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April 04, 2023
America Dissected
The Contagion of Liberty with Prof Andrew Wehrman

In This Episode

“Those who cannot remember the past are doomed to repeat it.” That’s for damn sure when it comes to vaccinations. Abdul reflects on the hypocrisy at the heart of the anti-vaxxer movement. Then he chats with Prof. Andrew Wehrman, historian and author of “The Contagion of Liberty,” about the role of smallpox inoculation in revolution-era America.

 

TRANSCRIPT

 

[music break]

 

Dr. Abdul El-Sayed, narrating: The FDA approves over-the-counter naloxone, a nasal spray used in emergency situations to treat opioid overdoses. A federal judge in Texas strikes down an ACA provision that requires health plans to cover preventive care. North Carolina becomes the 40th state to expand Medicaid. Once again in America, children are murdered at the point of a gun in their school, this time in Tennessee. This is America Dissected. I’m your host. Dr. Abdul El-Sayed. [music break] What’s that famous quote about history? Those who can’t remember the past are doomed to repeat it. Well, so much of the current political opposition to vaccines today didn’t just happen yesterday or three years ago. Anti-Vaxxers have a long, sordid history. Today, we’re going back in history to understand the evolution of that history. We’re talking about smallpox inoculation campaigns that divided the country back before it was even a country in the late 1700s. Smallpox is a gruesome, deadly disease. Think thousands of small, painful pustules, pox all over your body as you writhed with a fever and pain. If you weren’t one in three who died of smallpox, you were almost certain to bear the pitted scars for the rest of your days. Smallpox was eradicated in the U.S. in 1949, globally in 1980, but not before it took hundreds of millions of lives. 300 million in the 1900s alone. You know how we finally eradicated it? Vaccination and contact tracing. Sound familiar? The fact that we’re more than 70 years since the eradication of smallpox in this country might have you think that it was a fait accompli. That the discovery of an effective prevention technique was all that was needed for folks to get on board and voila, smallpox gone. No anti-vaxxers, no gnashing of teeth. Nope, not what happened. Inoculation, the procedure we’re talking about today was the predecessor of vaccination. And let me tell you, whatever folks want to make of the safety of vaccinations, 1% of inoculated patients died. Yes, died. To put that in perspective, that’s the same chance as dying if you get COVID. But here’s the thing. Even if inoculation carried a 1% chance of death, it protected you from a 30% chance of death from actual smallpox. I’m no betting man. But 1 to 30 odds is a pretty safe bet. That said, inoculation was also well, let me just explain. To inoculate yourself, you had to inhale ground up scabs from an infected person or introduce an infected persons pus into a scratch on your body. All that to deliberately infect yourself with the disease. Not great. But if you’re living in 1720s Boston with smallpox raging all around you. I’d take my chances with other people’s pus rather than die of smallpox. That logic wasn’t all that clear, though, and it led to the rise of all the same debates we’re having now, three centuries later. As we’ll hear more about it in our interview with Professor Andrew Wehrman, a historian of the era and author of the new book Contagion of Liberty. Here is the rest of the story. And I’m jumping forward here because it shows you just how inane today’s anti-vaxxers have become. By the end of the 1700s, inoculation with that 1% chance of dying had been replaced by a true vaccination. Rather than infect themselves with smallpox to prevent smallpox infection. Early scientists discovered that an infection with cowpox was far less dangerous in humans and had cross-reactivity to smallpox in a process that was then called variolation, which ultimately led to the first smallpox vaccines. And one and a half centuries later, the eradication of smallpox. Mind you, though, this is the late 1700s or early 1800s. The whole germ theory of disease thing, the notion of such a thing called a virus. A nuanced understanding of the human immune systems. Those things wouldn’t come for nearly 50 years. So you can forgive the good folks in Boston for their healthy skepticism when they were told it might be a good idea to snort smallpox scabs when they had no clue how it worked, just that someone had told them that it worked. But now we’ve had the science for centuries. And not only did the vast majority of us sit in a classroom where someone, albeit extremely boringly explained the scientific method, the immune system, even how vaccinations worked. But take a look around you. Science, well, kind of delivered back in the 1700s. Life expectancy was 38. Yes, 38 years. And that’s for a white male. You know, the kind of person who could even own land, let alone not have their body owned by someone else. And the kind of person who didn’t have to give birth, which at that point carried an astronomical mortality rate. Today, life expectancy for the same white dude has more than doubled. That’s mainly because babies aren’t dropping dead like flies. Yeah, science. It’s delivered. But look, you might say Abdul. You can’t fault people for not having lived in the 1700s to see the contrast between how many people died then and how many people live today. Okay, fine. You know where all those anti-vaxxers go to spread their bullshit? The internet. You know that thing that started as a government science project. The product of centuries of electrical engineering, computer science, chemistry, the fact that this place works so flawlessly isn’t just a matter of nature. It took a lot of people doing a lot of yes science to make that possible. The willful ignorance of that, while decrying the same exact process applied to human biology. That’s either stupidity, ignorance, or willful disregard for the truth. I don’t even blame the mis and disinformation mongers as much as I blame people like myself. Scientists, because as we’ll learn, mistrust in science has been around. But science. Well, science hasn’t. And while I wish it did. Science doesn’t speak for itself. We’re supposed to speak for it. But instead of doing the work of public education, of teaching science in a way that shows just how exciting, interesting and accessible it can be, we’ve cloistered it. We’ve dressed it up in big words, hidden it behind elite educations and scoffed at those who haven’t had the privilege to penetrate the walls we’ve erected. We’ve made science so unintelligible that even centuries of science later, it still doesn’t speak for itself. So all you scientists out there, here’s my charge. Are you part of the problem or part of the solution? Doing great science is awesome. It’s fun. It’s meaningful. But what are you doing to let it out of your lab to give that gift to someone else? Okay, rant over. Now, for the history part. Here’s my conversation with historian and author of The Contagion of Liberty, Professor Andrew Wehrman. 

 

Dr. Abdul El-Sayed: Can you introduce yourself for the tape? 

 

Andrew Wehrman: I’m Andrew Wehrman. 

 

Dr. Abdul El-Sayed: So tell us a little bit about why you wrote a book about smallpox several centuries ago. 

 

Andrew Wehrman: Well, uh I’m a historian, right? So I was uh interested and in college and at a young age in the American Revolution and kind of the origins of the United States and its and its history. And I wanted to understand how ordinary people experienced the American Revolution. I thought we uh needed to to know more about how people in smaller communities and and places uh made decisions during uh the revolution, deciding which side to to go with or whether or not they would take up arms or what they would do during this this uh crisis. And so doing dissertation research at Northwestern. Um. I started digging around to different communities, town records, diaries trying to get um a handle on how ordinary people experienced this moment. And and smallpox just came out through that experience. I was I was looking at town meeting records and looking at uh diaries of people and started seeing this common theme of people talking about uh smallpox, what to do about it, the numbers of of people who were afflicted, dying. And debates over inoculation, whether whole communities should inoculate, whether they should build hospitals to stop it. And I realized I was I was on to something when I found it in sort of town after town being debated and and talked about. And I thought this is a part of the revolution that we didn’t uh know very well that the revolution itself took place during an epidemic. It wasn’t the war that that started the smallpox epidemic. It was it was the war that broke out during this epidemic. 

 

Dr. Abdul El-Sayed: Mmm. And, of course, one of the values of history well not to know history for history’s sake, but one of the values of history is, of course, it teaches us lessons for the present. Now did you know that there was going to be a pandemic when you set out to write this book? [laughing]

 

Andrew Wehrman: [laugh] I would have hoped that there wouldn’t have been, no. So, yeah, my my I got my Ph.D. in 2011 and that was my dissertation topic. And I had been expanding it over the years to incorporate more more places and over more time. And, uh no, so I was writing it and preparing to write it for people who had never experienced a quarantine and and didn’t understand inoculation orders and and cities shutting down and that sort of thing. And but as I was preparing to write my my final draft to send to publishers, that’s when uh COVID broke out. And all of a sudden those those words like quarantine and shut down, were regularly part of uh American’s vocabulary. And I realized um that my work could shed some light on what people were going through during the during the pandemic and afterward as we sort of think about what happened and how to do better. 

 

Dr. Abdul El-Sayed: You know, I’m an epidemiologist, and uh back in the day I used to have to explain to people that I was not actually a skin doctor and now uh half– 

 

Andrew Wehrman: [laugh] Right. 

 

Dr. Abdul El-Sayed: –of Twitter is an epidemiologist. So there’s that. Um. Tell us about smallpox. Uh. How awful is it? I mean, we read a lot about it in our schoolbooks, but I think it’s lost on people just how bad of a disease it is. Um. Put us in the mind of the average American early uh in the history of this place. What is your fear level when it comes to smallpox and how do you experience it? 

 

Andrew Wehrman: Smallpox was terrifying. It was called uh the sovereign disease, the king of terrors, just known in the 18th century and previous centuries as the greatest killer of mankind, more feared, especially in the 18th century, than than the plague or yellow fever or cholera or any other kinds of diseases that you hear about at the same time, smallpox was known as the worst. It had uh the highest uh case fatality rate in the 18th century in in North America, um the case fatality rate um was somewhere between 15 and 20%. Usually. Um. Earlier centuries, and especially when smallpox affected Native American populations, like with the Spanish and uh in in the 1500s, you would see uh fatality rates greater than 50% um in those uh populations. Uh. It had been uh managed a little bit better, understood a little bit better by the time I’m writing, by the American Revolution, but still uh a 20% mortality rate. And and that’s just the deaths. I mean, the people that that got it um had severe effects from it, right? It’s it’s those namesake pox that appear on the uh usually on the extremities. Hands and feet, face and uh could leave uh lifelong scars but also caused blindness in a lot of people as they concentrate around the eyes. Um uh long term disabilities came came from it as well, a really uh terrifying disease and a disease that uh people in communities did everything they could to prevent to stop. [music break]. 

 

[AD BREAK]

 

Dr. Abdul El-Sayed: What is the first known inoculation uh in the colonies and where did inoculation come from? 

 

Andrew Wehrman: So inoculation is the uh purposeful implantation via an incision usually in the arm of a little bit of smallpox matter taken from one of those sores the pustules and inserted into the skin. This had been known about in a lot of different societies where smallpox had become endemic, and there’s debates over where it originated, whether it was in Africa, uh the Middle East, or in China. And uh in these places. Um. It had been carried on for uh hundreds of years. Europeans, and by extension colonial British North Americans were some of the last to know about it. So in the early 1700s, the Royal Society in London was starting to get reports out of out of Turkey um about how Turkish women were inoculating children. They got some reports out of China at the same time, and these were published in uh their scientific journals. And in Boston, Massachusetts, uh Reverend Cotton Mather, who was a member of the Royal Society in England, read those published reports and and said, Oh, I already know about this. And he wrote a letter back to London saying that uh an enslaved man belonging to him, a man named Onesimus, an African man who was actually given to Mather by his congregation in Boston, had told Mather of inoculation. Actually Mather asked, have you ever had smallpox before? And Onesimus who must have been really clever, said uh yes and no, and then described how he was, you know, purposefully um infected with with smallpox in Africa. And uh that’s the origin of it in America. Was that an African slave named Onesimus described the practice. Mather thought during an epidemic in 1721 uh that it should be widely used. And he publicized it, wrote about it, and it caused a massive controversy in Boston, as some people thought that Europeans shouldn’t take medical advice from African people. Maybe this was just the slaves way of tricking us or fooling us into doing something really stupid. Others thought, you know, this could work, but it needs more scientific testing. It needs more experimentation. Others thought this was playing God that um purposefully making someone sick to prevent a disease seems like doing God’s work. That God ought to decide who’s sick and who’s well. Um. And that, you know, people shouldn’t intervene in this way.

 

Dr. Abdul El-Sayed: Hmm. How effective was inoculation? 

 

Andrew Wehrman: It was uh extremely effective. Um and see the thing about natural smallpox is the only saving grace of this terrible disease was that uh once you were infected once and you survived, uh you would have lifelong immunity to it in the future, the body would recognize this virus. And uh so inoculation uh gave a patient a much milder uh case of smallpox that was much more survivable, usually uh having a mortality rate of around one or 2% compared to 20 or 25%. Still, you know, not great. Um. But this is a time before they sterilized instruments. There were all sorts of uh issues that we could see now that would make it a lot uh safer still. But the the statistics started proving it. So in every place where they tried inoculation in the in the 1700s and it became more and more common over the decades, it was clear that inoculation saved lives, so that protected people against uh smallpox in all cases. 

 

Dr. Abdul El-Sayed: You know, it’s fascinating because I just want to summarize the story you’re telling us. There is this incredibly effective treatment that does carry some real risks in the context of an epidemic of a very, very serious, very, very deadly disease, gruesome disease that’s devastating communities. That comes from the lips of an enslaved African man. And the question at hand is, do we use this? And a lot of the same contours about whose medicine is this versus what does the science and the evidence tell us, versus how much fear do we have empirically of the treatment versus the disease? These shape a lot of the contours of the debate about COVID vaccines hundreds of years later. And, you know, it’s both um incredible that this was a conversation that was happening at the time uh that it did. And also extremely sad that we have not moved past this conversation with all of the scientific progress that has come. Because, you know, you talk about inoculation. You don’t I mean, there’s so many things that we take for granted. You talked about, you know, sterilization, etc., but even just a standardized dose. Right. How much do you actually need? Where should you put it? 

 

Andrew Wehrman: Yeah. 

 

Dr. Abdul El-Sayed: In whom is it most effective? Like, these are scientific questions that we study ad infinitum now, um and we can give you really strong statistics from very, very well-designed studies that did not exist in the past. And um and so it’s just it’s a testament of how far we’ve come and yet how far we have yet to go in terms of the social discussion of everything from science to the origins of treatment uh to how we we take on um the conversation about prevention. 

 

Andrew Wehrman: It’s a fascinating story. It has all of these elements of religion and race and science. And you’re right, um they did argue about and there are uh doctors talking back and forth about uh the the techniques. How large should the incision be? Um uh. When is it ideal to inoculate? What season of the year, uh what sorts of people, young or old, um men or women? And of course, they argued a lot about um how effective it was by race. If this is something that’s safe for white people, if it’s good for Black people and different things, that was a big topic in the colonial period as well. Um. All of these issues uh come up and come up again. And you’re right that, you know, we can almost excuse people in the 1720s for having these sorts of doubts and questions about um inoculation, because to them it was a really strange thing. But after hundreds of years of success, both inoculations and the and the vaccinations that have followed and the science, that that has come uh since then, it’s it’s harder to justify any kind of anti uh vaccination arguments today. But here they are and they’re echoing many of the same kinds of things as we see in the past. 

 

Dr. Abdul El-Sayed: Ultimately, um we’ve eradicated smallpox and that is a huge public health achievement. And a lot of the the beginning of eradication came about when community inoculation started to take hold. Can you walk us through what that was and um what ultimately tipped the scales toward, you know, community driven inoculation? 

 

Andrew Wehrman: Yeah. So there in Boston in in 1721, about 280 people volunteered, or some of them were children. So were, you know, uh forced or made to undergo inoculation. Um. And of those uh 280 or 290 people, uh six died. Um. And then compared statistically to the to the 5000 who got uh natural smallpox and the and the 1000 people who who died nearly, uh the statistics showed okay, this method, as strange as it is to purposefully infect there ourselves, seemed better. 

 

Dr. Abdul El-Sayed: You know, just to ask a clarifying question. The six who died, they were the ones who died overall as smallpox moved or they died specifically from or soon after being inoculated? 

 

Andrew Wehrman: As a result of their inoculation. 

 

Dr. Abdul El-Sayed: Okay. 

 

Andrew Wehrman: So. 

 

Dr. Abdul El-Sayed: And do we know do we know survival statistics among the others who were inoculated? 

 

Andrew Wehrman: The other 280 or so who who survived the inoculation? 

 

Dr. Abdul El-Sayed: Yeah. Did they all sort of live through the smallpox period or die of other causes? 

 

Andrew Wehrman: Yeah. They they lived uh normal lives as far as we can we can tell. You know, I was looking at some of those statistics because the records from smallpox hospitals and from these smallpox doctors are not very good in the 18th century. And a lot of them would get burned right afterward because, you know, this is stuff taken from smallpox patients. They they weren’t really sure how smallpox spreads. So doctors notes and hospital records and that kind of stuff didn’t didn’t survive very often. But I did find some uh records from the 1770s, very complete patient records. And so I looked at some of these really bad cases, people who who were inoculated and had they would write down how many pox they got on their face or on their body as they would try to track it. So some people would get one or two pox. That was it. They had a good experience. They survived it. Others would get thousands. And so I would I I tried as best as I can to see, you know, some of these worst cases, would they, you know, live long lives? And often they they did, even despite having a difficult inoculation process. But anyway, uh back to the the previous questions about communities. So over time, they were looking at these statistics and they said, look, we should make uh smallpox inoculation as available as we can. Now, the difficulty with smallpox inoculation and what separates it from later vaccination was that inoculated patients could still spread smallpox when you when they had uh smallpox inserted into them. And they had this mild case um for about three weeks, they were considered infectious. They could they could spread smallpox to other people. So they had to be isolated in hospitals or quarantines.

 

Dr. Abdul El-Sayed: Which makes sense because it’s just a controlled infection. 

 

Andrew Wehrman: Right it’s a controlled infection. And the procedure itself was expensive. Right. So if you were an ordinary worker, you had to pay the doctor to inoculate you, but you also had to, you know, take basically a month off of work to recover. So poor people, ordinary people could not afford the procedure. And this was unacceptable. So in these town meetings, you would have debates and arguments about how do we provide inoculation, the saving grace from smallpox to the most people possible. And uh Boston was a real leader here. Um. In 1764, they announced a general inoculation of the whole city. They shut down the city of Boston for months at a time and provided inoculation free uh to the poor. They contracted with doctors and doctors agreed that they would provide inoculation to everyone. The city would reimburse them for their expenses. The city paid for food for the poor during during this time, uh spared no expense. Uh. So thousands of people in the spring and summer of 1764 uh were inoculated at government expense during this time. It shut down the economy for a few months, um but after it was over,  uh there were very few deaths. The city was was spared from uh an epidemic, and other towns and communities across the colonies first in New England, but it also happened in the south uh mid-Atlantic as well, started following that model or came up with other solutions to try to um make inoculation more accessible to everyone. 

 

Dr. Abdul El-Sayed: And from what I gather, um that was that was everyone of a particular uh group, even poor folks. But but not always Black folks, at that point would have been enslaved people uh or Native Americans. What was the posture there? Were they included or were they excluded? 

 

Andrew Wehrman: It depended on where you were. So um in New England, a lot of the medical advice and guides um and in these general inoculations, it would be any inhabitant within Boston. They wouldn’t say this was only for white people, it was whites, enslaved people. If there did happen to be, and there undoubtedly were some native people living in Boston at that time who were probably also inoculated. Um. They did not go seek to inoculate Native people outside of these communities. Uh. They didn’t talk about it. They thought smallpox was uniquely dangerous to them. Um. They also realized that the spreading of disease um aided in colonization, um uh that that uh so there were no real guides or suggestions that, you know, we should we should spread this idea to to native people, especially not in the in the 18th century. Now, enslaved people is a little bit different. So there were enslaved people who were inoculated um across America and in the South. Right. And an inoculated slave, carried some extra value. They would survive future smallpox epidemics. It seemed maybe a protection of a of an investment of sorts for an enslaver to do that, um it might make sense that they would. Uh. But it turns out that most enslavers did not inoculate their slaves. Um. That was time and money that they weren’t willing to spend on them. If you inoculated a slave that meant that they couldn’t work for a month, there’s a risk that that that slave might might die or be debilitated. And uh most enslavers were not in the business of providing health care to their slaves. Right. They they dressed them shabbily. They provided them terrible accommodations, and for the most part did not inoculate them, even when they knew better, even though they knew that that would protect them. They didn’t want to spend that that money. So when the uh revolution comes, when armies are marching through the south, uh most of the white population is inoculated that or that point or can be inoculated, can seek it out. Um. But the enslaved population, especially in Virginia and South Carolina, um uh has devastating epidemics. And of course, um the the smallpox epidemic that happens during during the revolution doesn’t stay contained to uh Black and white population. It spreads west among native populations as well. So that’s one of the real tragedies of this, is that uh colonial Americans learn about this process from a Black man uh named Onesimus in Boston. But it’s ultimately Black and Brown people who are kept from the salvation. 

 

Dr. Abdul El-Sayed: Yeah, and that that was the question I wanted to ask. Right. There’s this brutal irony here where um the person who made this possible uh belongs to a class of people who are systematically disallowed from from from getting it. Um. War almost always begets more disease. You know, and that is true in the past. That is true now. Um. A lot of the ways that people die in wars is because of the diseases that spread in that context. And the revolution was no different. Um. You’d think that uh inoculating troops against smallpox would be a real advantage and you’d seek to do it. But that wasn’t always the case, um you know, involving a very, uh a very famous uh general. Can you talk to us a little bit about George Washington’s position on inoculation and uh maybe where that came from? 

 

Andrew Wehrman: Yeah. So I think when I started this research and writing about Washington’s decision to inoculate the troops, I don’t think that it wasn’t very well known. It wasn’t something that was in most textbooks. And now, I think with with COVID and uh vaccination orders and and uh we know more, or at least I see it a lot on Twitter that people understand that Washington ordered the inoculation of the Continental Army. And that’s often used to sort of say that the founders were in favor of inoculation. Um. So so we shouldn’t be afraid of it today, or it certainly isn’t a violation of anyone’s freedom to to be uh vaccinated or to have vaccination um encouraged or compelled. But Washington was from Virginia. He wasn’t from from Boston, where these massive public inoculations were taking place. So Washington was skeptical of this process. He had experienced smallpox as a young man, as a as a teenager. He had survived it. He knew how dangerous it was, but he also knew it was survivable. Right. He had survived it as a young man. He expected most of these young soldiers in the Army, if smallpox broke out. And he tried to do everything to to to keep it contained, to to quarantine the the soldiers um that he could. He thought that they’d be able to survive it, too. Um. Virginia had had not had these large scale inoculations that were happening elsewhere. So Washington kind of has a fuzzy understanding of how broad inoculations would work. So even though he knows that smallpox is breaking out, even when he knows that the British are inoculating their soldiers, he does not order it um for American soldiers uh in 1775 or in 1776. There are some disastrous results as uh soldiers are dying from smallpox, especially when they try to invade Canada in the winter of 75′ 76′. Uh. Washington’s medical directors are publicly urging uh Washington to uh inoculate the Continental Army. Washington resists. He actually actively punishes jails, some doctors who are inoculating secretly. But eventually, uh all of these pleas the soldiers themselves, who are demanding it, sometimes secretly inoculating. The doctors, the medical directors. George Washington’s wife, Martha, goes and gets inoculated in July 1776, herself. And Washington writes a letter to I think, John Hancock and says, I don’t think she’s actually going to go through with it, but she does and survives it and is uh has a has a very successful inoculation. And it’s only after that that Washington starts to weigh his options and waver on it. But it’s not until February 1777 that he actually decides to go with his medical directors who are telling him, we can do it, we can we know how to inoculate in large numbers, we’ll rotate troops through it. It’ll be fine that Washington trusts them uh and and gives the order and after to Washington’s great credit, he changes his mind. Right. Which I think he deserves a lot of credit for. Um. Don’t we wish more of our politicians were willing to change their mind based on the evidence that they’re presented with uh and totally do a 180 on their position right. 

 

Dr. Abdul El-Sayed: If only.

 

Andrew Wehrman: And afterward, Washington admits uh that that he shouldn’t have waited this long, uh that it is uh wonderfully successful. Washington, unlike lots of other plantation owners, does order the inoculation of his entire plantation, his family, his his enslaved people at Mount Vernon. Uh. He writes letters to the governor of Virginia saying that there should be a law to compel all uh heads of households to inoculate their children under certain penalties. He becomes a real evangelist for inoculation after he sees how successful it becomes. 

 

Dr. Abdul El-Sayed: Hmm. Well, you know, you got to you got to admire him uh him moving with the evidence and um and then, you know, advocating for a position he once uh he once failed to hold. 

 

[AD BREAK] 

 

Dr. Abdul El-Sayed: Smallpox was ultimately eradicated. Right. This is this is one of the most successful public health efforts in uh human history. And it took centuries to do this. 

 

Andrew Wehrman: Yeah. 

 

Dr. Abdul El-Sayed: Um. What do you think that tells us about people’s ability to engage in potentially risky preventive actions that prevent them from higher risk? I mean, this is the hard part about a vaccine, is that you start with health. And so you’re betting if you do get vaccinated, you’re betting on the high probability of exposure. And if you don’t get vaccinated, you’re betting on a low probability of exposure and a high probability of bad outcomes if you get the vaccine. And this wager right ought to be done rationally. And if everybody acted rationally, then everybody would get inoculated, because the numbers are clear, especially in the context of uh what is a massive epidemic. And yet people don’t always act rationally. Based on your research of this disease of of of this moment in American history. What do you think that tells us about our ability to or what we ought to be thinking about when we drive these campaigns to uh to promote a public health measure that we know to be safe and effective? 

 

Andrew Wehrman: Well, campaigns and public health measures are key. Um. After Washington inoculates the Continental Army after town after town conducts its own inoculation campaigns, building inoculation hospitals, ensuring that the poor have access to those hospitals becomes a a debate even after the revolution, during smallpox epidemics. You see these public efforts to protect people from disease. There’s a real feeling in the 1700s that they could eliminate smallpox. Um. Europeans are writing letters to George Washington and telling him uh that not only will the United States have but the right first merits in overthrowing monarchy, that they’re going to be the first country that overthrows smallpox. They think it’s going to happen um and it takes these communal efforts. What ends up happening uh it’s ironic, and I talk about it in the book, is that the introduction of vaccination, which should make things easier because it’s safer, um actually doesn’t, because inoculation had to be done with these public efforts because it was contagious. They needed town meetings. You needed a lot of regulation. You needed governors and city council people on board to to run these citywide inoculation campaigns. But vaccination, because it’s not contagious, because I can get vaccinated and it doesn’t affect anybody at my workplace. It doesn’t affect anybody in my household. Uh. It just protects me. That changed the the calculation. All of a sudden, um it’s an individual choice on whether to be vaccinated. Doctors in early America start saying, well, this is a profitable uh technique. And because if I vaccinate my patients and they pay me for it because they’re not a risk to the rest of the community, it’s not the government’s business to regulate this anymore. Now, there can be private charitable efforts. There can be laws passed to require um schoolchildren to be uh vaccinated. Um. But ultimately, what we get are these big gaps. There are states, communities, it creates a patchwork system where some Americans are being vaccinated publicly, others are seeking it out privately, and vast numbers either are refusing or most cases don’t have access themselves to it. Um. And there’s uh the 19th century goes by, and despite having all the tools to eradicate uh smallpox, it’s not done. Um. And it eventually it gets done right. In the 20th century, there’s a renewed campaign for for vaccination globally. This is uh the World Health Organization. This is the United States with cooperation from uh the Soviet Union to really isolate the remaining cases of of of smallpox in in the world and to to to vaccinate in some of the most um war torn uh countries. I think the last cases were in Somalia and Afghanistan in the 1960s and 1970s. Um. But that’s what it takes. It takes this kind of committed uh government effort to to stop a disease, just allowing it to be a patchwork effort of of public and private um isn’t enough. 

 

Dr. Abdul El-Sayed: Mm. So what’s fascinating is it’s once the risk of the treatment goes down, the amount of public effort and coordination that was required goes down. And it was it was that public effort and coordination that was really driving folks to come and do this thing together. 

 

Andrew Wehrman: I think that’s right. 

 

Dr. Abdul El-Sayed: I mean, it’s fascinating, right, because because the risks of of inoculating are are a.) To you, but also B.) To other people around you. And so this is not just, you know, a risk you’re taking. It’s a risk we are taking to keep you safe. And vaccines, the costs of them are so much lower. I mean, if you think about the COVID vaccines, they were so safe. 

 

Andrew Wehrman: Yeah. 

 

Dr. Abdul El-Sayed: I mean, really just safe full stop. But relative to an inoculation that had like a, you know, 1 to 3% chance of killing you, like, exceedingly safe, and yet people just kind of wouldn’t do it and and what’s so frustrating to me is that we’ve had even a backslide on other vaccines because of this COVID moment of mis and dis information. 

 

Andrew Wehrman: Yeah. 

 

Dr. Abdul El-Sayed: I mean I, I think it also helps that in the time of uh the pre-revolution and during the revolution, there was no Twitter. So at least you had like pamphleteers. But you know, the ability to to share and move mis and disinformation was substantially more limited. The cost of doing so was a lot higher. 

 

Andrew Wehrman: Yeah, I mean, there was nobody no, no soldier in the revolution refused to get inoculated. There’s there’s no record of any, you know, there it wasn’t like half of the Continental Congress said that that inoculations were too dangerous or were some wicked plot from another country. I mean, there wasn’t any of that. There was a a rallying uh around it um in a way that’s that’s really striking, especially, as you say, because it was more dangerous in ways that the COVID 19 vaccine just isn’t um, anti-vaccination in 2020 or 2023 is a is a different animal has different causes than the any sort of anti inoculation sentiment was in the 18th century. 

 

Dr. Abdul El-Sayed: Mm. And maybe it’s also because we don’t see the consequences so clearly. I mean, everybody has somebody who is affected, but COVID was the kind of disease where the symptoms were not out of the ordinary of something that anybody would have experienced, tends to tends to be a really, really bad cough or a fever. And everybody’s– 

 

Andrew Wehrman: Yeah. 

 

Dr. Abdul El-Sayed: –had a bad cough or a fever, um unlike the pustules that are just so visible and obvious. And it’s also in a time when when people get sick, really sick, they go away. I mean, I hate to say it, but like, you know, we we um treat sick people in hospitals. And so most people don’t see really sick people. They don’t come in contact with death in as uh carnal a way as they did back in that time when most of the time people died at home. And so I think the death and the disease aspect of it didn’t have the same kind of or didn’t create the same kind of alarm because of the nature of of death and dying now and also because of the nature of the disease itself. And so I think people were it was easy for people to discount the death and the disease when it came to COVID versus when it came to smallpox, when you saw somebody get really, really bad pustules and then die in your own home. Right. Which is a very different experience. 

 

Andrew Wehrman: Exactly. And it was also so much easier um in a sense, with with smallpox to quarantine and contain people, because that was very natural to do. There was no asymptomatic smallpox. Right. You either you had it and it was visible um or you didn’t. Um. COVID is just a nasty disease, the kind of thing that epidemiologists warned against. Right. There’s these asymptomatic cases. You have to have a really strong testing program to even know who has it or who doesn’t. And it um uh was a real problem. But as a as a historian, the other aspect here that that frustrated me um is, I think a lack of a of an understanding of of history and of a history of medicine, the history of public health in the United States, because it had been so long since uh uh public health boards uh had to uh install quarantine orders or had to uh regulate vaccinations in the way that uh we did with with COVID 19, that uh these restrictions felt so alien to people that this was some government gone awry, that uh these these shutdowns and lockdowns were something that that only a tyrant would do. Right. And of course, if you look back at the history of of disease. Quarantine is is done in all uh governments to help stop disease. It isn’t necessar– it could be done cruelly, but it isn’t necessarily tyrannical. It’s a way to way to uh way to help people and the way to uh a natural way to stop, especially a disease who uh that we don’t have a cure for, that we don’t have a, a vaccine for to slow things down. That these public health orders have have long roots in American history. And I think we have to remember that one of the reasons and this is what the uh founding fathers talked about, it’s what John Locke talked about in in his writings, that the reason we have government is to protect the lives of the citizens, to protect each other, that’s protect each other uh uh from from war, from foreign enemies, and things like disease. And that uh government has a duty to protect its its people and protect their health. And that that comes first and foremost. So um, you know, here in in Michigan with these protesters in Lansing that took over the Capitol and they’re waving 1776 flags and stuff like that, it just burned me up in in 2020 because like the the founders, people, the colonists understood quarantine and they understood, you know, freedom. Certainly they’re they’re fighting for it. But uh quarantines were never considered violations of freedom. Inoculation orders uh uh secured liberty. They didn’t uh violate it. 

 

Dr. Abdul El-Sayed: Yeah, well, if you if you um if you call freedom, freedom from disease, then absolutely. And um, you know, unfortunately, we we do live in an era where uh people want to pick and choose their history because they don’t understand it. And uh Professor Wehrman we’re really um grateful to you for coming and helping us understand it. Our guest today was Professor Andrew Wehrman. He’s the author of the book The Contagion of Liberty. I really hope you all check it out. Uh. Andrew, thank you so much for taking the time. 

 

Andrew Wehrman: Thank you, Abdul. [music break]

 

Dr. Abdul El-Sayed, narrating: As usual. Here’s what I’m watching right now. 

 

[unspecified news reporter] With the nationwide overdose crisis near record levels, the FDA today took the extraordinary step of approving the over-the-counter sale of Narcan.  

 

Dr. Abdul El-Sayed: Naloxone. The opioid overdose reversal drug is now available over the counter and for good reason. Opioid overdose continues to rage on, helping account for the nation’s falling life expectancy. Before the FDA’s move this week, it was only available under a doctor’s prescription. But the drug is so effective and so safe that doctors took to writing blanket scripts in an effort to get the lifesaving medication as far and wide as possible. This move by the FDA basically formalizes that practice. Narcan, the trade name for the inhalable version of Naloxone is about as close to a miracle as it gets. Opioids kill people by blocking the brain’s natural breathing reflex in the midbrain. Naloxone acts almost immediately to block those opioid receptors, reversing the overdose then in there. A person can be on the verge of death and walk away from that moment as if it never happened. That said, that’s precisely not what folks should do, because one in 30 people who are treated for an opioid overdose will die of another overdose in the next year. And that’s because while that first overdose may have been overturned, the underlying substance use that caused it is not. So it’s critical. Just as we flood the zone with Narcan, we need to flood the zone with long term opioid use treatment. And that means way more investment in mental health and substance use care. Part of that means extending access to health care itself, which is why last week’s move by a federal court judge in Texas uh didn’t help. That judge struck down a plank of the Affordable Care Act that requires health insurance plans to cover a panel of preventive services, things like mammograms and colonoscopies or prep treatment to prevent HIV. The case, brought by a company called Braidwood Management, argues that because the volunteer expert panel that issues the recommendations on what preventive services must be covered isn’t appointed by the president or confirmed by the Senate that they lack the standing to make binding recommendations at all. That’s called a loophole and a technicality. The ruling took effect immediately, meaning that in theory, someone could be doing bowel prep right now for a colonoscopy tomorrow, only to find out that it’s no longer covered by their insurance. That said, that scenario is unlikely to happen immediately because well the ACA has been law for 13 years now and insurance companies aren’t likely to want to upset the apple cart, especially in a tight labor market where offering high quality insurance is part of what entices people to work for a company. But if the law stands, it could lead to the generation of a different class of health insurance, a cut rate insurance that doesn’t cover basic things like preventive services. And those kinds of cut rate insurance plans is exactly what the ACA was intended to prevent. For their part, the Biden administration is already planning an appeal. But the thing this should remind us is that the proponents of our for profit health care system, the folks who want to profiteer off of sick people, they’ll stop at nothing to tear down this law and any law that forces them to actually provide meaningful health care free of charge. But there was some good news when it comes to health care this week. 

 

[unspecified speaker from North Carolina] And today is a historic step toward a healthier North Carolina. When this law takes effect, it’ll make health care accessible for more than 600,000 North Carolinians. 

 

Dr. Abdul El-Sayed: North Carolina became the 40th state in the U.S. to expand Medicaid under the Affordable Care Act. What this means is that low income North Carolinians will now receive a huge bolus of funding for Medicaid, which should substantially increase the number of folks who will be eligible. And make no mistake, Medicaid expansion saves lives. Studies of the impact of Medicaid expansion have shown an up to 64% reduction in annual mortality among those who are newly eligible. But while there’s good news on this front for folks in North Carolina, in almost every other state, low income folks are getting kicked off of Medicaid. Why? Because the COVID era policy that kept them on the rolls through the pandemic is sunsetting. And that means that over the next several months, we’ll see upwards of 15 million people lose their health insurance. That’s the largest number of folks to lose their health insurance since the first month of the pandemic. And one of the largest net losses in health care coverage in American history. And guess who gets hit hardest by this? Black and Brown folks around the country. You know how we can fix it? Medicare for All. Alongside a story of millions of people losing basic health care. Here’s another problem you’re only being forced to listen to because this is a podcast called America Dissected. 

 

[unspecified news reporter] At 10:13 this morning, the police department received a call of an active shooter inside Covenant School, Covenant Presbyterian Church. 

 

Dr. Abdul El-Sayed, narrating: That’s right. Another elementary school got shot up this week. This time it was a Christian private school in Tennessee where a shooter killed three adults and three children, all under nine years old. Rather than the perpetual problem of unfettered access to guns. Right wing media have chosen to concentrate on the shooter, a former student at the school who identified as trans, arguing that the attack was some kind of broader attack in an escalating battle between trans people and Christians. Look, y’all I’m Muslim. I know what happens when people essentialize everyone with a particular identity based on the actions of one individual who happens to identify that way. And that’s a dangerous brew. Because the other thing that happened this week is that the Republicans in the legislature of the state of Kentucky forced through a draconian set of anti-trans laws overriding the veto of their Democratic governor. And all that’s going to do is rob thousands of people of basic civil rights. The epidemic of gun violence in this country has nothing to do with trans people. It has everything to do with the unfettered access to guns. Considering the last story I told you about. Imagine what America might be if we took access to health care as seriously as some people take access to guns. If I could tweak one thing about the Constitution, it would be two words in the Second Amendment from the right to bear arms to the right to have health care. Guns take a lot of lives in America. Health care. Health care saves them. That’s it for today. On your way out. Don’t forget to rate and review. It really does go a long way. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked store for some America Dissected merch. Oh, and happy Public Health Week, everyone. And Ramadan Kareem to all those observing. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illic-Frank. Vasilis Fotopoulos mixes and masters the show. Production support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Before I tell you about our executive producers, I want to give a big thank you and farewell to Sandy Girard. He’s been an incredible champion for the show. Thank you and we’ll miss you. Our EPs are Leo Duran, Sarah Geismer, Sandy Girard, Mike Martinez and me. Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.