The Founder and the Epidemic

“There are many instances upon record of physicians who have rendered themselves unpopular and even odious to their fellow-citizens by giving the first notice of the existence of malignant and mortal diseases.”

—Benjamin Rush, Medical Inquiries and Observations

August of 1793 was unusually hot, even for Philadelphia. In the marshy areas near the docks, an unclaimed supply of coffee was putrefying and drawing vermin. People in the surrounding neighborhoods were becoming sick with fever, vomiting, and jaundice. As an apprentice physician, Benjamin Rush had seen this situation 31 years earlier. Realizing that an outbreak of yellow fever was descending upon the city, and suspecting it was related to the rotting coffee, he sounded the alarm. He urged the College of Physicians and local politicians to take immediate action, institute sanitary measures, and quarantine the sick. He also suggested possible treatments, which he based on his own experience and on scientific reports from past occurrences in the West Indies and South Carolina.

Rush was an accomplished physician and statesman: a graduate of Princeton University at age 14, signer of the Declaration of Independence, founder of Dickinson College, treasurer of the United States Mint, beloved teacher, and father of modern psychiatry. Some of his medical treatments were unorthodox, and, in a country divided by partisan politics, he had enemies both political and medical.

Authorities in Philadelphia were slow to react to his warning and to the outbreak itself. By the end of September, the number of yellow fever cases had ballooned from 40 when Rush originally spoke up to 6,000, with 1,400 people dead. The disease would eventually wipe out 10 percent of the city’s population of 50,000.

The experience of Benjamin Rush in Philadelphia is eerily familiar today. In December 2019, Li Wenliang, a doctor at the Wuhan Hospital in China, began to see patients stricken by a respiratory illness similar to SARS, which was first diagnosed in November 2002 and spread during the following year. He warned fellow physicians in a chatroom to begin to take protective measures for what he feared was going to be a major outbreak. Four days later he was summoned to the Public Security Bureau and told to sign a letter accusing him of “making false comments” that had “severely disturbed the social order.” It would be weeks before Chinese officials would confirm that the disease could be spread by human contact. Li contracted the virus while treating hospital patients. By the time he died a month later, the virus had killed 636 people and infected 31,161 in mainland China. As we now know all too well, the disease would spread within six months to millions of people worldwide.

My own quarantine in Rhode Island is anything but quiet. I use my best phoneside manner to answer unanswerable medical questions from members of my family. I help fellow physicians, one of whom has contracted the virus from a patient and then infected his own family, on how best to provide telemedicine to isolated patients, decide how many employees to lay off, and deal with patients who refuse to wear masks in the office. On TV, the conflicting information coming from politicians and medical professionals would be comical if it wasn’t proving fatal. In a country desperately seeking some kind of unified guidance on how best to cope with an emerging disaster, messages are fragmented across political lines. State governors concoct contradictory quarantine orders for their citizens and bicker openly with the president.

Across the news media, the term “unprecedented” is being used in an unprecedented fashion (a Google Trends search shows a 100-fold increase in searches using the word in the past three months). Economics writer John Authers notes that while the economic impact of the current crises may truly have unprecedented fallout, the term is “often used as a defense by politicians to explain away or exaggerate” a situation in order to avoid responsibility for their poor responses. But ignoring medical advice at the expense of a political agenda is not new at all. Rush, looking back on the yellow fever outbreak, wrote in 1805:

The report of a malignant and mortal form being in town spread in every direction but did not gain universal credit. Some … denied that any such [disease] existed … the account I had given for a while was treated with ridicule and contempt.

Rumors fraught with racism and xenophobia spread through Philadelphia alongside the emerging outbreak. Some blamed Hispanic refugees from Santo Domingo for importing the disease. Others accused black Americans (who were thought to be immune to the fever) of poisoning the city’s wells. Like the rest of the country, Philadelphia was divided in the partisan split between political parties, and Rush, a Republican, found himself at odds with Federalist politicians and physicians. Then, as now, political agendas shaped the discourse surrounding a medical emergency. A committee of physicians and politicians issued an 11-point bulletin of guidelines advising mild treatments for the fever and suggested that “tolling of the bells” for the dead be discontinued as it depleted morale. But the committee did suggest that the arcane practice of burning gunpowder to rid the home of contagion (a treatment left over from the plague in Europe in the 1600s) might be efficacious. Federalist Alexander Hamilton jumped into the yellow fever debate, touting a cure from his personal physician, which he published in opposition to Rush’s methods.

Like Li and the hundreds of healthcare professionals who have died in the current outbreak, Rush assembled his own team and risked his own life fighting on the front lines, making up to 50 housecalls a day. As people fled the city and commerce broke down, he published regular updates and advice in the only two functioning daily newspapers. Rush’s prescriptions reflected his Republican approach; he believed in the capability of individual Americans and suggested medicines that could be purchased easily at the local chemist. Patients could treat themselves if they could not find or afford a physician. Rush got hate mail from friends for publishing his findings, but hundreds more letters poured in asking him to take on difficult cases. He and his students were professionals, but his servants, including an 11-year-old boy, were enlisted on the team as well. With his wife, Julia, out of the city, Rush’s sister, Rebecca, against advice to leave the city herself, moved in to run the household. His home would serve as a clinic for the poor who could not afford housecalls.

Things rapidly deteriorated. It is estimated that, at one point, only 10 physicians remained in Philadelphia (most had fled or refused to treat new patients) to care for the entire population. Everyone on Rush’s team and in his household soon became seriously ill. His sister would die, as would three of his five students. When Rush became too sick to leave his bed, his students reported to him there with frequent updates from throughout the city. Some patients were brought to his bedside for advice. Rush advocated aggressive bloodletting as part of his treatment regimen, and so his front yard ran bright red with the drainage of more than a hundred patients a day.

Yet Rush thrived on the situation and the opportunity for service. He was a man of action who loved to take control. He put forth a bold face in his Medical Inquiries and Observations, writing, “It was meat and drink to me to fulfill the duty I owed to my fellow citizens in this time of great universal distress,” yet admitted in letters to his wife to sitting in the dark and “weeping aloud” at “the friends I have lost and the faces of distress I have witnessed which I was unable to relieve.”

A deeply religious man, Rush saw himself as an agent of both God and of science. For him, there was nothing he could do with his medical arts that was not divinely inspired. He wrote to Julia that he would “perish with my fellow citizens rather than dishonor my profession or religion by abandoning the city.” He did his best to generate and publish results from his treatments and, when he did become ill, subjected himself to the same bleedings and ingestion of mercury-containing medicines as his patients. No doubt, as now, some of the treatments produced as much harm as they did good, but he was working with what he had and what he believed was the best chance of fighting the disease.

I imagine what it must have been like to have been one of Rush’s five determined young students, and I admire Rush’s dedication to teaching and keeping the scientific community and public informed of his progress while the epidemic raged on. I wonder what he must have been feeling when writing to the families of his dead students, Drs. Washington, Stall, and Alston. He must have felt a degree of responsibility. He wrote to Julia that Stall died in “the highest acts of benevolence to his fellow creatures,” but the words belie the frustration, the rage, he must have experienced when his warning and advice were ignored.

In doing what he believed was a solemn duty, Rush still draws criticism, for example for believing that an epidemic could have started from that load of rotting coffee. When some modern doctors write articles like “Benjamin Rush: Assassin or Beloved Healer?” it makes me cringe. In correctly identifying the geographical source areas for the infection, Rush was a pioneer in epidemiology whose work did influence future generations of medical professionals. That yellow fever was a virus, spread by mosquitoes, would not be known for another hundred years. A vaccine would not follow until the 1950s. Mercury treatments were the anti-infective agents of the time, and they were toxic, but 227 years later, we still have ineffective treatments for most active viral infections.

Physicians feel a helplessness in the midst of the current crisis. It is not only the frustrating search for a cure, which will surely come, but also the failure of politicians and sections of the public to heed scientific and medical advice. I imagine the composure it must take for leading physicians Anthony Fauci and Deborah Birx to stand by in press conferences as their recommendations are countermanded. But, as the current administration quietly sidelines its task force, perhaps a voice of reason will emerge from the institutions already in place, like the CDC, FDA, NIH, and FEMA, which should have been taking the lead all along. We may still learn from Benjamin Rush’s dedication and humanity, using the tools at our disposal, thinking creatively, and never losing sight of the collective needs of people. I am reminded of the sacrifices of those like Li Wenliang and Roberto Stella, a physician in northern Italy who recently died, having continued to treat coronavirus patients after his town ran out of protective gear.

I am fearful of the inevitable spike in coronavirus cases that will happen as politicians, intent on “opening up the economy,” relax quarantine measures before reliable treatments and vaccines are available, and as sections of the population ignore social distancing guidelines, against a broad spectrum of expert medical advice.