By Miriam Fauzia
BU News Service
BOSTON — In 2000, the CDC declared the United States measles free, but in recent years there have been major outbreaks. There have been three confirmed cases of measles in Massachusetts since October 2019, one of those involving a Boston resident. It was the first reported case for the city since 2013.
The resurgence of this previously absent disease has been associated with the emergence of an anti-vaccination movement in the United States in recent years. But one expert says this tension between science, personal beliefs and public policy has been going on for much longer.
In a recent lecture at the Old North Church, David Jones, a professor of the culture of medicine at Harvard University, explored the deep roots of this debate by examining Massachusetts’ history with smallpox.
The first documented smallpox outbreak took place during the winter of 1633. Several more outbreaks would occur over the years as the New England colony expanded and the city of Boston grew.
At the time, the standard protocol for smallpox epidemics involved quarantine, strict hygiene and a change in diet. There was a fourth treatment option though, and it came from the observation that smallpox survivors were resistant to re-infection. It was called inoculation.
Inoculation is the practice of inducing immunity by exposing the patient to a disease. For smallpox, this involves taking the pus from sores and rubbing it into a cut or incision.
The technique was practiced in Africa and India for centuries, and did not enter the European consciousness until 1714 by way of a report written by a physician from Constantinople. Published in the “Philosophical Transactions of the Royal Society,” the report provoked and intrigued many great intellectual minds at the time, one of whom was a prominent Boston Puritan minister named Cotton Mather.
During the Boston smallpox outbreak of 1721, Mather spearheaded a movement to inoculate the local population to prevent further spread of the disease. His insistence to the medical community to consider inoculation as a preventative measure was met with frank hostility. Disagreement ranged from religious – that it was God’s will for some individuals to die and inoculation would violate divinity – to scientific skepticism.
Only Zabdiel Boylston heeded Mather’s call. The surgeon, who had learned the trade from his father Thomas Boylston, oversaw the inoculation of 287 people. Of this group, only 2% died, Jones said.
In comparison, the mortality rate was 14.8% among the nearly 6,000 individuals who naturally contracted smallpox. Mather and Boylston’s advocacy appeared to be a success, but that triumph was not universally acknowledged, said Jones. Instead, it drew ire from some locals.
On Nov. 14, 1721, a citizen attempted to assassinate Mather by tossing a small bomb through a window of his house. Luckily, the wick of the explosive had come off just as it hit the glass pane. A note attached, however, conveyed the assassin’s sentiments: “Cotton Mather, you dog, dam you! I’l[l] inoculate you with this; with a pox to you!”
Smallpox inoculation would remain controversial until the early 18th century when Edward Jenner created a smallpox inoculation using its close relative, cowpox. He called the new practice a vaccination. Seen as much safer compared to its predecessor, Massachusetts introduced compulsory vaccination in 1809.
In 1855, the Legislature took it a step further by mandating all public school children be vaccinated. By 1900, over a dozen states joined the Commonwealth and enacted compulsory vaccination laws. If an individual failed to comply with vaccination, there were consequences.
“You couldn’t go to school, you might have to pay a fine. Some places you might be in prison, and other places you might be vaccinated by force,” Jones said.
Vaccination by force was seen as an encroachment of civil liberties and heightened governmental distrust amongst groups such as immigrants and African-Americans, who were usually the targets of vaccine enforcement.
“[These groups] were very suspicious of when the government would come out and demand that they be vaccinated when, most of the time, the government was doing very little to help them,” Jones said.
Much like today, there were also religious arguments against vaccination that swayed public opinion.
“There were strong religious arguments on both sides – if God had meant us to use vaccination or whether God forbids us from taking poison deliberately into our bodies,” Jones elaborated.
The Anti-Vaccination League, which arose during the mid-nineteenth century in response to compulsory vaccination laws in the U.K., inspired the creation of the Anti-Vaccination Society of America in 1879, and later the New England Anti-Compulsory Vaccination League.
Anti-vaccinationists, as members were known, tried several times over many years to abolish the compulsory vaccination law in Massachusetts, but to no avail, Jones said.
Boston suffered smallpox epidemics in both 1901 and 1903. There were 1,596 cases with 270 deaths in neighborhoods across the city. To control the spread of disease, the Boston Board of Health issued an order requiring all adults be vaccinated or risk paying a fine if they refused.
Henning Jacobson, a Lutheran pastor and Cambridge resident, refused vaccination.
“Jacobson said he had been vaccinated in Sweden [his native country]. There was no need for him to be vaccinated again and he refused to pay the fine,” Jones said. “[He] stated compulsory vaccination was hostile to the inherent right of every free man to care for his own body and health… That the law was anti-religious and compels a man to authorize [his] body to pollution and filth and disease.”
Jacobson sued, and his case, Jacobson v. Massachusetts, eventually went to the Supreme Court. In its 1906 ruling, the court upheld the Cambridge Board of Health’s authority to require vaccination during an epidemic, though Justice John Marshall Harlan noted there was a limit to what states could enforce.
“You can only do compulsory vaccination when there was a public necessity and present danger… [enforcement] measures need to avoid harm… You had to allow people to opt out for medical contraindications and a variety of other restrictions,” Jones said.
The legacy of Jacobson v. Massachusetts generated a shift in public health trends from explicit coercion to more figurative and metaphorical, such as using advertisements to send a message of criminality and moral culpability if medical advice was not followed.
But in the decades after, with new diseases like poliomyelitis conjuring terrifying fears of paralysis, no coercion to get the vaccine was needed.
“Parents, having experienced these diseases as children themselves, [were] quite happy to spare their children from the risk [of illness],” Jones said.
As immunization technology continued to improve, public support and compliance continued to surge. Entering the 1990s, however, confidence in vaccination began to wane. This was in due in part by a British Medical Journal report by Dr. Andrew Wakefield in which he argued a link between the measles, mumps and rubella vaccine and autism.
Wakefield was found to have been paid $674,000 to create the claim by Richard Barr, a personal injury lawyer who was involved with Justice, Awareness and Basic Support – a parent-led organization that believed their children contracted autism from vaccines.
Although Wakefield’s article was eventually debunked, fears of vaccine safety remain unabated, especially with the rise of the internet, dissemination of unreliable information and a generational gap.
“We have this generation of parents who have never seen any of these diseases and I think anyone who has seen a child in an iron long or paralyzed by polio would be extremely enthusiastic about immunizations,” Jones said.
However, after the state’s second measles case in May, a bill was put forward in June to overturn the religious exemption clause.
“I think a very strong case could be made now that we have a much stronger obligation to submit to compulsory measures…than we did in the past,” Jones said.
The bill will be seen early next month by the Department of Public Health during a hearing scheduled for Dec. 3.