There are virtually no photographs of twenty-first century American children covered with measles. The disease, as well as the sight of it, is something we have banished to the past: the stuff of medical archives and undeveloped foreign countries. Consequently, the photos and stock images that illustrate the news stories about the recent measles outbreak are almost entirely of healthy children—usually white—either crying or sitting patiently while a disembodied adult hand holds an unusually large syringe near their tiny bodies. This image, of course, means a vast array of things to our national population, which has nevertheless found itself split in two broad halves across a new party line: We are either pro-vaccination, or anti.
The development of the measles vaccination in 1963 (and later, the MMR vaccine in 1971) is considered one of the great triumphs of modern medicine. Campaigns to vaccinate American children were so successful that the disease was declared eliminated in the United States at the turn of the twenty-first century. Measles once killed hundreds of thousands of people, so, in turn, we killed it—and now, forgetful of this ghost's history, we have willingly raised it from the dead.
Measles was designated a "preventable" disease as soon as the vaccine was developed. The word, neutral and scientific, lacks the moral overtones attached to vaccine politics. "Preventable" implies vigilance but resists judgment; it panders to the myth of bodily autonomy and independence, connoting prevention not only as a choice but also a choice that will only affect the individual. Like the stock photos, "preventable" is a sanitized descriptor, born of the tumultuous history of vaccination, in which the fact that we can prevent something doesn't mean that we will.
The so-called vaccination debate is an inherently modern one, though it long precedes the politics of the twenty-first century. Anti-vaccination activists seemed to appear at nearly the moment that the English physician Edward Jenner published his first paper on his experiments with smallpox vaccination in 1789. (Jenner's experiments were by no means the first: China, Japan and Turkey among others had practiced variolation for centuries.)
The Essentials of Smallpox, 1720. Japanese. Image via Wellcome Images/Creative Commons
Variolation, the act of inserting live disease in the form of pus or scabs into cut skin, was introduced to England by Lady Mary Wortley Montagu in the mid-eighteenth century. She had witnessed this form of smallpox inoculation while accompanying her husband on a diplomatic mission to the Ottoman Empire, and believed she had stumbled on a medical miracle. Once a woman celebrated as both a great beauty and a great wit, Montagu had barely survived her own dance with smallpox, which left her scarred and disfigured. The loss of her beauty appeared as a frequent subject in her writing, as well as in angry rhymes from spurned lovers, like Alexander Pope, who wrote about her: "From furious Sappho scare a milder Fate; Poxed by her love, or libeled by her Hate."
Montagu's championing of variolation was immediately controversial. To put illness into an otherwise healthy body flew in the face of eighteenth-century doctoring that, at the time, posited that treatment should consist of either "sympathy" toward a wound or "antipathy" toward disease. Variolation served neither of these purposes; it neither healed nor expelled, and was thus considered unnatural, a violation of "Physick." And, though safer than an uncontrolled bout of smallpox, purposefully infecting a person with a deadly disease with the hope that they would either be protected or contract a mild case, wasn't an exact science. The survival rate of the inoculated population was still much higher than those who hadn't been inoculated, but selling an uneducated public on such a complicated and risky treatment—particularly one imported from Muslim lands—was, to say the least, an uphill battle.
Attributed to Jonathan Richardson, Lady Mary Wortley Montagu a la Turque, 18th Century. Image via Wiki Commons.
But Montagu was a woman of rank and importance, and her position within the British class system largely protected her from her detractors. In the more "egalitarian" Massachusetts Bay Colony, Cotton Mather, an early proponent of variolation, faced more direct opposition—a purely American mix of hardline Protestantism coupled with suspicion of foreigners and a distrust of scientific advancement.
Like Montagu, Mather had learned of variolation from a foreigner: a slave called Onesimus who had been inoculated for smallpox while still in his native Africa. Intrigued by Onesimus' protection from outbreaks, Mather launched a variolation campaign after a particularly deadly outbreak of the disease in 1721.
Unsurprisingly, the campaign was met with distrust, fueled by the personal position of the local newspaper editor, James Franklin—Benjamin's brother—who gave a disproportion amount of space to inoculation detractors. Skewing public perception was the fact that Bostonians had been protected from the disease for decades; the strict quarantine imposed by the city had kept the disease at bay, banishing it from public view to local pesthouses. Until 1721, the grotesque sight of a body consumed with smallpox had been unknown to an entire generation. The American commitment to short-lived memory of the devastation of contagious disease seems, perhaps, written in our cultural DNA.
Mather was the "Object of their Fury," the Puritan minister wrote in his diary, "their furious Obloquies and Invectives." But more than mistrust, Mather faced opposition from his own religious sect, many of whom saw disease as "one of the strange works of God," and inoculation as "fighting with the most High," as one fellow minister wrote. Perhaps it was God that put the brick through Mather's window. And perhaps it was God, or nature, or any number of inexplicable forces that condemned nearly a 1,000 people to die from smallpox that year.
It was in this already fractured climate that Jenner began his own research. It's difficult to say whether or not Jenner was aware of opposition to inoculation, but he was certainly knowledgeable of the estimated 400,000 Europeans who died of the smallpox every year. Unlike variolation, Jenner's method relied on essentially injecting cowpox—a less virulent strain of smallpox carried by cows—into the human body, thus producing an immunity to smallpox.
Injection with cowpox could produce mild fever and rash, but it proved to be far safer and less debilitating than earlier inoculation methods. To say that Jenner's discovery was groundbreaking would be an understatement: His vaccine would fundamentally change scientific understanding of contagious disease, reclassifying suffering and even death from smallpox from nearly-inevitable to that old friend, "preventable."
Introduced at the end of the eighteenth century, Jenner's vaccine was met with a peculiar mix of wonder and distrust. Doctors and scientist immediately began re-testing and confirming his results, and by the early nineteenth century, Jenner's vaccine was available to the public.
The public, however, was less enthusiastic about a vaccination derived from a diseased cow. Rumors spread that the vaccination would quite literally transform one from human to bovine, or at least make cows spontaneously grow from the body. Smallpox scars might be unsightly, but certainly they were preferable to sharing your body with a farm animal.
James Gillray, The Cow-Pocks__or__the Wonderful Effects of the New Inoculation!, 1802. Image via Wiki Commons.
At the time, there existed no obligation to vaccinate in England. Physicians and health reformers encouraged vaccination and, in 1840, successfully convinced Parliament to make the shot free of charge. But the public continued to spin fears about the vaccine's effects, and in doing so, continued to catch smallpox. It became increasingly clear that simply suggesting vaccination to the public was not enough.
In 1853, those same reformers convinced lawmakers that "smallpox posed a serious danger to the national community," and Parliament responded by passing the Compulsory Vaccination Act of 1853. The law mandated that everyone must be vaccinated, and those who refused to vaccinate themselves or their children were fined every year until they did so.
This law seems simple, but it fundamentally changed the relationship between the state, the citizen, and medical decision-making. In essence, the act was the first continuous public-health project undertaken by the state, and it ushered in a new era in which healthcare and government intervention became inextricably linked. Even physicians worried about this seismic shift, one doctor wrote in medical journal The Lancet, the same journal that would over a century later publish Andrew Wakefield's discredited findings. Forced vaccination would be viewed as "an act of oppression and tyranny on the part of the vaccinator, and will convert the practitioner… into an agent of aggression."
This anonymous physician was, it seems, a bit of a prophet; his prediction foretold the birth of a well-organized, well-funded anti-vaccination movement.
In Victorian Britain, anti-vaccinators were prolific pamphlet writers, and their rhetoric will likely be familiar to the twenty-first-century reader. Their writing is filled with appeals to "common sense," to the "devoted parent," and to those smart enough to doubt the "laborious trifling… described as 'research.'" The writers of the pamphlets decry the unseen effects of vaccines, advocate for a cleaner environment, and point to the health of those who live an idyllic lifestyle, far from the toxic environs of the city.
Early anti-vaccinators, like today's anti-vaccinators, were a cohesive group only insofar as ideology was concerned: some were religious, while others were devotees of the burgeoning field of alternative medicine, while others were sanitarians, a group who believed that disease was the result of a toxic, polluted environment; while still others were merely skeptics of modern science or parents who believed vaccination would poison their children. But the motley crew had a singular goal: to repeal the Compulsory Vaccination Act.
Organized under the National Anti-Vaccination League, the anti-vaccinators were deeply effective. Founder William Tebb wrote numerous anti-vaccination books, almost all of which advocated a lifestyle of physical purity, alternative medicine, vegetarianism, a life free of the pollution and waste that littered major city streets. Tebb's position appealed to a middle class whose lives were increasingly affected by industrialization; his vision of a healthy, clean lifestyle must have seemed a welcome alternative to the realities that made forced vaccination a public health need. "Alternative medicine's language and its generalized theories of disease served a political purpose," historian Nadja Durbach notes, "for they were easy to understand and thus available to all."
Tebb didn't simply tap into an idyllic vision; like today's anti-vaccinators, he also, quite effectively, tapped into fear. In his 1881 book, Sanitation, not Vaccination the True Protection against Small-Pox maintained that vaccination led to the increase of cancers and leprosy. Tebb and his ilk also denied that contagious disease had a point of origin, that it could not be "caught, but must have begun." Tebb also founded the journal Vaccination Inquirer in 1879, and it was in those pages that the modern anti-vaccination movement would find both its enduring voice and themes. For example, distrust of the medical industry that might be financially vested in forced vaccination:
The vaccinators prove that of those who are attacked by small-pox, very few who have been vaccinated die, while the disease is generally fatal to those who have not been vaccinated. On the other hand, the anti-vaccinators contend that a very large number of children die by vaccination, and many suffer terrible diseases transmitted by the arm-to-arm process. Here is an issue that cannot be fairly settled by force. It cannot be settled solely by a profession pecuniarily interested in vaccination and much more constrained by the intolerance of medical orthodoxy.
An almost willful misunderstanding of how vaccination works:
Then, at the very least, the State is in this dilemma. Either Vaccination is a certain prophylactic, and then you don't need compulsion, because those only run a risk who neglect the operation, or it is not at all certain, then you have no right to enforce it on parents.
And the prioritization of parental decision-making over "untrustworthy" entities like medicine or the state:
To coerce parents into its practice [vaccination] rests upon that assumption of medical infallibility which has again and again been proved false.
Anti-vaccination postcard, 1879. Image via Creative Commons.
Anti-vaccinators were adept at deploying spectacle to radically effective means. Besides their endless pamphleteering, they distributed postcards, mailed letters and placed birth announcements in major newspapers for imaginary babies killed by vaccination, such announcements warned readers that vaccination would only "Welcome Early Death!"
They also had the force of celebrity. The great naturalist Alfred Russell Wallace—who, with Charles Darwin, was an early proponent of natural selection—wrote Vaccination a Delusion; Its Penal Enforcement a Crime: a book that was roundly discredited, but constantly cited by anti-vaccinators. More publicly, the anti-vaccination cause was taken up by playwright George Bernard Shaw, who gave impassioned speeches claiming that vaccination "is really nothing short of attempted murder."
Anti-vaccinators, lamented Ernest Hart, editor of the British Medical Journal, have "an extremely energetic system of distributing tracts, inflammatory postcards, grotesquely drawn envelopes, and other means of disseminating their views." He, and the anti-vaccinator's opponents, only had the boring stuff of science.
And the anti-vaccinators were very successful in their goals. The Compulsory Vaccination Act was revised in 1898 to grant conditional exemption to conscientious objectors. It was revised again in 1907, introducing a full conscience clause that allowed parents to obtain exemption. By 1908, an estimated 40,000 exemptions were obtained. The law, now without any teeth, was completely repealed when National Health was introduced in 1946.
Fold out color plate showing vaccination scars, 1803. Spanish. Image via Wellcome Images/Creative Commons.
The anti-vaccination movement that swept Great Britain was a blend of dissent, government distrust, and science skepticism. Those same themes appeared in the American anti-vaccination movement of the late nineteenth and early twentieth centuries—along with the powerful, historic force of American individualism. Though personal freedom was clearly meaningful to their British counterparts, American anti-vaccinators found a primary purpose in the preservation of the self from the tyrannical state.
While the United States had toyed with the idea of a federal vaccination act, the federal government never had either the power or will to pass and enforce such an act. Instead Congress passed and James Madison signed "An Act to Encourage Vaccination," which established the National Vaccine Agency and essentially regulated the mailing of smallpox material. Some states mandated vaccination, especially among schoolchildren, but the prevailing ideology was still that the federal government had no right to interfere with an individual's medical decisions. Vaccination, like most laws, was left to states and local municipalities.
But by the end of the nineteenth century, Americans became suspicious of even state laws that required vaccination. Between 1898 and 1904, America was in the midst of a smallpox epidemic, one that increasingly revealed a medically interconnected country for whom the jurisdiction of of state and local government was failing miserably. Contagious disease did not recognize state lines; the epidemic had begun in a West Virginia coal mine and in five years spread to California gold mines and through Manhattan.
What was striking about this particular outbreak was the shockingly low number of people that died, an estimate of 5,627 people. Historian Michael Willrich notes that "if it had been on track as previous outbreaks then roughly 50,000 Americans should have died." Jenner's vaccination was a small part of the reason the number was low, but the real reason was the mild strain behind the outbreak. Because the new strain of smallpox killed less than 1 percent of the people it infected, many refused to believe that it was smallpox at all. In the absence of disease-ridden bodies and overflowing morgues, many argued that vaccination was entirely unnecessary—and even harmful. Anti-vaccinators maintained that vaccination caused syphilis, cancers, and a variety of other unknown diseases.
As there always is, there was a grain of truth to some of the anti-vaccinators' claims. In both Great Britain and the United States, the turn-of-the-century government shied away from regulating the market and did little to ensure the production of safe vaccines. And there were a handful of cases where inoculation had caused syphilis—the first reportedly in 1814 through arm to arm transmission—although to believe the anti-vaccination literature would be to think that all batches were little more than disease-ridden Stygian pools. The delivery method could also produce "sore arms," a temporary condition that could leave someone bedridden for days or weeks: for those on the financial edge, a vaccine could mean the loss of much-needed money.
It was in this landscape—one populated with mild strains of smallpox, concerned mothers and disgruntled workers—that anti-vaccinators commanded the public, exploiting social and political tensions. Willrich argues that the roots of American anti-vaccination beliefs included everything from racial tension (white taxpayers had little interest in paying for vaccines to protect blacks), to religious freedom, to fear of "creeping state medicine"—factors that remain powerful today.
With no federal law to overturn, anti-vaccinators turned their attention toward court cases. and in 1905 found their way to the Supreme Court. Though the Court's decision in Jacobson v. Massachusetts reaffirmed the state's right to mandate vaccination, anti-vaccinators had laid a strong foundation for legal dissent in the realm of public health—so much so that Justice Oliver Wendell Holmes, Jr.—a champion of free speech—wrote in in a 1918 letter, "Free speech stands no differently than freedom from vaccination."
This same ideology, where refusing to vaccinate is part and parcel of individual freedom, is what operates when Rand Paul or Chris Christie demurs to the vague concepts of parental or personal choice when asked about mandatory vaccination. Paul's libertarianism (and Christie's pander) must, by its very nature, prioritize individual freedoms over collective good. Indeed, to even appeal to a "collective"—to suggest communal responsibility—chafes against a national belief system pinned on the desire of the individual.
But contagious disease knows no politics. Nor does it respect autonomy of the individual body. It seeks only to live—to multiply itself and to ravage even the bodies crying out for choice. Regardless of what William Tebb wrote in the nineteenth century, or what a strident mother writes on Facebook, or what Jenny McCarthy tweets, there are no toxins in vaccines that make them dangerous; there is only a very modern fear over the loss of absolute control over the self, over the family. Diet and lifestyle cannot repel disease. Natural immunity does not exist. These are all phantoms conjured up centuries ago.
At least, you could argue that anti-vaxxers of the nineteenth-century knew what contagious disease could do. They knew how it could ravage the population of an entire city. They were more explicitly choosing what they saw as the lesser of evils—smallpox was preferable to the poisonous needles of doctors or the intervention of the state into their domestic fortresses.
Now contagious disease is more abstract. It no longer kills entire families. And indeed, measles and whooping cough in particular seem to operate as somewhat of a fantasy for antivaxxers—the preventable disease, which is also "natural," is synonymized with "healthy" and "safe." Vaccines—man-made by untrustworthy scientists—must, therefore, be toxic or dangerous. But a time where nature was kind and benevolent can never be recaptured; it never existed. Like the Garden of Eden, a safe nature is a myth born of anxiety.
Let's return for a moment to the stock photographs of the unblemished babies that are becoming standard illustrations for today's measles outbreaks. The irony of these photographs is that, regardless of our views on vaccination, we all desperately want these images to be real—for every child to be healthy, to be unmarked, and to live to adulthood.
But two very divergent paths appear to lead to this end. One is paved with scientific testing, observation and a sense of communal necessity. The other is paved with denial about the body's inherent nature—potentially contaminated, as well as potentially contaminating—and a true belief that individual choice reigns supreme. History, the ghosts of old superstitions and mistrusts, still haunts both these paths, which cannot, by their nature, ever cross. They represent fundamentally different beliefs about the relationship between the self, society and government, and who is worthy of protection against whom.
Stassa Edwards is a freelance writer and editor.
Illustration by Jim Cooke.