Johns Hopkins University Press
abstract

Vaccine hesitancy continues to pose a formidable obstacle to increasing national COVID-19 vaccination rates in the US, but this is not the first time that American vaccination efforts have confronted resistance and apathy. This study examines the history of US vaccination efforts against smallpox, polio, and measles, highlighting persistent drivers of vaccine hesitancy as well as factors that helped overcome it. The research reveals that logistical barriers, negative portrayals in the media, and fears about safety stymied inoculation efforts as early as the 18th century and continue to do so. However, vaccine hesitancy has been markedly diminished when trusted community leaders have guided efforts, when ordinary citizens have felt personally invested in the success of the vaccine, and when vaccination efforts have been tied to broader projects to improve public health and social cohesion. Deliberately cultivating such factors could be an effective strategy for lessening opposition today, when COVID-19's distinctive characteristics make addressing vaccine hesitancy more urgent than it has ever been.

[End Page 145]

Three years into the COVID-19 epidemic, vaccine hesitancy remains a significant challenge, as new sub-variants emerge and periodic surges continue. With the Omicron variant's emergence in winter 2021/22, cases reached new heights in the US, and the health-care system once again faced overburdening. More recently, the ability of Omicron sub-variants like BQ.1, BQ.1.1, and XBB.1.5 to evade previous immune responses to vaccination and natural infection has spurred a new round of vaccination efforts with novel "bivalent" mRNA boosters. However, uptake remains low (ca. 16.8% of eligible people as of February 2023; CDC 2023). Because vaccination remains the greatest tool at our disposal for facilitating the transition of COVID-19 from pandemic to endemic (Gandhi 2021), we need to explore diverse strategies for overcoming hesitancy. Historical experience provides some guidance in this effort.

The term "vaccine hesitancy" is less than 20 years old, and it has been defined as "the spectrum of behaviors that include reluctant, selective, or delayed vaccination" (Colgrove 2016), with individuals also falling on a "spectrum of indecision" impacted by various social, cultural, political, and personal factors (Kestenbaum and Feemster 2015). Although the term is relatively new, the phenomenon it describes is not. Vaccination campaigns in the past, including those considered quite successful, have faced resistance and apathy.

In this essay, we examine hesitancy in past campaigns against smallpox, polio, and measles, finding a number of challenges in common with the campaign against COVID-19 today. These include logistical roadblocks, fears about the perceived dangers of vaccination, and inaccurate media portrayals. In each case, personal tragedy and experience with the disease helped encourage vaccination, but so too did improving accessibility, addressing safety concerns, and energetically countering misinformation. Familiarity with this history can help temper our expectations regarding vaccination while offering insight into how current hesitancy might be effectively surmounted. Additionally, the detailed reasons for hesitancy may be downstream effects of a deeper problem in our current historical moment: a broader crisis of trust in science and government by the public they serve (Goldenberg 2021). The intransigence of hesitancy may be explained by a lack of sufficient community engagement in policy formation and a failure to address the perceived threat of vaccination to cultural values.

In contrast to the past, when most Americans felt government and medical institutions had their best interests at heart, in today's fractured political climate, many remain skeptical. To move forward, it appears we may have to rebuild public trust through intervention by individuals, including family physicians and pediatricians, who retain close relationships with their patients, as well as by involving community leaders in vaccine policy at an early stage. When people feel more involved in policy decisions that respect their cultural traditions, vaccination may be more easily accepted, and therefore more effective. [End Page 146]

Smallpox

Vaccine opposition is not a new phenomenon, and past instances are remarkably similar to the challenges we face today. In America, the earliest inoculation efforts began with the early 18th-century campaign against one of the most devastating diseases affecting colonial society: smallpox. In addition to having a dismal 25–30% mortality rate, smallpox often left those who recovered blind and disfigured by the telltale pustules (Hopkins 1983). Variolation (or inoculation), the insertion of material from a smallpox sufferer's pustules into a healthy person's skin, offered the best protection against infection at the time.

The introduction of variolation was perhaps the most significant advance in colonial medicine. As one historian put it, "Probably nothing in the field of early American medicine was more revolutionary" (Barrett 1942, 169). The technique had long been used in China, India, and Africa, and it had made its way to America via the Ottoman Empire and England. Boston's famous minister-physician Cotton Mather, who lost his wife and three of his children in one severe wave of smallpox in 1713, was one of the first Americans to successfully introduce inoculation in the colonies, after he had learned about the procedure from his slave Onesimus (Abrams and Kopperman 2019). As early historian Charles Francis Adams observed in his introduction to Abigail Adams's letters, the clergy were especially revered in early Massachusetts and they "not infrequently became the family physician," but at the beginning, many clergy opposed inoculation because they believed it went against the will of God (Adams 1841, xxiii).

Mather had a genuine desire to improve social welfare through medical advances, and in this he sought to change the cultural norm. He was assisted in his pioneering preventative smallpox campaign in 1721 by Dr. Zabdiel Boylston. Boylston inoculated himself and his six-year-old son, as well as Mather's younger children, to demonstrate the efficacy and safety of the procedure. Soon, several hundred locals Boylston and Mather had convinced underwent variolation.

Yet many doctors in Massachusetts, such as the university-trained William Douglass, initially opposed the procedure as both dangerous and medically unproven. Inoculation was so controversial that Boylston was threatened with hanging, and Mather's house was bombed (unsuccessfully) by an irate critic. Newspapers were filled with emotional editorials from both those who opposed and those who supported the procedure, resembling media reaction to COVID-19 in our times. Many colonies even passed laws to prohibit inoculation, which over time gave way to regulation, as the benefits of inoculation became more appreciated (Duffy 1976). Benjamin Franklin observed that "the practice of Inoculation always divided the people into parties, some contending warmly for it, and the others against it" (Franklin and Heberden 1759), reminiscent of today's opposition.

As critics charged, inoculation was both risky and expensive. The death rate for the procedure ranged from one to five in a hundred, and one could still experience a strong case of smallpox as a result of inoculation (Hopkins 1983). To [End Page 147] compound matters, those who could afford inoculation but did not observe a quarantine of many weeks sometimes infected the vulnerable poor. Such dangers prompted many to decry inoculation. Similarly, without regular testing and effective contact tracing, COVID-19 may be spread by those who have mild illness, or through pre-symptomatic transmission (Zhang et al. 2021).

Inoculation, even when successful, sometimes caused significant side effects, and complying with medical requirements could be intense and time-consuming. After John Adams was inoculated in 1764 at the age of 29, his teeth became loose after a regimen of mercury administered as part of preparation for the procedure (Butterfield 1961). In 1776, when Abigail Adams took advantage of the temporary lift of the ban against smallpox inoculation in Boston, she and her four children suffered various side effects. One son had to be inoculated twice because the first procedure did not take, and another became violently ill with fever and vomiting. The Adamses' daughter broke out in a spectacular mass of pustules, and Abigail informed her husband John, who was in Philadelphia attending the Continental Congress, that "Nabby has enough of the small Pox for all the family beside" (Adams 1776).

Some early inoculation campaigns required a combination of compulsion and trust in authority. For example, responding to a smallpox epidemic from 1775 to 1782 that killed more than 100,000 people and snuffed out many more lives than the British Army during the Revolutionary War, an initially reluctant General George Washington required inoculation and stressed preventive measures among his troops (Fenn 2001). Although the military inoculation mandate was controversial, the urgency of war and the trust and loyalty Washington had developed among his soldiers enabled the effort to succeed, even though some troops objected and others slipped through the cracks, resulting in pockets of infection.

Gradually, as they saw the wisdom of smallpox inoculation, physicians, officials, and the wider populace grew more accepting. It required both community and government support. In Massachusetts, where citizens elected their selectmen, they generally trusted their representatives to do the right thing. Of course, New England was an American region with a strong belief in representative government and tightknit communities, so due to social norms at the time, it was often easier for local authorities to impose measures (Woodard 2011). Historian Ben Mutschler (2020) demonstrates how "family, household, town, colony, state, and finally national government" there engaged cooperatively with the challenges that disease posed (5). As inoculation became more generally accepted, citizens began to demand that it be made more broadly available. In Marblehead, Massachusetts, in 1774, irate members of the working class burned to the ground the inoculation hospital built on Cat Island to serve the well-to-do. Their radical effort to make access to the procedure more egalitarian resulted in providing inoculation to the poor at a modest cost, largely paid for by donations and local government funds (Wehrman 2009). Benjamin Franklin raised funds in the Philadelphia [End Page 148] community to provide the inoculation free of charge to children whose parents could not afford to pay for it from their modest earnings.

Smallpox continued to be a serious threat throughout the world in the late 18th century, and in 1798, Dr. Edward Jenner, a country doctor in England, introduced the more effective procedure of vaccination with cowpox; the term vaccination was taken from the Latin word for cow (Rusnock 2009). Yet, the American medical community remained slow to adopt the safer method. Boston's Dr. Benjamin Waterhouse studied the subject closely. Even in the face of skepticism, Waterhouse became an advocate for vaccination, experimenting first on his own children in 1800 (Halsey 1936). President Thomas Jefferson, propelled by his keen interest in infectious diseases and public health, played a significant role in the wider acceptance of the Jenner vaccination. In 1806, Jefferson extended praise to Jenner and wrote, "Having been among the early converts, in this part of the globe, to its efficacy, I took an early part in recommending it to my countrymen. Medicine has never before produced any single improvement of such utility. … You have erased from the calendar of human afflictions one of its greatest."

Gradually, variolation gave way completely to vaccination, and states began to make vaccination compulsory. In response, anti-vaccination sentiment surfaced. Although it appeared as soon as the early 1800s, and the Anti-Vaccination Society of America was formed in 1879, anti-vaccination sentiment became more vocal during the smallpox epidemic of 1898–1903 (Willrich 2012). However, the courts upheld challenges to vaccine mandates, most notably in 1905, when Jacobson v. Massachusetts (197 U.S. 11) upheld compulsory vaccination laws, and in 1922, when Zucht v. King (260 U.S. 174) confirmed the constitutionality of school vaccine requirements.

As in the past, the only way to counter vaccination resistance today is to meet those who are hesitant on their own ground, by acknowledging their concerns and fears but explaining the safety and efficacy of COVID-19 vaccines versus the significant dangers associated with natural infection. Physicians and clergymen, along with elected politicians and media personalities, are perhaps best poised to leverage the trust they have built with their constituents.

Overcoming resistance to vaccination requires vaccine champions, laypeople who promote vaccination for those who are unwilling or unlikely to receive the message from medical or government institutions (Callender 2016). Over 200 years ago, when he was a well-known printer but not yet a statesman, Benjamin Franklin became such a figure. Speaking from the heart after losing his four-year-old son to smallpox in 1736, Franklin shared his pain with other parents:

I long regretted him, and still regret that I had not given it [smallpox] to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition that they should never forgive themselves, if a child died under [End Page 149] it, my example shows that the regret may be the same either way and therefore the safer [inoculation] should be chosen.

Franklin did not make the same mistake twice: his daughter Sally was successfully inoculated in 1746 at the age of four. It is a cautionary tale that holds relevance today.

Polio

The mid-1950s through early 1960s, when the Salk and Sabin vaccines against polio were rolled out, is remembered as a time of very little vaccine hesitancy, but that generalization obscures important exceptions. In the wake of transformative therapeutic advances in the 1940s—antibiotics, steroids, and other such miracle drugs—faith in the power of medicine, and specifically pharmaceuticals, was high. Additionally, experience of polio's devastation was deep, and those promoting vaccination savvily used techniques from the advertising industry to influence behaviors (Colgrove 2016). In 1954, as the Salk vaccine underwent its final trials, American newspapers buzzed with anticipation that the end of polio was in sight (Raffetto 1954; Springfield Sunday Republican 1954). The National Foundation for Infantile Paralysis (NFIP), which had largely funded Salk's research, had gathered money from millions of people in the form of small contributions through its March of Dimes campaign. Many Americans therefore felt they had personally invested in the development of the vaccine. Not only that, but American parents had also invested their children's lives, in large numbers: some 2 million children participated in the Francis Field Trial that resulted in the vaccine's government approval (Seytre and Shaffer 2005).

It is no surprise, then, that once Salk's vaccine was approved in April 1955 it met with celebration. Awards and thank-you letters flooded the Salk laboratory; church bells rang; parents inundated pediatricians with calls demanding shots. Rates of polio dropped precipitously thereafter. In 1956 there were only half as many polio cases in the US as in 1955, and in 1957 the caseload halved again (Oshinsky 2005). Progress stagnated by the end of the 1950s and the early 1960s, until the cheaper, orally administered Sabin vaccine became available in 1961. Over the course of the 1960s, only 100 Americans were paralyzed by polio, as compared with 15,000 in the 1950s; by 1970 polio was largely a disease of the past for Americans (CDC 2000, 2020b).

Closer inspection of the historical record, however, reveals a more complicated picture. In the months preceding the Francis Field Trial, a popular radio host claimed that the government was preparing thousands of "little white coffins" for the children they anticipated the vaccine would kill. Cutter Laboratories, one of a handful of companies authorized by the FDA to produce the polio vaccine, accidentally issued batches containing live virus in April 1955. As a result, within weeks of the vaccine becoming publicly available, 40,000 people contracted [End Page 150] polio from it. About 200 were paralyzed and 10 killed as a consequence (Offit 2005). The Cutter vaccines were recalled, and the campaign was temporarily halted. A round of public finger-pointing among Salk, government officials, the NFIP, and rival scientists such as Albert Sabin can only have further dismayed the public and damaged confidence. Remarkably, however, when vaccination resumed, demand was still high.

This, perhaps, is the best testament to the faith in medicine that was so widespread at the time. Today, a comparatively tiny proportion of COVID-19 shots has been associated with adverse side effects. Yet anxiety about blood clots, myocarditis, and Guillain-Barré syndrome associated with the COVID-19 vaccines has been widely reported (Burton and Schwartz 2021; Grady and Robbins 2021; Mandavilli 2021).

By the early 1960s, after the initial missteps had been overcome, some states proposed legislation to require proof of polio vaccination to enroll children in schools. In California, the main groups that opposed the bill were health libertarians, who saw a government mandate to take the vaccine as an infringement on individual choice. Their objections compelled the bill's sponsors to include an exemption for those whose sincere personal belief—not necessarily religious in nature—led them to oppose compulsory vaccination. The bill passed, and the personal-belief exemption became the model for exemptions to school-vaccination requirements in other states, for other diseases, in the decades to come (Conis and Kuo 2021).

What has been even less noticed than overt resistance to polio vaccination in the 1950s and 1960s, however, is vaccine apathy. In much of the country, demand dwindled after the initial rush. Little more than a year after Salk's vaccine became available, 16 states were returning their allotments of shots to the federal government unused, even though less than half of the population aged 40 and younger had been vaccinated (Chicago Daily Tribune 1956; Dallas Morning News 1956b). Around the anniversary of the vaccine's approval, the Dallas Morning News (1956a) reported that the city's vaccination campaign had been a great success, even though the figures it reported indicated that only two percent of the target demographic (people under age twenty) had been fully vaccinated.

Finally, in addition to safety fears, objections to mandates, and apathy, one last obstacle that polio vaccination encountered in the US was unequal access. After the dramatic decline in cases over the first few years of the Salk vaccine, polio persisted in poorer and minority communities, where vaccination rates remained low (Oshinsky 2005). Getting completely vaccinated involved getting three shots at particular intervals, plus a booster every year. The shots were not free. It was only when Albert Sabin's live-virus version of the vaccine became available—cheaper and delivered in one dose, orally instead of by injection—that vaccination began to overcome polio in its last stubborn bastions in the US. [End Page 151]

Beyond the American example, however, the struggles of the global polio eradication effort, now in the fourth decade of what was originally projected to be a 10- to 12-year project, shed light on challenges to vaccination campaigns. Although the global polio burden did decrease dramatically in the initial decade of the campaign, progress slowed in the 2000s. In parts of Africa and South Asia, families began to refuse vaccine drops and stopped opening their doors to house-to-house vaccinators. In Pakistan, over 100 vaccinators were murdered in the course of their duties (Abraham 2018).

This resistance highlights how energetic vaccination campaigns can arouse suspicion when conducted in the absence of attempts to improve health or quality of life more broadly. In India, Pakistan, and Nigeria, poor families observed that their governments, the WHO, and philanthropic organizations were able to mobilize the resources to conduct house-to-house polio vaccination campaigns—sometimes as frequently as once a month—but not to build or maintain sewage systems to keep people from living in filth, or to ensure access to clean water (Abraham 2018). Since the number of children dying of ordinary gastrointestinal infections in such places is far greater than the number paralyzed or dying of polio, citizens wonder why people with power and money are making such an outsized effort to tackle this single, rare disease.

Their search for explanations sometimes leads to conspiracy theories. In Pakistan, many believed that polio vaccination was a cover for Western intelligence gathering meant to find members of the Pakistani Taliban who could be targeted by drone strikes. In regions with large Muslim populations, some suspected that the vaccine campaign's true objective was to sterilize Muslims. The fact that the Central Intelligence Agency employed a door-to-door vaccinator in their effort to find Osama Bin Laden in Pakistan, and that contraception was the only other health-care intervention that governments in these regions provided to people in their homes, only made such conspiracy theories more plausible (Abraham 2018).

Different as the cases of polio in South Asia and COVID-19 in the US are, when it comes to vaccine conspiracy theories one sees some similar dynamics. Unlike polio in poor countries, COVID-19 is very prevalent in the US. But because so many people have experienced, or know someone who has experienced, a relatively mild case of COVID-19, they may not share the sense of urgency that some political leaders and public health officials express when promoting vaccination. Here, too, routine health care has not been readily accessible or affordable to all; in such an environment, a sudden, insistent, well-resourced campaign to get a vaccine into every body is bound to raise suspicion.

In the final analysis, vaccine hesitancy has been less consequential in its impact on anti-polio efforts than it has been in the COVID-19 pandemic, but that reflects epidemiological and virological differences between the two viruses more than any difference in acceptance of the vaccine. Polio is less easily transmitted than COVID-19, so its rates can be reduced markedly with a comparatively [End Page 152] low vaccination rate. By contrast, large-scale COVID-19 waves have occurred even in populations with vaccination rates of 60% or greater. Rather than thinking of polio vaccination campaigns as a success, and the COVID-19 campaign as a failure, it makes sense to investigate the obstacles that have stood in the way of anti-polio efforts. That can help us better address the similar obstacles to COVID-19 vaccination.

Measles

The story of measles vaccination brings us closer to the challenges of COVID-19 vaccination for several reasons. First, biologically and epidemiologically it resembles COVID-19 more than polio and smallpox do. Like SARS-CoV-2, measles is a highly infectious respiratory virus that requires large populations in the range of hundreds of thousands for sustained transmission. Despite both diseases having a relatively low case fatality rate (the proportion of cases that will end in death), they still constitute enormous challenges to public health due to their ability to reach large swathes of the population. Second, according to historian Elena Conis (2019), the contemporary anti-vaccination movement arose in response to the measles vaccination campaign. Opposition centered on Andrew Wakefield's 1998 Lancet paper—retracted in 2010—that tied the MMR (measles, mumps, and rubella) vaccine to autism. The theory was discredited but nevertheless is still pushed by anti-vaccination celebrities and grassroots organizations. Third, measles vaccination illustrates the ability of media coverage and social norms to influence public perceptions of and reactions to vaccines.

A measles vaccine was first licensed by John Enders and colleagues in 1963. Confidence in science was high, bolstered by the successes of vaccination efforts against other diseases, and President Johnson was about to enact Great Society legislation that emphasized the ability of government to bring about positive social change. In the context of several school outbreaks of measles, plans were made to tackle this disease, which was deemed more "mild" or "moderate" than polio, diphtheria, or smallpox. At the time, measles was a virtually ubiquitous childhood illness that was perceived as fairly innocuous, since it only rarely led to death. Measles-related mortality in the US had declined to 1 in 500,000 cases (0.0002%) with good supportive care; contrast that with West Africa in the early 1960s, where measles was still responsible for the deaths of 1 in 5 children less than six years (Conis 2019). Still, there were hundreds of thousands of new measles infections per year in the US and rare but serious complications like encephalitis did occur, which was thought to contribute to mental retardation. Herein there is again similarity with COVID-19: there have been increasing cases among children with the Delta and Omicron variants, most of which are mild, but they may sometimes result in more serious complications like acute respiratory distress syndrome (ARDS), multisystem inflammatory syndrome (MIS), or death. The [End Page 153] case fatality rate for children with COVID-19 is perhaps 0.02% or less (AAP 2021; Jackson et al. 2022).

Whereas vaccination requirements had been on the whole loosely enforced, with efforts triggered mostly by outbreaks (Quinn, Jamison, and Freimuth 2020), the new endeavor to extirpate measles involved mass vaccination of children with the aim of eradicating the illness in a single year. Although the 1967 CDC plan saw spectacular success (the typical 450,000 cases per year dropped to 22,000 cases in 1968), eradication did not occur, and cases rose again in the following years (Conis 2019).

For an extremely contagious illness like measles, the percentage of population with immunity must be very high (90–95%) to achieve herd immunity and prevent outbreaks. That level is yet unknown for COVID-19, but waves of infections occurring in populations with vaccination levels above 60% (and with many unvaccinated individuals who were previously infected) suggest it is similarly high. Moreover, the effect of vaccination is much more transitory for COVID-19 than for measles. Vaccine hesitancy therefore poses a more urgent problem to be addressed than in the past.

The initial measles vaccination program highlighted socioeconomic and racial disparities. The vaccine had been dispensed mostly in private practices, frequented by white children and their parents; black and Latino communities, who saw measles vaccination as less of a priority, were left vulnerable (Conis 2019). New federal efforts under Jimmy Carter in 1977 and Bill Clinton in 1993 helped address these gaps in coverage in part by eliminating logistical barriers to vaccination. As a result, measles was officially eliminated from the US in 2000, defined as the absence of continuous disease transmission for more than 12 months. But since then, due to declining levels of vaccination with an increasing contribution of sustained domestic transmission, measles has resurged, and WHO may yet rescind the US's measles elimination status (Phadke, Bednarczyk, and Omer 2020). In this sense, measles presents a cautionary tale for how highly infectious diseases require not only initial but also ongoing vaccination efforts.

While the measles campaign enjoyed great initial enthusiasm and support, the era in which it was launched also correlated with a powerful new anti-authoritarian current in American culture that has fed into growing concerns about vaccination. The 19th and early 20th centuries had been marked by coercive vaccine mandates enjoying steady judicial support (Colgrove 2016). Despite the birth of an Anti-Vaccination Society of America in 1879, resistance to vaccination efforts tended to be local, intermittent, and mostly unsuccessful (Colgrove 2005). This was a different era in American history when individual rights enjoyed less protection from the state. For example, there was forced military conscription and in 1927 Justice Oliver Wendell Holmes cited Jacobson v. Massachusetts in Buck v. Bell (274 U.S. 200), which allowed a state to sterilize the "feeble-minded" against their will and consent (Tampio 2021). [End Page 154]

The movements of the 1960s and 1970s present a marked contrast. Feminism, civil rights, rights for the disabled, patients' rights, environmentalism, and libertarianism presented a new language for challenging the ability of the state to override individual freedoms and protections. In the following decades judicial rulings would come to reflect this new cultural current. As Nicholas Tampio (2021) declared in a recent Boston Globe article, "we live in a culture, partly shaped by Supreme Court decisions, that celebrates the power of the individual to make decisions about their own bodies." A turning point came in 1982, with the airing of a TV documentary entitled DPT: Vaccine Roulette that emphasized side effects of childhood vaccinations and thereby gave equal attention to the vaccine's critics as to the scientific consensus (Schwartz 2012). Following this documentary, Dissatisfied Parents Together (DPT) became the National Vaccine Information Center, which continues to be a leading source of vaccine misinformation (McDonald 2020).

The power of media to shape public opinion regarding vaccination was also highlighted in 2014–2015 with the Disneyland measles outbreak in which almost 700 children were affected. Negative coverage of the incident brought to light California's lenient policy of nonmedical exemptions to vaccination and sparked public outrage. Accordingly, the state legislature of California passed bill SB-277, ending nonmedical exemptions to vaccination in the state (Quinn, Jamison, and Freimuth 2020). Conversely, negative stories about vaccine safety in the news and on television have been shown to correlate with increased incidence of vaccine-preventable diseases (Kestenbaum and Feemster 2015).

The influence of media highlights the fact that opinions and perceptions regarding vaccination are malleable and shaped by one's surrounding culture. For example, studies have shown that patients or parents are more amenable to vaccination when aware that others have been vaccinated (Marshall 2019). Social norms can therefore be a powerful tool for shaping behavior. It is no surprise, then, that vaccine refusal tends to cluster at the local community level, creating pockets of vulnerability in which infectious diseases can spread (Callender 2016). The challenge today is that while a single, pro-vaccination social norm may have dominated the culture in the 1950s, a counter-norm now exists that is libertarian, anti-establishment, wary of government and established scientific institutions, mistrustful of the pharmaceutical industry, and focused on "natural" versus "unnatural" remedies. Thanks to the internet and social media, avoidance of or opposition to vaccination has become a norm with wider reach than ever. This movement also enjoys increasing political backing, as politicians capitalize on this counter-norm to win public support.

COVID-19 and measles have important differences. Measles lingers in the air for several hours to infect large numbers of individuals, whereas SARS-CoV-2 depends on shorter-range and shorter-lived aerosols or droplet spread within six feet. Moreover, the immunity conferred by infection or vaccination lasts much [End Page 155] longer for measles than for COVID-19. The substantial waning of SARS-CoV-2 immunity as evidenced by breakthrough infections just three to six months following vaccination means that control of COVID-19 on the population level will likely be a more difficult ongoing battle, one that will require both convincing people to be vaccinated and also having them keep up with regular repeat vaccinations. Meanwhile, good vaccines are in a sense victims of their own success (Schwartz 2012): as they decrease the burden of infections in the population, the experience of natural infection is lost and the dangers of natural infection become unappreciated. Thus, to those ill-informed about the disease, vaccination can seem more threatening than the disease itself (Callender 2016). With the Omicron variant having largely reduced COVID-19 to a common cold, many Americans now perceive the disease as a nuisance rather than the considerable threat to morbidity and mortality it remains at the population level. Without the direct experience of a severe infection in themselves or family and friends, everyday Americans may not appreciate the dire need for vaccination.

Conclusion

The vaccination efforts against smallpox, polio, and measles provide some reasons for optimism. While those campaigns spanned decades, they were ultimately successful despite the challenge of vaccine hesitancy. Meanwhile, the US vaccine effort against COVID-19 has already broken records, with over half of the adult population receiving an initial vaccine series in less than a year. And while the polio and measles campaigns were initially hindered by financial barriers, the COVID-19 vaccines have been free and efforts are being made to increase access for disadvantaged populations. Even after the depletion of the federally purchased supply and an end to the public health emergency declaration, free vaccination will continue for the vast majority of Americans (Kates et al. 2022).

But in other regards, we are neglecting the lessons of history. First, media depictions matter, as press surrounding both polio and measles vaccination demonstrated. Newspaper photos of Elvis Presley getting vaccinated against polio countered radio chatter about the alleged dangers of vaccines. California's legislature, having pioneered personal exemptions to vaccination, reversed course and banned them in the wake of coverage of the Disneyland measles outbreak. Yet today, negative portrayals of COVID-19 vaccination are insufficiently countered by positive messages. Second, in the past, individual citizens were able to attenuate suspicions that vaccination is a plot to undermine personal liberty and bodily autonomy, imposed by a central authority. By personally investing in the effort to develop the vaccine, as in the March of Dimes, they perceived vaccination instead as a homegrown tool to protect the bodies of friends and neighbors. Community leaders enhanced this message by acting as vaccine champions—for instance, by allowing themselves and their children to be among the first to try [End Page 156] a new vaccine. Third, as international polio vaccine campaigns have illustrated, pairing vaccination with broader efforts to improve health and welfare can help combat conspiratorial thinking. In such cases of public engagement, vaccines become a tool for upholding the cultural way of life of their intended recipients, rather than representing a challenge to value systems. Vaccine hesitancy persists, in part, because of deficiencies in scientific governance in which public voices and concerns are insufficiently present. As Dr. Rochelle Walensky stated in a recent interview, the CDC can no longer simply be an agency for public health officials, but must be an agency for the American people (Time 2022). Finally, for some, overcoming vaccine hesitancy may regrettably require tragic personal experiences like the death of Franklin's child.

In closing, the vaccination lessons of the past must also be seen in the context of the unique challenges that COVID-19 presents. Because COVID-19 is a novel disease, adults cannot rely on immunity from childhood illness or past vaccination. But also, unlike smallpox, polio, and measles, immunity to natural infection and vaccination has been transient. Ongoing repeat booster vaccination—at least of society's most vulnerable individuals—is proving necessary, though with diminishing returns for variants and subvariants causing milder disease, leading to vaccination fatigue. Moreover, the laboratory that is the global population has generated ever-more infectious variants as COVID-19 has spread around the world, with the bar for herd immunity likely now beyond 90% of the population. These events are unfolding in a background crisis of trust in science and government, accentuated by political polarization. In this current scenario, morbidity and mortality from COVID-19 in the US remain unacceptably high, and the disease may again threaten to overburden the health system, despite the impressive vaccination gains already made. Overcoming vaccine hesitancy has never been more important and more urgently needed than at this moment.

J. J. Eddy
Division of Mycobacterial and Respiratory Infections, Department of Medicine, National Jewish Health, Denver.
eddyj@njhealth.org
H. A. Smith
Department of History, College of Arts, Humanities, and Social Sciences, University of Denver.
J. E. Abrams
Center for Judaic Studies and University Libraries, University of Denver.
Correspondence: J. J. Eddy, Division of Mycobacterial and Respiratory Infections, Department of Medicine, National Jewish Health, 1400 Jackson Street, J200c, Denver, CO 80206.

References

Abraham, T. 2018. Polio: The Odyssey of Eradication. London: Hurst.
Abrams, J., and P. E. Kopperman. 2019. "Cotton Mather's Medicine, with Particular Reference to Measles." J Med Biogr 27 (1): 30–37. DOI:10.1177/0967772016662166.
Adams, A. 1776. Letter to John Adams (Aug. 14). Founders Online.
Adams, A. 1841. Letters of Mrs. Adams, the Wife of John Adams: With an Introductory Memoir by Her Grandson Charles Francis. 4th ed. Boston: Little Brown.
American Academy of Pediatrics (AAP). 2021. "Children and COVID-19: State-Level Data Report." https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/.
Barrett, J. T. 1942. "The Inoculation Controversy in Puritan New England." Bull Hist Med 12: 169.
Burton, T. M., and F. Schwartz. 2021. "FDA Adds Warning to Label of J&J Vaccine." Wall Street J, July 13.
Butterfield, L. H. 1961. Diary and Autobiography of John Adams. Cambridge: Belknap Press.
Callender, D. 2016. "Vaccine Hesitancy: More than a Movement." Hum Vaccin Immunother 12 (9): 2464–68. DOI:10.1080/21645515.2016.1178434.
Centers for Disease Control and Prevention (CDC) 2000. "Poliomyelitis Prevention in the United States: Updated Recommendations of the Advisory Committee on Immunization Practices." MMWR (May 19). https://www.cdc.gov/mmwr/preview/mmwrhtml/rr4905a1.htm.
Centers for Disease Control and Prevention (CDC). 2022. "Polio Elimination in the United States." https://www.cdc.gov/polio/what-is-polio/polio-us.html.
Centers for Disease Control and Prevention (CDC). 2023. COVID Data Tracker. https://covid.cdc.gov/covid-data-tracker/#datatracker-homevaccinations_vaccpeople-booster-percent-total.
Chicago Daily Tribune. 1956. "17 States Turn Back Unused Polio Vaccine." July 25.
Colgrove, J. 2005. "'Science in a Democracy': The Contested Status of Vaccination in the Progressive Era and the 1920s." Isis 96 (2): 167–91. DOI:10.1086/431531.
Colgrove, J. 2016. "Vaccine Refusal Revisited: The Limits of Public Health Persuasion and Coercion." N Engl J Med 375 (14): 1316–17. DOI:10.1056/NEJMp1608967.
Conis, E. 2019 "Measles and the Modern History of Vaccination." Public Health Rep 134 (2): 118–25. DOI:10.1177/0033354919826558.
Conis, E., and J. Kuo. 2021. "Historical Origins of the Personal Belief Exemption to Vaccination Mandates: The View from California." J Hist Med Allied Sci 76 (2): 167–90. DOI:10.1093/jhmas/jrab003.
Dallas Morning News. 1956a. "Figures Hint Worth of Salk Polio Serum." April 13.
Dallas Morning News. 1956b. "Texans Fail to Use Share of Polio Shots." July 25.
Duffy, J. 1976. Epidemics in Colonial America. Baton Rouge: Louisiana State University Press.
Fenn, E. 2001. Pox Americana: The Great Smallpox Epidemic of 1775–1782. New York: Hill and Wang.
Franklin, B. 1958. Autobiography and Other Writings, ed. R. B. Nye. Boston: Houghton Mifflin.
Franklin, B., and W. Heberden. 1759. Some Account of the Success of Inoculation for Small-Pox in England and America. London: William Strahan.
Gandhi, M. 2021. "Covid Will Soon Be Endemic, Thank Goodness." Wall Street J, Oct. 1. https://www.wsj.com/articles/covid-endemic-vaccines-measles-smallpox-pandemic-coronavirus-11633015316.
Goldenberg, M. 2021. Vaccine Hesitancy: Public Trust, Expertise, and the War on Science. Pittsburgh: University of Pittsburgh Press.
Grady, D., and R. Robbins. 2021. "Abnormal Bleeding? Clots? Explaining the Safety Scare." NY Times, March 16.
Halsey, R. H. 1936. How the President, Thomas Jefferson, and Doctor Benjamin Waterhouse Established Vaccination as a Public Health Procedure. New York: Robert H. Halsey.
Hopkins, D. R. 1983. Princes and Peasants: Smallpox in History. Chicago: University of Chicago Press.
Jackson, W. M., et al. 2022. "COVID-19 in Pediatric Patients: A Systematic Review." J Neurosurg Anesthesiol 34 (1): 141–47. DOI:10.1097/ANA.0000000000000803.
Jefferson, T. 1806. Letter to Dr. Edward Jenner (May 14). Library of Congress.
Kates, J., et al. 2022. "Commercialization of COVID-19 Vaccines, Treatments, and Tests: Implications for Access and Coverage." Kaiser Family Foundation, Oct. 18. https://www.kff.org/coronavirus-covid-19/issue-brief/commercialization-of-covid-19-vaccines-treatments-and-tests-implications-for-access-and-coverage/.
Kestenbaum, L. A., and K. A. Feemster. 2015. "Identifying and Addressing Vaccine Hesitancy." Pediatr Ann 44 (4): e71–75. DOI:10.3928/00904481-20150410-07.
Mandavilli, A. 2021. "Shot May Cause Heart Problem in Young Adults." NY Times, May 24.
Marshall, G. S. 2019. "Vaccine Hesitancy, History, and Human Nature: The 2018 Stanley A. Plotkin Lecture." J Pediatric Infect Dis Soc 8 (1): 1–8. DOI:10.1093/jpids/piy082.
McDonald, K. 2020. "Tracking Facebook's COVID-19 Misinformation 'Super-Spreaders.'" NewsGuard, April 23. https://www.newsguardtech.com/special-reports/superspreaders/#april23.
Mutschler, B. 2020. The Province of Affliction: Illness and the Making of Early New England. Chicago: University of Chicago Press.
Offit, P. 2005. The Cutter Incident: How America's First Polio Vaccine Led to the Growing Vaccine Crisis. New Haven: Yale University Press.
Oshinsky, D. 2005. Polio: An American Story. New York: Oxford University Press.
Phadke, V. K., R. A. Bednarczyk, and S. B. Omer. 2020. "Vaccine Refusal and Measles Outbreaks in the US." JAMA 324 (13): 1344–45. DOI:10.1001/jama.2020.14828.
Quinn, S. C., A. M. Jamison, and V. S. Freimuth. 2020. "Measles Outbreaks and Public Attitudes Towards Vaccine Exemptions: Some Cautions and Strategies for Addressing Vaccine Hesitancy." Hum Vaccin Immunother 16 (5): 1050–54. DOI:10.1080/21645515.2019.1646578.
Raffetto, F. 1954. "Salk Vaccine's Use Approved," Dallas Morning News, March 24.
Rusnock, A. 2009. "Catching Cowpox: The Early Spread of Smallpox Vaccination." Bull Hist Med 83: 17–26.
Schwartz, J. L. 2012. "New Media, Old Messages: Themes in the History of Vaccine Hesitancy and Refusal." Virtual Mentor 14 (1): 50–55. DOI:10.1001/virtualmentor.2012.14.1.mhst1-1201.
Seytre, B., and M. Shaffer. 2005. The Death of a Disease: A History of the Eradication of Poliomyelitis. New Brunswick: Rutgers University Press.
Springfield Sunday Republican. 1954. "A Vaccine to Conquer Polio." Feb. 14.
Tampio, N. 2021. "A Weakness in the Argument for Vaccine Mandates." Boston Globe, Aug. 25. https://www.bostonglobe.com/2021/08/25/opinion/weak-constitutional-case-vaccine-mandates/.
Time. 2022. "8 Questions: Dr. Rochelle Walensky the Director of the US Centers for Disease Control and Prevention Is Trying to Change the Agency to fix its 'Dramatic Mistakes' During COVID-19." Sept. 12/19.
Wehrman, A. 2009. "The Siege of 'Castle Pox': A Medical Revolution in Marblehead, Massachusetts, 1764–1777." N Engl Q 82 (3): 385–429.
Willrich, M. 2012. Pox: An American History. New York: Penguin.
Woodard, C. 2011. American Nations. New York: Viking.
Zhang, Y., et al. 2021. "Role of Presymptomatic Transmission of COVID-19: Evidence from Beijing, China." J Epidemiol Community Health 75 (1): 84–87. DOI:10.1136/jech-2020-214635.

Footnotes

The authors are grateful to Liz Kellermeyer, Director of Library and Knowledge Services at National Jewish, for helping to find literature for this paper, and to Charles Daley in the Division of Mycobacterial and Respiratory Infections at National Jewish for reading and editing the manuscript.

JJE and HAS contributed equally to this work.

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