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Epidemics are more than biological events. They are deeply social phenomena produced by the very societies affected by them. The ways in which we build our communities, organize our housing, arrange our water and sewerage systems, feed our people, organize our industries or treat our fellow citizens at home and at work are profound determinants of who shall live and who shall die. Further, the ways we react to disease outbreaks are products of our beliefs, our knowledge, our prejudices, and our social and political histories. Disease is often emblematic of the societies we build and often reflect deeper fissures in the social and political fabric that cannot be addressed solely through technological fixes. As we confront the resistance to COVID-19 vaccination, those involved in public policy should be aware of this history.
Early in the 1700s a series of seemingly isolated epidemics foreshadowed the social changes and crises that would transform the American experience in the century to come. First came the devastating epidemics of smallpox in commercial ports dotting the East Coast, epidemics borne of social and economic changes that would result in the waves of disease from cholera to typhoid, malaria and typhus that spread through the nation by the outbreak of the Civil War.
The smallpox epidemics that struck small, isolated agricultural communities in New England marked the beginning of the end of an enormously healthful period in the region’s history. During the previous three generations, the lifespans and reproduction rates of New England’s white population were better than any in world history. Men who reached the age of 21 could count on living into their 60s, 70s, and, in some communities, their 80s and 90s. Women who did not die in childbirth or shortly thereafter could similarly expect long lives.1
However, the salubrious experience was about to change. In 1721, Zabdiel Boylston, a Boston physician, called for the adoption of inoculation to prevent the spread of smallpox, the terrifying disease then sweeping from the small port city of Boston. He recalled having narrowly escaped with his life during a smallpox epidemic 19 years earlier. But, this second epidemic was vastly more terrifying, infecting approximately half of Boston’s 10,000 residents and killing nearly one out of every seven. In the face of widespread popular resistance to his call for inoculation, Boylston wrote a long treatise to the British Queen, Caroline of Ansbach, in the hope of gaining her support for using this new technology. He and the Puritan preacher Cotton Mather had learned of the success of inoculation in the largely Muslim eastern Mediterranean and northern Africa, and from Mather’s slave, Onesimus. After some ethically questionable experiments, they found the technology enormously effective. Nearly all that Boylston treated survived a sometimes-grueling course, but it was infinitely easier than the experience of those who went uninoculated, who experienced:
“Purple Spots, the bloody and parchment Pox, Hemorrhages of Blood at the Mouth, Nose, Fundament, and Privities; Ravings and Deliriums; Convulsions, and Other Fits; violent inflammations and Swellings in the Eyes and Throat; so that they cannot see, or scarcely breathe, or swallow any thing, to keep them from starving. Some [victims] looking as black as the Stock, others as white as a Sheet; in some, the Pock runs into Blisters, and the Skin stripping off leaves the Flesh raw, like Creatures flea’d. Some have a burning, others a smarting Pain, as if in the Fire, or scalded with boiling Water; Some have insatiable Thirst, others greedy Appetites; and will crave Food when dying. Some have been fill’d with loathsome Ulcers; others have had deep, and fistulous Ulcers in their Bodies, or in their Limbs or Joints, with Rottenness of the Ligaments and Bones: Some who live are Cripples, others Idiots, and many-blind all their Days; beside the other-Deformities it brings upon many, in their Faces,- Limbs, or Body, with many more grievous- Symptoms, which the World has had too great Experience of, as being the Attendants of that fatal Distemper called the Confluent Small-Pox.”
Death was not the end of their troubles, however:
“Parents being left Childless, Children without Parents, and sometimes Parents and Children’s being both carried off, and many families broken up by the destruction the Small-Pox made in the natural way….”2(pp 38; iii-vi)
Despite the obvious suffering of the uninoculated, many in Boston saw the epidemic as divine intervention, God’s judgment, and therefore not to be questioned or contradicted. Like Jonathan Edwards, the fire and brimstone preacher who two decades later would admonish his parishioners that “There is nothing that keeps wicked Men at any one Moment, out of Hell, but the meer Pleasure of GOD,” many in the community ascribed to a fundamentalist belief that humans’ fate was not in their control. Edwards argued, and many believed, “Your healthy Constitution, and your own Care and Prudence… would have no more Influence to … keep you out of Hell, than a Spider’s Web would have to stop a falling Rock…. Nothing that you have ever done, nothing that you can do, [can] induce God to spare you one Moment.”3
Boylston countered, in what would be one of the first arguments pitting fundamentalist ideas against medical science, that, if such were the case, God would not have provided the means by which to thwart the disease’s prevention. “Providence has wisely and mercifully order’d it, … & has now, in greater Goodness, discovered to us a Way or Method how to moderate that Distemper, & to render the Small-Pox, inoculated, no further dangerous than a common intermittent Fever….” 2(pp 38-40)
The popular rejection of inoculation fed a more general instability in the changing American landscape, one that was reflected in increasing death rates, political instability, increasing inequalities, the creation of a social order and slave society, religious “reawakenings,” and by the end of the century, revolution. In Boston, the center of growing coastal and international trade, 37 of every 1,000 residents died by the middle years of the 19th, just slightly lower than that of England. The scattered, isolated epidemics of yellow fever, smallpox, and diphtheria that once had been concentrated in Boston, New York, and Philadelphia spread. Native Americans, who were the first to be devastated by disease spread and the movements of Europeans into the continent’s interior, were never to fully recover.
The epidemic signaled the beginning of a long decline in health status, one that lasted into the 20th century. The demographic explosion of the first three generations fed the breakdown of the small, rural peaceable kingdoms, and as smallpox epidemics struck, they brought “a terror to New England” that the English settlers had not experienced since emigrating from England.2(p1) By the end of the 19th century, the life expectancy of New Englanders had declined to European levels, men in 1900 were two centimeters shorter than those born more than a century before, and infant mortality and maternal mortality had both increased. In 1855, Catherine Beecher, the sister of Harriet Beecher Stowe, author of Uncle Tom’s Cabin, and Henry Ward Beecher, abolitionist and head of Plymouth Church in Brooklyn, wrote Letters to the People on Health and Happiness, a 200-page effort to “prove that the American people are pursuing a course, in their own habits and practices, which is destroying health and happiness to an extent that is perfectly appalling.”4(p7)
For this historian, it is difficult not to see parallels between the resistance to COVID-19 vaccination today and the looming threats that indicated a dissolution of social order, political stability, and community cohesiveness leading to Civil War by the middle of the 19th century. The resistance to vaccination against COVID-19 and the Delta variant seems part and parcel of the paralysis we face in trying to mobilize to address climate change, Afghanistan, and a former president and his enablers who glory in promoting political instability. It is hard not to worry that our current inability to convince many Americans to get vaccinated is a signpost of the coming decline of the American experiment.
1 See the extensive literature on the extraordinary health experience of the early New England towns among them, Philip Greven, Four Generations, (Ithaca: Cornell University Press, 1970), pp. 103-258; James Henretta, The evolution of American society, 1700-1815 ; an interdisciplinary analysis (Lexington: Heath, 1973); John Demos, A Little Commonwealth: family Life in Plymouth Colony, (New York: Oxford University Press, 1971);
2 Boylston Z. An historical account of the small-pox inoculated in New-England, upon all sorts of persons, whites, blacks, and of all ages and constitutions: with some account of the nature of the infection in the natural and inoculated way, and their different effects on human bodies ; with some short directions to the unexperienced in this method of practice ; humbly dedicated to Her Royal Highness the Princess of Wales, (London: S. Chandler; 1726. Reprinted Boston: S. Gerrish, 1730. https://collections.nlm.nih.gov/ext/mhl/2544007R/PDF/2544007R.pdf. Accessed January 30, 2021.
3 Edwards J. Sinners in the Hands of an Angry God, A Sermon Preached at Enfield. July 8, 1741. https://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1053&context=etas. Accessed December 6, 2020.
4 Beecher CE. Letters to the People on Health and Happiness. New York: Harper & Bros; 1855. https://collections.nlm.nih.gov/bookviewer?PID=nlm:nlmuid-61360570R-bk#page/6/mode/2up. Accessed July 24, 2020.
David Rosner is the Ronald H. Lauterstein Professor of Sociomedical Sciences and professor of history at Columbia University and codirector of the Center for the History of Public Health at Columbia’s Mailman School of Public Health. He is also an elected member of the National Academy of Medicine. In addition to numerous grants, he has been a Guggenheim Fellow, a recipient of a Robert Wood Johnson Investigator Award, a National Endowment for the Humanities Fellow, and a Josiah Macy Fellow. He and Gerald Markowitz are coauthors on ten books, including Deceit and Denial: The Deadly Politics of Industrial Pollution (University of California Press/Milbank, 2002; 2013) and Lead Wars: The Politics of Science and the Fate of America’s Children (University of California Press/Milbank, 2013). He also testifies for plaintiffs in lawsuits on industrial pollution and occupational disease.
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