During a smallpox outbreak in March 1662, officials in East Hampton, near the eastern tip of New York’s Long Island, tried to cut off movement between the town and surrounding Indian villages. “It is ordered that no Indian shall come to town into the street after sufficient notice upon penalty of 5s. or be whipped until they be free of the smallpox,” they decreed. Town residents who visited nearby “wigwams” were to suffer the same punishment.
Year-round residents of East Hampton might have welcomed such a restriction this March, when rich New Yorkers fled the city for their summer homes in the Hamptons and elsewhere, in some cases bringing the new coronavirus with them. Now, the states of New York, New Jersey and Connecticut are requiring travelers from 22 states where Covid-19 is on the rise to self-quarantine for 14 days after arrival. No whippings await those who flout the rules, but a fine of up to $10,000 might.
The limitations on movement, commerce and fashion (by which I mean face-mask mandates) that have been imposed to fight Covid-19 in the US this year have been decried in some quarters as unprecedented and unconstitutional affronts to liberty. As is apparent from the historical example above, there’s nothing unprecedented about restricting freedom in the name of fighting infectious disease. There’s nothing unconstitutional either: The US Supreme Court explicitly endorsed state quarantine powers in 1824, and though citizens have occasionally challenged the application of those powers as violations of the due process clauses of the Fifth and 14th Amendments, they have usually lost their court cases.
Still, it is at least conceivable that some measures used this year to slow the spread of Covid-19 have been so harsh and so disproportionate that they represent a break with this country’s disease-fighting history and values. A couple of questions posed recently on Newsmax by Stephen B. Presser, an emeritus professor at the Northwestern University Pritzker School of Law and a critic of coronavirus lockdowns, put matters nicely if hyperbolically in focus:
Would George Washington, Alexander Hamilton, or Thomas Jefferson wear facemasks?
Would they have closed down American society, abrogating all constitutional rights and freedoms out of fear of a pandemic?
The answer to the first is easy. Yes, they probably would wear face masks. Washington, Hamilton and Jefferson were all creatures of the Enlightenment, firm believers in science and in progress. Not every Founding Father was like that (John Adams had his doubts about progress), but the three that Presser cites certainly were.
All three were pro-vaxxers, for example. As commanding general of the Continental Army, Washington required in 1777 that all his soldiers be inoculated against smallpox by infecting them with mild cases of the disease, leaving his right-hand man Hamilton to tangle with officers who balked at the edict. Then, after English doctor Edward Jenner introduced vaccination with cowpox, a largely harmless disease that conferred immunity to smallpox, Jefferson enthusiastically embraced the practice as president, conducting trials of the vaccine on his family and neighbors, disseminating it among Native American tribes and promoting the career of the Boston doctor who was Jenner’s chief American disciple. In 1813, Jefferson’s successor and political ally James Madison signed into law a Vaccine Act that made maintaining an adequate supply of smallpox vaccine a federal responsibility and provided free postage for its distribution.
With face masks there is no “proof” in the form of randomized controlled trials that they slow the spread of Covid-19, but there is by now a growing pile of persuasive evidence and a firming scientific consensus that widespread mask-wearing probably helps a lot in keeping the disease under control. It is difficult to imagine Washington, Hamilton or Jefferson observing such a consensus and not putting on a mask in response.
Abrogating Rights to Fight Disease
Presser’s second question is a little harder to answer. Government officials have many times since the 1600s abrogated some rights and freedoms to fight disease, as they have done again this year. It’s worth noting, though, that the diseases they were fighting in the past — mainly smallpox and yellow fever in the era of the Founding Fathers, with cholera coming along later — were far deadlier on a case-by-case basis than the coronavirus, which has so far killed 4.5% of those with confirmed cases around the world and probably something under 1% of those infected. The most common variant of smallpox has a fatality rate of 30%, yellow fever’s ranges from 15% to 50%, and cholera, while not very dangerous now if treated, kills half of those afflicted without treatment.
Smallpox was the first big threat, plaguing colonists — and, even more, the Native Americans they encountered — from the beginnings of European settlement. The disease spreads through close contact with those who have it and their clothing and blankets, and the colonists appear to have understood this well. In 1678, the selectmen of Salem, Massachusetts, ordered a smallpox sufferer named William Stacy to confine himself to home for three weeks and then “shift his clothes” afterward. In 1763, Jeffery Amherst, the top British military commander in the colonies, infamously suggested to an underling that he infect his Indian adversaries in western Pennsylvania with smallpox-infected blankets.
In the interim, a slave working in the Boston household of famed Puritan preacher Cotton Mather had introduced smallpox inoculation to North America. Onesimus, one of Boston magazine’s “100 Best Bostonians of All Time,” told Mather about the procedure and said it was widely performed in West Africa. The minister then began an inoculation campaign in 1721, overcoming early opposition to make the practice widely accepted in Massachusetts. After Jenner’s cowpox discovery, the state began encouraging towns to offer free smallpox vaccination in 1810, and in 1855 it became the first state to require that children be vaccinated against smallpox in order to attend public school.
Smallpox thus began to recede from the picture. But yellow fever outbreaks gained in frequency in the late 1700s and early 1800s, and after arriving from Europe in 1832 cholera became the worst scourge of all. Yellow fever is spread by mosquitoes and cholera via contaminated drinking water, but doctors didn’t begin to figure out either transmission mechanism until the latter half of the 19th century. The main defense was thus quarantine, with Massachusetts adopting the first such regulation in the colonies in 1647 to combat a “plague” from the Caribbean that was probably yellow fever. The rule required vessels from the West Indies to anchor off an island in Boston harbor and banned crew members from coming onto the mainland or coming within four rods (about 50 feet, or 15 meters) of anyone not from their own ship without permission from local authorities. Some serious social distancing, in other words.
Most of the quarantine efforts that followed were similarly aimed at threats from overseas, with islands by major ports dedicated to holding new arrivals from places experiencing epidemics. In New York, the quarantine location moved over time from Governor’s Island to what is now Liberty Island to Staten Island and finally, after Staten Island residents burned the facilities down in 1858 in the wake of a yellow-fever outbreak, to two artificial islands just south of Verrazzano Narrows.
Over time more and more of the responsibility for this work shifted to the federal government’s Marine Hospital Service, which had been created by Congress in 1798 as a sort of health maintenance organization for American merchant seamen, was rechristened the US Public Health Service in 1912 and lives on today as the umbrella entity for a group of agencies that includes the Centers for Disease Control and Prevention, National Institutes of Health, Food and Drug Administration, and Office of the Surgeon General. An 1891 law put the Marine Hospital Service in charge of screening newly arrived immigrants for diseases, and another enacted in 1893 instructed it to station medical officers in ports around the world to head off ships that were harboring infections.
There were domestic quarantines and other measures too, and not just in East Hampton. Some of the toughest were imposed in 1793, when yellow fever devastated Philadelphia, killing thousands of the city’s inhabitants and sending tens of thousands fleeing. With Philadelphia the nation’s temporary capital at the time, Washington, Hamilton and Jefferson were among the refugees. President Washington said later that he had considered staying longer in Philadelphia but didn’t want to endanger his wife, Martha. Secretary of State Jefferson wrote that he was going to stick around because “I do not like to exhibit the appearance of panic,” but ended up leaving a week after Washington. Both were able to make it home to Virginia unscathed and unimpeded.
Treasury Secretary Hamilton and his wife, Eliza, though, came down with the disease. After recovering they headed north to visit her family in Albany, but it wasn’t easy getting there. “At town after town, they had to contend with barriers erected to keep out potentially contagious Philadelphians,” wrote Hamilton biographer Ron Chernow. “Even New York posted guards at entrances to the city to deter fugitives from the plague-ridden capital.” When the couple finally arrived across the Hudson from Albany, they learned that a city ordinance enacted two days earlier banned ferrymen from transporting people from disease areas. It took intense lobbying from Eliza’s father, and examinations by multiple physicians, before they were allowed across.
Nearly a century later, restrictions on domestic travel were still being used to stop yellow fever. In 1879, the Marine Hospital Service established a cordon of quarantine stations from Laredo to Corpus Christi, preventing inhabitants of Texas’s southern tip from traveling northward until they had cooled their heels for 10 days first. In 1888, the agency erected a detention camp near the Florida-Georgia border to hold those fleeing yellow-fever-beset Jacksonville.
For a long time it was believed that yellow fever, cholera and other diseases spread via foul air, so another big priority was improving sanitary conditions, which cities did by banning “noxious” trades such as soap- and glue-making from city centers, ordering property owners to clean up garbage and drain flooded cellars, taxing dogs and otherwise restricting both bad smells and economic freedom.
Not all such efforts were salutary: In New York City, the Tammany Hall Democratic political machine was by the mid-1800s using health inspections as a vehicle for graft, and in Honolulu an attempt in 1900 to stop an outbreak of bubonic plague by burning infested buildings resulted in an out-of-control fire that consumed 35 city blocks, destroying the city’s Chinatown and leaving 6,000 people homeless.
Still, from the 1860s onward local and state health agencies did grow increasingly professionalized just as advances in germ theory enabled them to target their interventions much more effectively. New York City’s mortality rate, which had risen over the first half of the century, began a long, spectacular decline, and other US cities saw similar drops — up until the deadly influenza pandemic of 1918-1919, that is.
Coping With Influenza
Influenza pandemics were nothing new. A giant one swept through Europe and North America in 1781 and 1782 and another in 1789 and 1790, and no I’m not aware of Washington, Hamilton or Jefferson endorsing drastic measures to fight either, even though Washington came down with a pretty severe case as president in the spring of 1790. Controlling the spread of the disease was much harder than with smallpox or yellow fever — by one estimate, three quarters of Europe’s population became infected in 1781 and 1782 — and the risk of dying if you got it was for otherwise healthy people usually quite low. As lexicographer and proto-epidemiologist Noah Webster put it in reference to the especially virulent second wave of the 1789-1790 pandemic: “Many plethoric persons of firm habit almost sunk under it; while consumptive people and hard drinkers fell its victims.”
For most people, and for government officials, the disease was simply something to be endured. Compared with the other health threats they faced in those days, the risk-reward calculations on influenza didn’t seem to justify much action. The last great pandemic before 1918, the “Russian epidemic” of 1889 that a few scientists have suggested was caused by a coronavirus but was probably influenza, had a case-fatality rate that has been estimated between 0.1% and 0.28% and is more or less indetectable in the mortality records of US cities.
The 1918-1919 influenza, which killed an estimated 675,000 people in the US, certainly is detectable in the mortality charts. That’s partly because it was more dangerous than earlier strains: More than 2% of the people who came down with it died, and young adults were among the hardest hit. But the great improvement in overall health conditions also made its effects stand out more. The US mortality rate (in age-adjusted deaths per 100,000 inhabitants) jumped 12% in 1918 — which merely brought it back to about the level of 1900.
The reaction to the pandemic in the US seems to have started out as old-style influenza fatalism, albeit informed by increased knowledge about how the disease spread. When I asked Alex Navarro, a medical historian at the University of Michigan and co-editor of the invaluable online Influenza Encyclopedia, about attitudes as the disease began to spread, he emailed:
In the late summer of 1918, as the influenza epidemic began to take off in the military camps, the general consensus among civilian public health officers was that these outbreaks would be over soon. They almost universally warn residents to cover their coughs, avoid crowds, and avoid panic, and reassure them that it will pass quickly.
After hospitals started filling up and people began dying in large numbers, health officials changed their tune. With the country entangled in a World War and President Woodrow Wilson unwilling to pay heed to the disease, Washington’s role was limited. The two massive mid-20th-century histories of the US Public Health Service from which I got many of historical details in this column give only cursory attention to the 1918 pandemic.
But many cities took significant measures to slow the spread of the flu, from isolating infected people and quarantining their households to closing schools, theaters, pool halls and churches, banning other large gatherings and, yes, mandating the wearing of face masks, whose usefulness in thwarting the spread of infections in hospitals had been established two decades earlier. Most of these rules were in place only briefly, though, and some faced fierce opposition. Owners of shuttered businesses protested in many cities, and in San Francisco an “Anti-Mask League” agitated for the resignation of the mask-mandating mayor.
Afterward, these efforts were not seen as a big success. A major study of the 1918 pandemic published by the American Medical Association in 1927 concluded that while quarantines had kept influenza out of some small towns they were less effective in cities, and that the evidence on school closures, bans on gatherings and face-mask mandates was inconclusive.
In subsequent years, as vaccines and pharmaceutical treatments vanquished once-dreaded disease after once-dreaded disease, such seemingly primitive methods of disease control fell out of fashion. The federal government dismantled most of its infrastructure for keeping diseases out of the country, and the rise of mass international air travel made it seem impractical in any case.
With influenza, scientists first isolated the virus in 1933, and vaccines soon followed. It was then discovered that there were multiple influenza viruses, which mutated over time, limiting the effectiveness of vaccines. But they did reduce the threat. The two worst influenza pandemics of the vaccine era, those of 1957-1958 and 1968, killed an estimated 116,00 and 100,000 Americans respectively, mostly in the absence of interventions other than brief school closures.
The Return of Nonpharmaceutical Interventions
Over the past two decades, though, attitudes have shifted. A key reason was the emergence of new diseases for which there were no pharmaceutical treatments, most notably Covid-19’s coronavirus cousins Severe Acute Respiratory Syndrome and Middle East Respiratory Syndrome. SARS, which appeared in the Chinese province of Guangdong in November 2002, spread rapidly in several East Asian countries and in Canada before isolation of afflicted patients, quarantines, travel restrictions and near-universal mask-wearing in some places succeeded in bringing it in check by mid-2003.
After that, researchers began re-examining the effectiveness of what they had come to call “nonpharmaceutical interventions.”
A much-cited 2006 modeling study in Nature concluded that case isolation and household quarantine could be extremely effective in mitigating an influenza pandemic, and that school closings might at least slow it down substantially. Two different 2007 studies of pandemic-fighting efforts in US cities in 1918, one co-authored by Navarro, found that, when implemented in a timely fashion, quarantine orders, school closures and public-gathering bans appeared to have reduced deaths from the disease. And in 2007, the CDC made “early, targeted, layered use of nonpharmaceutical interventions,” including what it called “social distancing,” the centerpiece of its strategy for fighting influenza pandemics.
Which brings us, finally, back to Covid-19. It seems to be in the same ballpark as the 1918 influenza in overall fatality rate, but doesn’t pose nearly the danger to young adults. Eighty percent of deaths from it so far in the US have been among those 65 and older. If Washington, Hamilton and Jefferson had been confronted with this exact disease when they were running the then-very-youthful US together in the early 1790s, it seems highly unlikely that they would have endorsed large-scale quarantines and business and school closures to fend it off. (As already noted, I don’t think they would have had any objection to wearing masks.)
Still, there are good reasons we seldom turn to the Founding Fathers for medical advice. Science has progressed a lot since their time, and the infectious diseases that worried them most have been largely defeated, at least in the developed world. Among the threats that remain, Covid-19 is the biggest one to come along in quite a while. The 138,784 American lives it had taken as of Friday are still less as a percentage of the population than the toll of the 1957-1958 or 1968 influenza pandemic, but that’s been in the space of just four-and-a-half months, and in the face of what has to be the most widespread application of nonpharmaceutical interventions ever seen in this country.
Some of those interventions have surely been more effective — and cost-effective — than others. With the benefit of hindsight and several months of research into how Covid-19 spreads, it seems like stay-at-home orders are probably excessive, as are “nonessential business” closures that fail to differentiate between businesses likely to be hotbeds of disease spread (bars) and those that aren’t (garden centers). The efficacy of school closures also remains a topic of much debate. But it’s clear from looking around the world that the countries that treated Covid-19 as a disease to be contained like smallpox or yellow fever have fared much better than those that by policy or by default have let it wash over them like influenza. Also, even just delaying the disease’s spread has great value in an environment where doctors can quickly develop better ways to treat patients, and new pharmaceutical treatments and maybe even vaccines can be ready in a matter of months. This isn’t the late 1700s, happily enough. We can do better.
Bloomberg
