Great reads: POX — a history of vaccine resistance

A swiftly moving contagious disease threatens children. The government urges parents to vaccinate. But parents are suspicious: They believe the vaccine has unpredictable side-effects and they distrust the government’s motives. When persuasion fails, coercion takes its place. The government demands vaccination — and a showdown looms.

In many aspects, that vignette sounds like today, when pertussis and measles are spreading through unvaccinated children. But what it actually describes is a lost episode of history: not 2010, but 1900, when smallpox spread across the country and life-saving universal — and compulsory — vaccination was imposed on the US population.

In a new book, POX: An American History (The Penguin Press, $27.95) historian Michael Willrich describes what happened next.

I wrote a history of US public health, and so I thought I knew something about vaccines, but I had never heard this story. I asked Willrich, an associate professor at Brandeis University, to answer some questions about it.

Among all the vaccine-preventable diseases, smallpox was uniquely deadly — and so I always assumed there was wide agreement over eliminating it. But POX tells the story of a broad, and surprisingly little-known, resistance movement against smallpox vaccination. Tell us that history briefly.

Today’s heated controversies over childhood immunization pale in comparison to the vaccine war that took place in the United States at the turn of the twentieth century – at the height of a nationwide wave of smallpox epidemics. Smallpox killed 730 people in New York, 400 in Philadelphia, 270 in Boston, and 500 in New Orleans (to name just a few of the most serious urban outbreaks). A new, milder form of the virus spread across the entire country, infecting hundreds of thousands of people, wreaking havoc on local economies, and putting the country’s emerging public health departments to the test. Struggling to control smallpox, local, state, and federal health officials enforced vaccination aggressively – all too often with brute force – in factories, work camps, crowded tenement districts, aboard steamships and trains, and in the public schools.

Smallpox vaccination 110 years ago was a risky and invasive procedure, with virtually no government controls on vaccine quality and safety. Many Americans regarded compulsory vaccination as a threat to their health and an invasion of their individual rights. They formed antivaccination leagues, demanded state laws to abolish compulsion, challenged compulsory vaccination in the courts, rioted, forged vaccination certificates, staged school boycotts, and hid sick children from the authorities to prevent them from being hauled off to the local “pesthouse.” POX tells the story of this forgotten civil liberties struggle and its legacy for American society and law.

The epidemic you focus on in POX leads to the government decreeing “universal compulsory vaccination” against smallpox — and to the spread of resistance that is both organized and individual. Who wins, if anyone does?

In a sense, both sides win. The struggle culminates in a series of major court decisions that put public health power on a firmer constitutional foundation while also recognizing important safeguards for individual liberties. For example, even as the courts upheld the collective right of a state government or local health board to compel vaccination in order to protect the entire population during an epidemic, the courts also held that such measures could not target particular racial minorities, that health officials could not lawfully use physical force to vaccinate unwilling individuals, and that individuals whose medical condition made vaccine particularly dangerous for them had the right to seek an exemption.

Significantly, in 1902 Congress responded to the crisis of public confidence in vaccine by establishing the first federal system of licensing and regulation of vaccines, antitoxins, and other commercial “biologics.” That law made vaccines safer and helped create a measure of confidence in vaccines. It was a victory for all of us.

You argue that the vaccine resisters of the 1900s had a point: The vaccines in use then had significant side effects, and the measures used to contain spread infringed on civil liberties. Since then, vaccines have been refined, and legal vaccine exemptions are abundant. So does the vaccine dissent of a century ago have relevance today?

Absolutely. The story resonates with many contemporary issues – from concerns about bioterrorism to childhood immunization to the debate over “Obamacare.” I think the single biggest lesson from my historical story may be that the public health community (and I include science and medicine journalists) must always strive to present the case for childhood immunization with candor and a measure of respect for parents’ fears.

We have to remember that most parents have the best interests of their children at heart. Vaccines still seem mysterious and unnatural to many people. And the best way to reach skeptics is through reason and persuasion, rather than condescension and coercion. This was the hard-bought lesson of the turn-of-the-century vaccine war.

The vaccine-resistance movement of the 1900s was driven in part by colorful personalities, including a Lutheran minister who was a movement leader. That was 100 years before social media and 40 years before television. How did their influence spread so widely, and can you draw parallels to today?

The organized antivaccinationists were part of a colorful transatlantic movement with roots in a broader tradition of libertarian radicalism that claimed the mantle of the nineteenth-century antislavery movement. (British antivaccinationists were so successful that Parliament in 1898 created a special exemption in the vaccination law for “conscientious objectors” – the first political use of that term.) They produced a fascinating literature of books, pamphlets, and alternative medical journals. They turned local school board elections into referenda on vaccination policy.

And a lot of concern about vaccines simply spread by word of mouth, particularly among working-class communities. Public health officials tried to dismiss antivaccinationists as a bunch of cranks and loners. But their concerns about individual liberty in an era of rising state intervention and corporate power resonated with many working-class and middle-class people.

Today’s opposition to vaccinationists seems to me both much more narrow – it’s almost entirely a question of parents and young children – and far more technologically advantaged. The Internet is, of course, an unbelievable force for the spread of information and misinformation about vaccines. The British medical researcher Andrew Wakefield’s infamous 1998 paper, suggesting a possible link between the MMR vaccine and autism has been thoroughly debunked. But every time I write or say something positive about vaccination, I receive angry e-mails filled with web links to Wakefield’s work. It’s all still out there.

There is an increasing amount of evidence that current vaccine resistance is leading to the resurgence of once-quelled preventable diseases, such as pertussis in California and measles in Minnesota. How would you balance this modern conflict between personal  liberty and public health? Are you concerned at all that your book will be interpreted as supporting vaccine resistance?

In POX, I certainly give both sides their due. And I argue that the historical “vaccination  question” posed a serious question of civil liberties. American judges of the day certainly thought it did. And I think today’s antivaccine activists might be interested to learn more about the history of their movement. On the other hand, I’m very much on the record in support of childhood immunizations today. My sense is that the balance of personal liberty and public health is much more carefully drawn today that it was at the dawn of the twentieth century. In fact, I think we are all the beneficiaries of that earlier civil liberties struggle.


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