Here’s what the past can tell us about the future of the pandemic.
As soon as the vaccine mandate went into effect, people began to rebel. Some saw it as government overreach — what right did faraway lawmakers have to tell people what to do with their bodies?
Others worried that the vaccine was dangerous, or that they were being used as guinea pigs — what proof was there that this concoction even worked? Protests were staged, opinion pieces written, and parents resorted to subterfuge to avoid vaccinating their kids — they changed addresses to confuse officials, got fake vaccine certificates, and even tried to reverse the process once their kids had already been vaccinated.
This sounds like a tale of the Covid-19 era, with a vocal minority of vaccine opponents staging rallies and filing lawsuits across the United States. But all of the above also happened in 19th-century England, when the government mandated the smallpox vaccine for children. “As soon as that mandate is introduced, that’s when we get an organized anti-vaccination movement,” said Nadja Durbach, a history professor at the University of Utah. “That’s when people are like, ‘Oh my God, you cannot tell me to do this to my child.’”
The history of smallpox is a reminder that, while they may seem new, anti-vaccination movements are as old as vaccination itself. People’s reasons for opposing vaccines — concerns about side effects, a preference for natural remedies, fear of government overreach — haven’t changed that much either. Our current moment is actually just one more chapter in a story about vaccines and infectious diseases that’s been going on for hundreds of years.
If policymakers and people in power can recognize that, maybe they can find better ways of convincing the hesitant, fighting conspiracy theories, and regaining the trust of communities that have faced discrimination or abuse from the very authorities charged with protecting their health. That work is already happening, with doctors, faith leaders, and others on the ground building relationships with patients to find out their own particular histories and needs before they even bring up the vaccine.
“If you really want to get people on board with public health and public health measures, you have to address the sources of mistrust,” said Maya Goldenberg, a philosophy professor at the University of Guelph and the author of Vaccine Hesitancy: Public Trust, Expertise, and the War on Science.
Vaccines are old. So is vaccine hesitancy.
The whole concept of vaccination derives from a centuries-old practice called inoculation or variolation, Durbach said. The idea was essentially to give yourself smallpox so you could control the severity and timing of the disease. Inoculation was practiced in the Middle East, China, and elsewhere for hundreds of years before it made its way to Europe, and it was eventually introduced to England by Lady Mary Wortley Montagu, the wife of the British ambassador to the Ottoman Empire, in the 18th century.
Methods of inoculation varied — often, doctors would insert a small amount of preserved smallpox scab under the skin of a healthy patient in order to give that person a controlled dose of the disease. The method was actually fairly effective, Durbach said, especially among the rich who could afford to check into a special facility where they would “be tended to and cared for and laze around” while they waited for the infection to clear. However, people would sometimes contract severe smallpox and die from the inoculation. Also, smallpox contracted through inoculation was still contagious, so the practice could cause unintended outbreaks.
Indeed, 2 to 3 percent of people inoculated against smallpox died, started an outbreak, or caught another disease like tuberculosis from the inoculation.
The solution was the smallpox vaccine, developed by Edward Jenner in the 1790s. Jenner found that people who contracted cowpox, a virus spread by cattle, were immune to smallpox. He developed a vaccine using the pus from infected cattle — the word “vaccine” comes from the Latin word for cow.
Cowpox is extremely mild in humans, making the new vaccine (at least in theory) far less dangerous than intentionally infecting oneself with smallpox. Cowpox also did not spread from person to person, removing the problem of contagion.
For decades, however, the new vaccine and the older, more familiar technique coexisted in Britain, Durbach said. Then, in 1840, the government decided to push vaccination over inoculation. First, government officials tried offering the vaccine for free at public workhouses. They encountered resistance, since workhouses were seen as places of destitution and desperation. “It would be like saying, the only place you could get a free vaccination is if you went to a welfare office,” Durbach said.
So in 1853, the government made the vaccine mandatory. That, according to Durbach, was when the organized anti-vaccination movement began. Some opposed the vaccine on grounds that might now be called libertarian, believing that the government had no business telling people how to take care of their health.
Others had religious or ideological concerns. Adherents of naturopathic or alternative medicine, for example, opposed all traditional medical treatments (many of which were actually toxic), used alternative treatments based on plants or water, and believed in the need to keep the body pure. For this group, vaccination was “just another form of toxic medicine coming into your body,” Durbach said.
Still others, meanwhile, were worried that the government was essentially experimenting on them by requiring vaccines. Working-class people, who at the time lacked the right to vote in England, were especially skeptical that the government really had their best interests at heart. “There’s a lot of pushback against the idea that people should have to do something that the government is telling them to do, when they are not actually equal and free citizens,” Durbach said.
Anti-vaccination protests swept the country, with activists waving signs with messages like, “Better a felon’s cell than a poisoned babe.” Vaccine opponents distributed pamphlets with titles like, “Vaccination, a Curse.” Ordinary people engaged in forms of “grassroots subterfuge” to avoid vaccinating their children, Durbach said. Some moved shortly after giving birth so that public health officials couldn’t track them down; others paid doctors to issue false vaccine certificates. Some even tried to suck the vaccine out of their children’s arms after it was administered.
It didn’t help public confidence that the new vaccines, while in theory safer than inoculation, could be dangerous in practice. The vaccine was highly effective, with the smallpox death rate among children dropping by 50 percent in the years after the mandate was passed.
However, the way it was administered could cause its own problems. Public health officials used lancets or scarification devices equipped with blades that “shoot out and make these multiple incisions all at once,” Durbach said. Doctors didn’t yet understand the importance of sterilizing instruments and would often use the same instrument to vaccinate multiple children in a row, leading to infections. “You have kids whose arms are dropping off,” Durbach said. “Kids are dying.”
All of this led to intense anti-vaccine sentiment, both in Britain and in the US. British anti-vaccine activists actually sent representatives to the States, where cities were introducing their own vaccine mandates, to help launch a similar movement there. They found fertile ground, with opposition to organized medicine and a focus on purity and avoidance of “toxins” gaining popularity in the US as well. Similar attitudes spread in France, Canada, and elsewhere; an “international anti-vaccination movement” took shape in the 19th century, Durbach said.
Things got better. Then they got worse again.
This movement didn’t last forever. To begin with, government officials in the US and the UK began to introduce exemptions to the mandates. In 1907, for example, the British government began granting exemptions to the smallpox mandate to pretty much anyone who applied for one. “That ends the movement almost overnight,” Durbach said, “because there’s really nothing, at that point, to be able to argue against.”
As the 20th century wore on, meanwhile, many Americans began to have an increased respect for doctors and organized medicine, said James Colgrove, a professor of sociomedical sciences at Columbia and the author of State of Immunity: The Politics of Vaccination in Twentieth-Century America.
The middle of that century was “a high-water mark for trust and respect in medical science,” Colgrove said, thanks to “a whole slew of dramatic medical advances” — not least the polio vaccine, which inspired far less pushback than smallpox vaccines had a century before. These advances did not benefit all Americans equally, and Black, Indigenous, and other Americans of color were often ignored or victimized in health care settings. However, media coverage often extolled the virtues of new drugs and treatments, sending a message of general progress even if that progress wasn’t available to all.
Meanwhile, something else was happening in Britain: the creation of the National Health Service. The UK went from “a society in which working-class people feel targeted by the government and by medicine” to one in which “people are getting medical care for the first time for free,” Durbach said. The creation of the NHS helped usher in a “profound cultural shift” in which “people are much less suspicious of things provided by the government,” including vaccines.
The middle of the 20th century wasn’t a time of unalloyed public health progress, however. In 1932, the United States Public Health Service began the now-infamous Tuskegee experiment, in which researchers monitored hundreds of Black men with syphilis without actually treating their disease. Even after an effective treatment — penicillin — became available in the 1940s, researchers continued the study, only stopping in 1972 after more than 100 men had died from syphilis or complications of the disease.
The experiment, rooted in the racist idea that Black men’s bodies were fundamentally different from white men’s, is often cited today as an explanation for vaccine hesitancy in Black communities, but it’s more complicated than that, says Karen Lincoln, a professor at the USC Suzanne Dworak-Peck School of Social Work who has studied health disparities.
In reality, Tuskegee was far from the first instance of medical racism targeting Black Americans, nor would it be the last. The history of American medicine is full of examples like Tuskegee, dating back to slavery — for example, J. Marion Sims, known by some as the “father of modern gynecology,” conducted painful and invasive research without anesthesia on enslaved women. Racism in medical settings continues to this day, with discrimination a major driver of the high rates of maternal mortality among Black Americans, along with other health disparities.
Alongside the longstanding racist abuses in the medical system, a number of other events led to a slow erosion of trust in vaccines during the late 20th century, Colgrove said. In the 1970s and ’80s, several highly contested studies suggested that the pertussis vaccine (then called DPT) could cause brain damage. The research received significant media attention, with one TV documentary colorfully titled “DPT: Vaccine Roulette.”
Then, in 1998, British physician Andrew Wakefield published a study of 12 children that purported to suggest a link between the MMR (measles, mumps, and rubella) vaccine and autism. The study has been thoroughly discredited — Wakefield was found to have manipulated his data and lost his medical license, and subsequent research has found no link between vaccines and autism. But as Julia Belluz reported at Vox, media outlets covered the study with excessive enthusiasm and credulity, helping fan the flames of anti-vaccine sentiment.
The Wakefield paper also came out just as the internet was coming into wider use, Colgrove said. It was an unfortunate historical coincidence — a new piece of misinformation being released “at precisely the moment when this new medium for the spread of misinformation and conspiracy theories was really taking off.”
Wakefield’s discredited research and the media coverage and online conversation around it helped kick off the contemporary anti-vaccine movement. That movement grew throughout the 2000s thanks to a combination of factors, including a rise in anti-government sentiment and the emergence of a social media environment that tends to amplify conflict and controversy, Colgrove said.
Anti-vaccine sentiment has come to a head again during the Covid-19 pandemic, with protests and rhetoric not dissimilar from the opposition to the smallpox vaccine in the 19th century. Anti-vaccine demonstrators march in cities around the country, carrying signs protesting government overreach or bearing false warnings about the dangers of vaccines. Just like in the 1800s, people who are skeptical of traditional medicine or who embrace natural “wellness” worry that vaccines are unnatural or contain toxins.
Some people even try to “undo” their vaccines after complying with vaccine mandates, much like the parents who tried to suck out their children’s smallpox vaccine 100 years ago. As of January 2022, 16 percent of Americans said they would “definitely not” get vaccinated against Covid-19 or would only get vaccinated if required to, a number that’s remained relatively stable for more than a year.
Public health, though, has come a long way since the 19th century. Gone are the days of vaccinating multiple children with the same dirty knife — vaccination today is very safe, the Covid-19 vaccines have been rigorously tested, and serious side effects are rare. However, just telling people those things is not enough — public information campaigns, though they have had some effect, have not eliminated vaccine hesitancy, according to Goldenberg, the University of Guelph professor.
To combat vaccine hesitancy, we have to understand where it comes from
To reach people who remain unconvinced or uncertain, we may have to turn to the lessons of the past. One key is to look at the root causes of vaccine hesitancy. “The attitudes people have about vaccines generally reflect what they think about the governing structures around them,” Goldenberg said. Anti-vaccine sentiment is often “grounded in some kind of belief that your own interests or your community’s interests are not being well-addressed” by the government.
Think of the working-class Britons who were being told to get vaccinated without being given the right to vote. Those who are distrustful of or outright opposed to vaccines today span demographics and races, and their experiences of government vary widely. However, there may be a similar sense among vaccine holdouts of authorities demanding something without giving much in return. After all, the US doesn’t have a National Health Service like the one Britain established after World War II — many Americans don’t have the experience of the government actually providing for their health care needs.
That’s especially true for Black Americans and other people of color, who have faced discrimination both from government agencies and health care providers. Medical racism in America goes way beyond Tuskegee, and it continues today.
To understand vaccine hesitancy and distrust of the medical establishment in Black communities, you need to recognize that “people today are experiencing being dismissed, being underdiagnosed, being overdiagnosed, being undertreated, having a lack of access, living in pharmacy deserts and neighborhoods where there are no health care providers, where there are no mental health care providers, where the quality is poor, where access in general is low because either the services aren’t there, or the services that are provided have lower quality or have practitioners who lack the competency to really understand and relate and serve African Americans,” Lincoln, the USC professor, said.
Changing that requires not just improving health care access but also changing the way health care workers are recruited, supported, and trained, Lincoln said. Establishing a health care workforce that’s actually representative of America will require creating pathways for people to become doctors without incurring enormous debt. What’s more, providers need to be trained to think about health at the level of the community, not just the individual, taking into account and addressing the access issues that may prevent people from following health guidelines.
“Without a broader lens, without focusing on the overwhelming majority of factors that really help us understand variation in health, we’re really going to miss the mark,” Lincoln said.
In addition to addressing the causes of hesitancy and resistance, there are vaccine policy issues to consider. Vaccine mandates, for example, have worked in the past — with smallpox, for example, they did increase vaccination and reduce deaths. However, those mandates may need to be coupled with exemptions in order to stem backlash, Durbach, the University of Utah professor, said.
Exemptions need to be carefully calibrated so that they’re not too easy to get — someone should need to have a firm conviction and be willing to expend some effort to get one. When done right, though, exemptions can be effective because “you’re removing the thing that the conspiracy theories theorists rally around,” Durbach said.
An understanding of the past can also inform the one-on-one conversations that physicians, outreach workers, and others are having every day with people who are unsure about or outright resistant to vaccines.
Patients bring a wide variety of histories to these conversations, from reactions to previous vaccines to “their own experiences with health care or with institutions more generally and their background in terms of what their family or community has experienced,” said Aaron Richterman, an infectious disease doctor in Philadelphia. That background can include facing racism in medical settings or being stigmatized for a particular disease or condition. For all too many Americans, “their experience historically with health systems is that health systems are not there to help them.”
It’s important to combat that experience by actually offering help, on the patient’s terms. “It often takes building a real relationship with someone and showing yourself to care about someone and to care about what they care about,” Richterman said. “I have my objectives, but it’s about their objectives.” Helping people meet their own health goals can help a physician build trust with patients, which is crucial when talking about something like vaccines. In order to become a “trusted messenger” on such a potentially difficult topic, “you have to try to understand where people are coming from and meet them where they are,” Richterman said.
Unfortunately, in today’s health care system, many people lack a relationship with such a messenger — the percentage of Americans who even have a primary care doctor has been falling in recent years. Making sure people can actually build a relationship with a provider is crucial to encouraging vaccination. “One of the things that really gets missed in the vaccine conversation in the US is how much it really requires that sort of one-on-one,” Richterman said. “People need to be talked to about it.”
It’s not only doctors who can forge these relationships, however. Community groups and businesses, from churches to barbershops, that already have a rapport with people in their area, have conducted successful campaigns of vaccine outreach in recent months. “Looking to community partners who have longstanding relationships in communities is really important,” said Rachel Villanueva, president of the National Medical Association, which represents African American doctors and their patients.
Whether in the 19th century or today, it should be no surprise that vaccines, more than other medical advances, require trust and conversation, and sometimes inspire intense resistance.
“People are healthy when you give it to them, and it’s asking them to accept this to protect them from a danger that may or may not happen to them,” Colgrove said. In some ways, communication around vaccines encapsulates the problem of public health as a field: “The benefits that it promises are invisible,” Colgrove said. “When it succeeds, you’re not aware of it.”
The challenge, then, is to convince people to trust the public health system enough that they will accept a treatment whose benefits they may not see right away — or ever. History shows such trust is possible, but it has to be earned. And when that trust is broken, it may take generations to repair.