As the United States struggles to distribute and administer COVID-19 vaccines, we’re looking back at the history of vaccine rollouts in our country, including the logistical roadblocks to shots and communicating with a fearful public. The COVID vaccines have been widely shown to be safe and effective, unlike some historical examples that had significant associated risks. But what can stories of failures from the past teach us about how to fairly administer them?
On Tuesday, Feb. 16, at 1 p.m. Eastern, join Future Tense for a conversation with Atul Gawande and Helene Gayle, co-chair of the National Academies framework for vaccine distribution, about the COVID-19 vaccine rollout.
Three small children, suffering through smallpox, huddled behind two locked tenement doors, until they were snatched away by public health officials conducting vaccination raids backed up by police. Elsewhere, vaccines, produced with no oversight and contaminated with dirt from the stables where they were incubated, delivered tetanus bacilli into the arms of schoolchildren, and employers forced laborers to bare their arms to the vaccinator in order to get their paychecks.
Historian Michael Willrich’s book Pox: An American History is a grim history of the government’s response to the smallpox epidemics that peppered American towns, labor camps, and cities at the turn of the 20th century, a generation after the last time smallpox troubled the country, during the Civil War. As a result of what happened during these outbreaks, the government claimed the power to vaccinate, but also began to regulate vaccine production, and to lay the foundation for law that allows vaccine exemptions for some. This is not the story of a vaccine rollout—smallpox inoculations had been used to curb epidemics in the United States for more than a century—but because of the force and urgency of the vaccination campaigns, and the resistance those campaigns provoked, it’s a foundational episode in the history of modern American vaccine distribution.
I spoke with Willrich about citizens’ resistance, the legal connection between vaccination and sterilization, and the way this particular history may have been drafted into later anti-vaccine discourse. Our conversation has been edited and condensed for clarity.
Rebecca Onion: Was this the first time Americans were made to get vaccines?
Michael Willrich: Well, yes and no. Massachusetts had the first state law requiring schoolchildren to get the smallpox vaccination, and that was passed in 1855. A lot of the debates around government and vaccination before the late 19th century concerned whether or not governments could use taxpayer funds to pay for vaccine supply. This idea of compulsory vaccination was really a new thing in the middle of the 19th century, and then the turn of the 20th century was really the high point of the effort.
Your book makes the point that in the late 19th century, people had experienced sort of a loss of generational knowledge about smallpox—or at least, a loss of direct experience with it. What was the situation, when the outbreaks happened around the turn of the century, with people’s understanding of smallpox?
Smallpox was a truly dreadful, horrific disease; historically, smallpox had killed 25 to 40 percent of all people infected, depending on the outbreak. Sometimes the fatality rate was higher than that. And for people who survived, they were often badly scarred from the disease, carrying visible scars on their faces. Some were also left blind.
But when the epidemics began to break across the United States in the 1890s, many local communities hadn’t really seen many, or even any, cases in years. So there was a loss of knowledge of the disease, and that was complicated by the fact that during this time, there was a new form of milder smallpox that was circulating in the United States. There were epidemics at the time—in New York, Boston, New Orleans—where hundreds of people died, but there were also epidemics of a fast-spreading milder smallpox that had a much lower case-fatality rate.
The result was that when outbreaks began in their towns, many people simply refused to believe it was smallpox at all. And it’s the same kind of thing we see with vaccination today—people became less familiar with the disease, and they were no longer very concerned about trying so hard to get vaccinated.
And the vaccines themselves—their production was not at all regulated, right? What was in a smallpox vaccine, at this time?
At the time, vaccine was still produced by inoculating calves with related viruses. When [material containing] those milder viruses was introduced into human skin, it could produce a reaction that would lead to having a protective immunity of a period of several years. During the time of these epidemics, they were almost entirely produced by commercial makers, which were often very small-time operations. A local doctor might keep a few cows for this very purpose—or in places like Philadelphia or Detroit, which were really at the front edge of vaccine development, vaccine production combined the stable and laboratory. But the entire industry for producing vaccines was entirely unregulated, which was one of the reasons why a few communities manufactured their own vaccines.
Did that mean that those vaccines might be safer? Or that the production might be cleaner?
Well, it’s a little hard to say, looking back, but no, maybe not. In New York City the vaccine was produced by the Board of Health in a stable somewhere on the island of Manhattan—it’s not like it was very much better.
So people had reasons to be concerned about taking these vaccines.
Getting the vaccine was an inconvenience to say the least, but even when it was administered in a safe way, and the vaccine wasn’t filled with impurities, it tended to give people a fever. Your arm would feel like it was on fire—it caused inflammation at the site—so many workers complained that their arms were so sore, they were put out of work for several days, even several weeks.
And then there were several well-reported incidents where compulsory vaccine drives led to serious consequences. The most famous case was in Camden, New Jersey, in the epidemic of 1901, when the community ordered schoolchildren to get vaccinated, and nine children died of tetanus poisoning.
How did authorities react? It sounds like they were so defensive about it—unwilling to acknowledge it.
Right. They said, “Clearly the problem is that the kids were dirty”—that it couldn’t be the vaccine.
This was really the problem of the era: The government was requiring people to get vaccinated but not doing anything to regulate the safety of vaccines. This was an incredibly dangerous policy.
How would the authorities enforce this? It seems like in some places, authorities were saying, “Oh, we’re not forcing people to be vaccinated.” But in the news stories you find, it’s people being dragged out of their houses.
Yes! The most dramatic example of this kind of cognitive dissonance was in New York, where public health officials might talk about the fact that there was no compulsory vaccination law in the state of New York. But then there were so-called virus squads—public health people working in tandem with local police, entering tenement districts in the middle of the night, inspecting door to door, looking for sick residents and whether people had evidence of recent successful vaccinations. If they hadn’t been vaccinated, they’d be compelled to be vaccinated on the spot—sometimes using physical force. So there was this disparity between the public message and the reality that could be very dramatic.
But there were also a huge range of inducements. Schoolchildren were pretty routinely required to be vaccinated against smallpox before the start of the school year, but then during epidemics, local health boards could use their police powers to compel adults to be vaccinated as well. In particular settings like industrial workplaces, or places of high concentration of population, health departments would enforce vaccination among the public as a whole. They could say, “You need to do this, in order to keep your job or in order to get a job.” Or, “You need to get vaccinated in order to avoid prosecution for contributing to a delinquency of a minor,” if you didn’t get your kid vaccinated. A wide range of penalties.
You write that the anti-vaccination activists of the time tended to be middle class, maybe people who came into contact with vaccination because they had children. Is it fair to say that working-class people were the ones who were more likely to be compelled to do it?
Publicly mandated vaccination during this time was really carried out in a class-biased way. For example, people arriving in the United States aboard ships—they were much more likely to be inspected, vaccinated on the spot, and quarantined in holding facilities if there had been a case of smallpox aboard their ship if they had traveled in steerage versus in the first-class cabins.
Middle-class and more affluent Americans were much more likely simply to be expected to get the vaccine from their own private physician, but there were very few circumstances where they’d be forced to show their compliance with a vaccine order.
The case of Jacobson v. Massachusetts—which went to the Supreme Court and was decided in 1905, with the court holding that the state did indeed have the right to compel vaccination—emerged from these epidemics. How did this come about?
The case arose during the Boston and Cambridge, Massachusetts, smallpox epidemics of 1901 and 1902, in which hundreds of people died in those communities. There was a state law that empowered local boards of health to order compulsory vaccination as they saw fit, and so the board of health of Cambridge ordered people to get vaccinated. There was a wide range of responses, from willing compliance to hesitancy to outright refusal, people running away from the vaccinators or filing lawsuits.
This case involved an immigrant from Sweden, a Lutheran minister named Henning Jacobson, who was sort of a pillar of this local immigrant community in Cambridge. He had some experience being vaccinated as a child, back in Sweden—compulsory vaccination, which they’d had in that nation for many years. He had an adverse reaction to it—he got very sick—and he saw his own child become very sick following vaccination, so he was convinced that vaccination was particularly harmful to him and his family members, if not people more generally.
So he refused. There’s this moment when the head of the local board of health actually comes to Jacobson, knocks on his door, and offers to vaccinate him on the spot, for free—and he refuses. So he gets brought to the local criminal court, put on trial, still refuses; eventually, the case goes through the judicial court of Massachusetts, all the way up to the Supreme Court.
Jacobson and his lawyers argued that the measures violated what they called the inherent right of every free man to take care of his body as he sees fit. And the Supreme Court came out resoundingly, in a 7–2 decision, in favor of the right of communities to protect themselves from epidemics. They compared it with the inherent right of a community to defend itself from a military invasion. If the government could require the population to take up arms and fight in a war, through conscription, which might result in somebody’s death, they should also be able to require vaccination.
Radical lawyers of a civil libertarian bent and medical people in the anti-vaccination movement said, “Wow. This decision is like another Dred Scott.” They were certainly wrong about that, but they were right to the extent that there was a slippery slope here. If compulsory vaccination was constitutional, what else might be constitutional? At the time, some critics of the decision raised the concern that compulsory sterilization, in an era of eugenics, might be found constitutional—and in 1927, when the Supreme Court, in Buck v. Bell, upheld compulsory sterilization for people deemed unsafe to have children, the only precedent that Justice Oliver Wendell Holmes Jr. cited in his infamous opinion for the court was Jacobson v. Massachusetts.
Then of course, this decision, between then and now, has also given support to all kinds of public health measures we have today, including the fact that all 50 states have mandates requiring schoolchildren to be vaccinated. But Justice John Marshall Harlan, who wrote the opinion for the Jacobson decision, also invoked the idea that there could be cases in which one individual, because of their medical history, could seek an exception. And now, every state has medical exemptions, religious exemptions; about 15 of them also allow for philosophical exemptions to vaccination.
Reading this history, which is extremely grim—forced vaccination; contaminated vaccines; forced isolation in pesthouses, under inhumane conditions; poor and minority citizens getting the brunt of it—I feel like I’m reading a libertarian fever dream of what the negative consequences of strong public health laws could be. It also fits right into a recent tendency on the right to demonize Progressive Era reformers. What is the cultural afterlife of this history, if that’s possible to discern?
Oh no! I mean, I want to say on the record, smallpox vaccination was a very effective measure, supported not just by scientific arguments but by ethical and moral arguments about an individual’s debt to their fellow citizen. If the Progressive Era was about anything, it was about this idea of social responsibility and social justice.
But then where this story from 120 years ago gets so concerning is the biased and dangerous way the vaccinations were carried out, which generated extraordinary levels of resistance—which in turn has had some very positive effects. One more consequence of this period, for example, was that the federal government, in 1902, enacted the Biologics Control Act, which established the first system of federal licensing and regulation of vaccine production. And there are also real lessons in this history about how not to address a public health crisis.
But the question of legacy is difficult because so much historical experience has intervened in the meantime—the world wars, the influenza epidemic of 1918–19, and of course the successful development of vaccines against polio, measles, mumps, rubella, tetanus, all of which have made childhood in particular a much safer passage than in the past.