S1E64: The Origins of Vaccine Hesitancy / Jonathan Berman, Nadja Durbach, Michael Willrich

“Every generation has generated its own anti-vaccinationism based on very similar concerns.” -Jonathan Berman

Vaccines are a safe and critical public health tool. They prevent crippling childhood diseases like polio. They’re responsible for the eradication of one of the deadliest diseases ever — smallpox — and, today, they’re one of the most important measures we have to end the coronavirus pandemic. But despite these achievements people have been worried about vaccines for as long as they’ve existed and this anxiety is a serious challenge to reaching herd immunity. In this episode of EPIDEMIC, we look back to the 1800s to learn from the mistakes of the first mass vaccination campaigns in the United Kingdom and the United States.

This podcast was created by Just Human Productions. We’re powered and distributed by Simplecast. We’re supported, in part, by listeners like you.

Nadja Durbach: What’s really, I think, important to understand about the first anti-vaccination movement, the one that erupted in Britain in the 1850s, is that it was made up with a lot of different groups of people.

Michael Willrich: This is very much in American political, legal tradition to allow governments under their police powers, to protect the public health.

Céline Gounder: You’re listening to EPIDEMIC, the podcast about the science, public health, and social impacts of the coronavirus pandemic. I’m your host, Dr. Celine Gounder.

Nadja Durbach is a professor of history at the University of Utah. Nadja loves archives.

Nadja Durbach: Oh, the archive is a wonderful place!

Céline Gounder: A lot of the things Nadja’s interested in are documents from the Victorian era. Often they’re kept in these plain, unassuming boxes.

Nadja Durbach: It could be very small. It could be huge. Some of the documents I was recently working with came in boxes that were almost as big as I was. And there were 300 of them. And the archivist was not that happy to pass over 300 of these boxes over the course of weeks and weeks.

Céline Gounder: It may sound dry to some, but for Nadja it’s like a treasure hunt.

Nadja Durbach: You know, it’s like opening a present. You open the box up and you see what’s in there and —And so what I love is the serendipity of it. You go through and you look at the thing you wanted, but sometimes beside it in the box that you’re allowed access to is something you didn’t know existed.

Céline Gounder: So one day, when Nadja was a graduate student, she was in an archive looking for something that could become her dissertation topic.

Nadja Durbach: And so I was trolling around in the National Library of Medicine and I stumbled upon what I think is the original anti-vaccination pamphlet that was written in the 1850s.

Céline Gounder: The pamphlet was called Our Medical Liberties by John Gibbs. It was opposing mandatory vaccination against smallpox in England.

Pamphlet reading: Last session, a measure robbing the subject of some of his dearest personal rights and liberties was indecently hurried through Parliament […] under the modest and unassuming title of the Vaccination Extension Bill. In reality, it was a Bill of pains and penalties.

Nadja Durbach: And I got really hooked by his language and his articulation of the vaccination issue as one that was fundamentally about sort of the personal rights to control your body versus the government’s right to control its subjects.

Pamphlet reading: The Vaccination Extension Act, or rather, the Compulsory Vaccination Act […] is the first direct aggression upon the person of the subject in medical matters. […] If not checked by a timely and energetic opposition [the medical profession] will indubitably succeed in establishing a tyranny as odious, galling, insulting and injurious as any against which Britons ever successfully struggled.

Nadja Durbach: And at the same time a kind of gothic language of fears around the body being violated and penetrated and entered, and this sort of clash between what seemed like a kind of ideological opposition to vaccination and at the same time, a really kind of emotional resistance.

Pamphlet reading: Britons, guard well your hard-won precious rights! Surrender not even that one, which, in the immensity of your riches, may appear of but trivial value.  Keep your medical liberties intact. You must preserve them all, or you must lose them all; and remember that with them must be lost, or preserved, no small portion of your civil and religious liberties as well; they are all intimately and inseparably united. Let no unhallowed tongue beguile you; let no unhallowed hand despoil you!

Céline Gounder: Vaccines are a safe and critical public health tool. They prevent crippling childhood diseases, like polio… they’re responsible for the eradication of one of the deadliest diseases ever — smallpox. And, today, they’re one of the most important measures we have to end the coronavirus pandemic. But despite these achievements… pamphlets like the one Nadja found show that people have been worried about vaccines for as long as they’ve existed. And this anxiety is a serious challenge to reaching herd immunity. According to a survey by the Kaiser Family Foundation in March, 15% of Americans say they definitely won’t get vaccinated against COVID, and another 7% say they’ll only get vaccinated if required to do so. That’s more than 1 in 5 Americans. And many more say they plan to wait and see. In this episode, we’re going to look back at the origins of vaccine hesitancy and see why the same arguments against vaccines keep coming up again and again. We’ll look at why people were wary of early vaccines…

Nadja Durbach: In the 19th century, the way vaccinations were performed were actually inherently dangerous.

Céline Gounder: How those early responses to vaccination shaped our laws…

Michael Willrich: Jacobson versus Massachusetts was, and remains, really the paradigmatic, public health law case.

And why these concerns are so persistent.

Jonathan Berman: Every generation has sort of regenerated a new anti-vaccination-ism based on very similar concerns.

Céline Gounder: Today on EPIDEMIC, the origins of vaccine hesitancy.

Smallpox was one of the most feared diseases in the world. Thanks to vaccination, smallpox was declared eradicated in 1980. But back in the 1790s, it was a serious concern in Europe.

Jonathan Berman: The first vaccine was based on an observation that milkmaids tended not to get smallpox.

Céline Gounder: This is Jonathan Berman.

Jonathan Berman: Assistant professor of basic sciences at NYITCOM–Arkansas, author of Anti-vaxxers: How to Challenge a Misinformed Movement.

Céline Gounder: The cows back then would often get a virus called cowpox. It’s a disease similar to smallpox but it’s not transmitted between humans.

Jonathan Berman: So it would cause postulates on the cows’ udders and humans who milked those cows could contract it. And it would be sort of a very mild, um, disease where they would get pockmarks on their hands, but they would not develop smallpox.

Céline Gounder: Smallpox was a huge deal. It used to kill nearly 1 in 3 people who contracted it. Survivors could have terrible scars all over their body. And people who’d had smallpox often struggled to find work. Families and businesses were wary of anyone who’d had the disease, afraid they could spread it. So preventing it was a major concern. One day, a physician named Edward Jenner noticed this connection between cowpox and smallpox.

Jonathan Berman An experiment was done taking a very small knife, uh, a lancet, and poking a cowpox pustule.

Céline Gounder: Jenner made small cuts on the arm of a person with that knife dipped in the pus from a cowpox sore.

Jonathan Berman: And so that would then result in development of, uh, maybe some irritation, usually some inflammation and redness, but they would then be immune to smallpox.

Céline Gounder: People at the time didn’t know how this worked. Today we know that the body’s immune system was mounting an immune response to fight off the cowpox… And those same immune responses were also effective against smallpox. One of the first people to get Jenner’s vaccine was the child of a poor laborer in the countryside. The vaccination worked. The child was immune to smallpox. But this early experiment would signal some of the biggest issues swirling around vaccines then and now — poverty and children.

Nadja Durbach: There was this theory that the poor were the people spreading disease.

Céline Gounder: Remember, this is before germ theory. Back then, people thought disease was caused by something called miasma.

Nadja Durbach: It’s the sense that the poor are spreading it to the rich, through their kind of miasmatic dirt. That’s floating out of neighborhoods. And so the poor really stigmatized as being responsible for disease at this time.

Céline Gounder: In the 1850s, England was struggling with repeated outbreaks of smallpox. So, with Jenner’s vaccine available, they passed a mandatory vaccination law — the same one John Gibbs was writing about in that pamphlet.

Nadja Durbach: So every single person was meant to have their child vaccinated before the baby was six months old. So this applied to everyone, but if you were a middle-class or upper-class, and by middle-class, I mean, you know, kind of fairly wealthy and fairly elite with quite a lot of disposable income, you could pay to have your physician do this in a minor way.

Céline Gounder: But many people could not afford this. So they had to rely on the free vaccinations given out at work houses. Think Oliver Twist.

Nadja Durbach: But the way that these vaccinations were performed was much more invasive and intrusive to the body. And they were much more dangerous. And so many, many working class people who had to accept these free government vaccinations also found that their children were more likely to be injured through the process.

Céline Gounder: Let’s be clear. Vaccines today are safe. They’re done with sterilized single-use needles, and temperature controlled vials to make sure there is little to no chance of infection. But that wasn’t the case in the 19th century. They used the same basic method as Edward Jenner did in the 1790s.

Nadja Durbach: And then they would take that same knife and they would stick it in the arm of a baby who had already been vaccinated the week before and scoop out the vaccine from that baby’s arm and smear it into the cuts on the next baby. And so what we’re having then is the vaccine matter, actually being incubated in the bodies of babies and then transferred from one baby to the next.

Céline Gounder: This is really unsanitary. There was a serious risk of infection once the baby got home. This method also ran the risk of spreading tetanus or other germs between children.

How these laws were enforced also hit poorer Britons harder.

Nadja Durbach: So if you don’t obey the government mandate, the government can fine you repeatedly until you have vaccinated your child. And the fines were about a man’s weekly wages. So they’re very stiff fines. If you can’t afford to pay them. The government would then seize all your personal belongings and auction them to the public to raise the funds. And if you still don’t have your child vaccinated, they send you to jail.

Céline Gounder: Harsh punishments, and fears about safety drove a lot of the pushback at the time. But there were other factors too. Some concerns at the time may sound funny to us today. Here’s Jonathan Berman again.

Jonathan Berman: There were some things that sound kind of funny now, like people concerned that if you take a disease in cows and use it to vaccinate humans, they’ll take on characteristics of the cows.

Céline Gounder: But other arguments feel very familiar to us today.

Jonathan Berman: You’ll see arguments based on concerns about a government overreaching to health decisions. Um, you’ll see concerns based on people’s fears of childhood illness.

Céline Gounder: Others objected to vaccination on religious grounds. These people believed the body was sacred. They felt medicine was unnecessary or even dangerous.

Nadja Durbach: And on the other, the idea that you don’t want anything polluting in your body. So that meant for many people being vegetarians, um, not drinking alcohol.

Céline Gounder: This contingent of anti-vaccinators sometimes turned to dramatic examples to convince the public.

Nadja Durbach: For the British, the real symbol of vaccination that I think is really interesting is the idea of the vampire.

Céline Gounder: There were a lot of vampire novels at the time, including the most famous one, Bram Stoker’s Dracula.

Nadja Durbach: The anti-vaccination movement kind of seized on this popular trope because it proved to be such a good metaphor around the pollution of the blood and the ways in which 19th century people thought about health had a lot to do with this idea of pure blood. And so the resistance to vaccination was very much a resistance to something that could pollute your blood.

Céline Gounder: A few decades later, in the 1890s, the United States was facing its own smallpox epidemic. We’ll hear what happened… and how those events are still shaping how some feel about vaccines today… that’s after the break.

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Céline Gounder: At the start of the 20th century, the United States was facing its own smallpox epidemic. Hundreds died in places like New York City, Philadelphia, and New Orleans.

Michael Willrich: The government responded by ramping up compulsory vaccination.

Céline Gounder: This is Michael Willrich.

Michael Willrich: Enforcing vaccination in the schools and workplaces, at the borders, and really across the nation. This created an enormous tension between public health officials who are trying to bring smallpox under control and ordinary people.

Céline Gounder: Michael is the chair of the History Department at Brandeis University. He also wrote a book called Pox: An American History.

Michael Willrich: And public health officials were exercising extraordinary measures to get people vaccinated. Sending out of so-called “virus squads,” teams of vaccinators and police into working-class neighborhoods and cities like Boston or New York in the middle of the night, showing up at a tenement buildings, cordoning off the area, entering the buildings and inspecting all the rooms and carrying out vaccination, often by force.

Céline Gounder: In Britain there was a strong class prejudice when it came to how people were vaccinated. In the United States, there was also a racial element to these early campaigns.

Michael Willrich: African-Americans were rightly very suspicious of public health authorities. Public health was a Jim Crow system that excluded African-Americans in times of need and viewed them as the first subjects of compulsion when epidemics arose.

Céline Gounder: This hardline approach to vaccination angered a lot of people for many of the same reasons Nadja and Jonathan described. Fears of government overreach, religious liberty, and fears over unsanitary vaccine practices. In one of the worst accidents during the epidemic, nine children died in Camden, New Jersey after they were given a vaccine contaminated with tetanus.

Michael Willrich: So this is, you know, not irrational concerns we’re talking about here. And the government actually was partly responsible for creating the situation by compelling vaccination without making sure that the vaccines were safe.

Céline Gounder: The federal government passed a law to try to shore up support for vaccines. The Biologics Control Act of 1902 established the first nationwide system for licensing and inspecting vaccines. But that same year, a Lutheran minister in Cambridge, Massachusetts named Henning Jacobson, refused to have his child vaccinated.

Michael Willrich: He was brought before the criminal court; tried, found guilty of the crime of refusing vaccination. It was an incredible case. It had a lot of attention at the time.

Céline Gounder: Jacobson’s case would eventually make it all the way to the U.S. Supreme Court.

Michael Willrich: Jacobson and his lawyers argued that compulsory vaccination violated the right of every free person to take care of their bodies as they saw fit.

Céline Gounder: The Supreme Court did not agree. The Justices decided states had the authority to mandate vaccinations to protect the public during an epidemic, even if those efforts limited personal liberties.

Michael Willrich: The justice who wrote that decision, John Marshall Harlan, was a civil war veteran, and like many judges at the time he viewed this whole question in the context of the sacrifices that could be required of citizens during times of war. He said governments can compel people to be vaccinated by the same rationale that they require citizens, whether they want to or not, to fight in wars and to risk being shot down in the defense of the country. But at the same time, in that opinion, included some language that’s really important about the limits of public health authority that, that public health measures must not be arbitrary. They must be reasonable. They must be closely related to an actual public health purpose.

Céline Gounder: But the decision left open a door for exceptions.

Michael Willrich: The courts did not issue a blank check to public health officials.

Céline Gounder: The justices said courts should consider someone’s medical history when it comes to vaccination, especially if a vaccine could somehow harm that person.

Michael Willrich: It’s also the origin really of some of the more, uh, philosophical and religious exemptions as well. So Jacobson, even though it is such a strong endorsement is a Supreme court decision and public health authority, was not an example of the courts just getting out of the way.

Céline Gounder: This ruling emboldened others to seek exemptions. Activists in some states passed laws prohibiting compulsory vaccination. But by the time Jacobson’s case was decided in 1905… the smallpox epidemic had ended. There wasn’t an urgent need for mass vaccination. And there was also a change in public health thinking.

Michael Willrich: Public health officials seem to be very aware of this – to lead through education, rather than coercion, and also the social responsibility, duties, rather than simply seeking to enforce them by fiat. I think public health has come a very long way since 120 years ago.

Céline Gounder: Nadja Durbach agrees. She says there’s a lot to learn from the mistakes of the first mass vaccination campaigns.

Nadja Durbach: I think that we’ve seen with the mask mandates that sometimes it is merely the compulsion that sets people off on a path of resistance.

Céline Gounder: The other is how public health officials talk to people about risk.

Nadja Durbach: I think people in the 19th century actually had a much better understanding of risk. They saw epidemic disease on a daily basis. People died all the time. They understood the risk of getting a disease versus the risk of a vaccination. And they were making, I think, a quite educated choice.

Céline Gounder: And vaccines have become victims of their own success. Because diseases like smallpox have been wiped out… people no longer have a visceral understanding of how bad it was.

Nadja Durbach: And it’s not till fairly recently with the rise of the anti-vaccination movement that we’ve seen the reemergence of things like measles. And so people are not in a very good position to make those informed choices about what’s more risky because they don’t really know what dangerous epidemic diseases look like, and they think they’re all the same, and that there’s something you just get over. And so I think we need to do a better job today about educating people about risk, how risky is a vaccination versus how risky is an epidemic disease.

Céline Gounder: Past vaccination campaigns also unfairly targeted groups based on class and race. Because of that, Jonathan Berman says any effort to help educate people on the need for vaccines has to speak to these specific community concerns.

Jonathan Berman: A lot of how people arrive at what they believe depends on the groups they belong to, their neighbors, what their friends are doing. When I am trying to decide whether or not I should do something, my first instinct, my first desire is to go ask my friends, ask my family, what did you do? What are you going to do? How do we make that choice? Who do we trust? It’s very difficult.

Céline Gounder: It is difficult work. But Nadja says people who don’t have confidence in vaccines shouldn’t be written off.

Nadja Durbach: I think it’s really, really important for governments, public health departments at the local level, all the way up to the federal government, not to dismiss anti-vaccinators as just crazy fringe people. I think really the lesson we need to learn from the past is that there are real fears here, and we may not see those fears as legitimate, but these people do and we should understand what is it that concerns them. Why are they resisting this and try and use an education program to inform people about vaccination being a better choice than non-vaccination, both for themselves and their families, but also for the community.

Céline Gounder: In upcoming episodes, we’re going to take a deeper look at some of the groups who have lower confidence in vaccines. We’ll hear how the African American experience with past and present public health efforts has created a culture of distrust around vaccines. And we’ll hear from a mom who went from being vaccine hesitant to an advocate for vaccines.

That’s next time on EPIDEMIC.

CREDITS

EPIDEMIC is brought to you by Just Human Productions. We’re funded in part by listeners like you. We’re powered and distributed by Simplecast.

Today’s episode was produced by Zach Dyer and me. Our music is by the Blue Dot Sessions. Our Production and Research Associate is Temitayo Fagbenle. Our interns are Annabel Chen, Bryan Chen, Julie Levey, and Sophie Varma.

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And if you like the storytelling you hear on EPIDEMIC, check out our sister podcast, AMERICAN DIAGNOSIS. On AMERICAN DIAGNOSIS, we cover some of the biggest public health challenges affecting the nation today. Past seasons covered topics like youth and mental health; the opioid overdose crisis; and gun violence in America.

I’m Dr. Celine Gounder. Thanks for listening to EPIDEMIC.

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