the extent of the disease and to count those under inoculation. The newspapers reported on all of this and kept the public updated. Residents counted on and trusted each other, but also held their neighbors accountable. They helped enforce quarantine rules, opened up their homes to strangers, and informed the public about illness in their households even when it may have been easier or more convenient not to admit it. They demanded aid be given to those who needed it and accepted it when given. Together they pulled through. In the epidemic of 1764, out of a population of 16,000, 700 caught smallpox naturally and 124 died (18 percent). A whopping 4,977 were inoculated, the largest single inoculation campaign perhaps in world history to that point, with only 46 deaths (1 percent).

As the people of Boston proved in the eighteenth century, however imperfectly, solving an epidemic requires an all-in public effort. It can’t be on the shoulders of healthcare providers, or elected officials, or the press alone. It requires the public to overcome its apathy to ensure equal and continuing access to effective prevention and treatment for all. l