When we look back to 2011 from some date in the future, it seems likely that people will wonder how there could have been such heated debate over the proposition that all Americans ought to have access to reasonably-priced health care coverage.  As they do, perhaps they will see the parallel between today’s argument over health coverage for all and an earlier public health issue.

In the early 17th Century, when the Puritans moved to Boston from Charlestown in search of good water, procuring it by the bucket was an unquestioned responsibility of every family.  Water came from the ground in wells and from the sky as rain.

As the population grew, so did the number of privies, and the groundwater became increasingly polluted.  Smoke from coal fires polluted open cisterns in which rain water was collected.  Over time, clean water for drinking and washing became increasingly hard to find and generally expensive.

In his new book, Eden on the Charles, Michael Rawson tells in detail about the “contentious debate” over water policy between “urban reformers fighting for a public system and wealthy and tax-averse Bostonians who opposed it.”  There were many disputed issues:  How much water was needed and so how large must the source of water be?  Was there a right to clean bodies and clean clothes in addition to drinking water? How clean need it be?  This was a hard question for people unaccustomed to thinking about water quality and its relation to infectious diseases.  Was water a commodity to be bought and sold?  Had the owner of a well the exclusive right to the resource or were all entitled to a share?  Who should be responsible for providing it?  What were the citizens’ rights to water falling on the peninsula or underlying it?

By about 1800 the situation began to change.  Wells, mostly private, supplied water to most Bostonians, augmented by a few city-maintained pumps for firefighting, an obvious societal need.  Some wealthy residents brought water by the cartload from nearby ponds.  Water was being piped from Jamaica Pond to neighboring, more affluent, homes.  Some, of course, maintained that the existing system needed no improvement, but others claimed that greater cleanliness would bring better behavior as well as sanitation.  The Boston Temperance Society hoped clean water would replace hard cider, the common drink long relied on as healthier and tastier than most of the available water. Dr John C. Warren, former dean of the Harvard Medical School, raised the issue of improving public health, not merely the health of individual residents.  Reformers and their less-privileged allies advocated a delivery system that would serve all in the community, while others feared higher taxes.  If all those needs were to be met, could privately-held water companies do the job, or must government step up?  This was a revolutionary concept.

An expert called in from New York by a study commission gave his opinion that only Long Pond (now called Lake Cochituate), which extends across parts of Natick, Wayland, and Framingham, could supply enough water to meet future needs.  Such a large project was feasible only through municipal borrowing, so the Boston City Council petitioned the Legislature for the necessary authorization.  The act required a referendum, which city voters passed overwhelmingly.

It took a generation, from the time Mayor Josiah Quincy first proposed a municipal system until his son, Mayor Josiah Quincy, Jr., presided over festivities celebrating the coming of water piped from Long Pond to the Frog Pond on Boston Common. One hundred thousand people gathered to cheer, to listen to speeches and school children singing, to watch a parade which included seven black horses drawing floats displaying huge water pipes, and to see a fountain spurt water 80 feet into the air.  Even so, it was years before every dwelling was connected to the pipes.

In the same manner, we are struggling to draw a line below which no one should lack health care, at least at a basic level, whether they can afford it or not.  Undreamt medical advances have brought philosophical questions far beyond what the Mayors Quincy faced.  At what income level can families afford insurance against medical ills with costly remedies? Dental care and eyeglasses for all, even the poorest?  CT scans with co-payments?  Kidney dialysis costing thousands?  Which  preventive measures pay for themselves?  Most of us would cringe at the prospect of closing emergency rooms but we haven’t agreed on an alternative. 

There are echoes of the great water fight in today’s argument about providing health care.  Is money the most intractable problem or is it reluctance to change the existing way of operating?

Look back to the Puritans’ swift decision that the brackish water of Charlestown was unacceptable and to the city of Boston’s lengthy deliberation before deciding to think big. The resemblance to today’s health care financing issue is striking.

Every one needs health care. Some can afford to pay for whatever they need, whether out-of-pocket or by insurance. Insurance works only when healthy people as well as less healthy ones are covered.  Subsidies to those who cannot pay the premiums bring into question whether every remedy, no matter how costly, can be offered to all. Will it take us another generation to decide?

Eugenie Beal is chairwoman of the Boston Natural Areas Network, which she helped found in 1977, and a longtime member of the Friends of the Public Garden. She was the first chairwoman of the Boston Conservation Commission, in the 1970s, and the first director of the Boston Environment Department.