Vaccine mandates are not new to American history. From smallpox to COVID, here's what public health learned

COVID-19 vaccine mandates are becoming a reality throughout the U.S. in states that set deadlines for residents to get their shots.

All Washington, D.C., health workers had to have their first dose by Thursday, and schoolteachers, staff and early-child care workers must be fully vaccinated by Nov. 1. In California, teachers and school employees, including custodians, aides and bus drivers, must get vaccinated by Oct. 15 or face weekly testing.

In New York, tens of thousands of health care workers at hospitals and nursing homes were required to get vaccinated by Monday or risk losing their jobs.

The mandates, which followed President Joe Biden's decision to require all federal employees get the shot, are divisive. Even as some states enact them, others have banned them. But government-required vaccination – and the backlash against it – is not new to American history.

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“Vaccine mandates have been around since as long as we had vaccines,” said Tegan Kehoe, a medical historian and museum professional at Paul S. Russell Museum of Medical History.

Smallpox vaccine: Early 1900s

Gen. George Washington was one of the first leaders to introduce mandates to the U.S. when he required his troops to get inoculated during the Revolutionary War, fearing the army would be decimated by smallpox, said Evan Hart, assistant professor of history at Missouri Western State University.

Although there was initial pushback, it set a precedent for inoculations to become the norm in the armed forces.

“The military has required vaccines of troops since we’ve had a military,” she said. “If you’re going into the military, there’s kind of an expectation that there’s a lot of control that you’re giving up … when you’re in the military, you were going to get some shots.”

The general American public was more resistant in the early 1900s, when smallpox outbreaks began popping up, said Michael Willrich, a professor of history at Brandeis University and author of “Pox: An American History.”

“Cities like New York, Philadelphia, Boston and New Orleans had pretty serious outbreaks of classic, very deadly smallpox that historically had killed 25 to 30% of people infected,” he said. “Other communities were dealing with a much milder form of smallpox that was becoming newly documented in the medical literature at the time … this affected the politics of vaccination.” 

Although public health officials wanted to get everyone vaccinated, many people were unconvinced smallpox was a dangerous disease. Officials began relying on vaccine mandates to ensure the public was protected against smallpox.

Mandates differed by state, much like today, creating a confusing patchwork of public health regulations. States that mandated vaccines were backed by a 1905 Supreme Court decision in Jacobson v. Massachusetts.

“That means courts were very ready to uphold public health measures that were passed by local boards of health,” Hart said. “Compulsory vaccination became a really powerful tool for the government when dealing with smallpox.”

With this newfound authority, public health officials, armed with law enforcement, went door to door forcing smallpox inoculations. Some of them showed up “uninvited and without warning” in “over-the-top garish protective gear,” with gauze wrapped around their mouth and nose, Kehoe said.

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“Even though there wasn’t coercion of the physical sense, there was a huge power imbalance and that was a big part of sowing distrust,” she said.

Health education efforts that began in the early 20th century sought to reduce vaccine hesitancy and resistance but it wasn’t very effective.

“There were instances when education looked like bullying and condescension,” Kehoe said. “Public health officials blamed vaccine resistance on the ‘ignorance of the people’ based on racism and classism.”

Polio vaccine: 1950s 

Cases of polio peaked in the early 1950s, but it arrived every summer, disabling on average more than 35,000 people a year for decades, sometimes causing paralysis and death, according to the Centers for Disease Control and Prevention.

Public officials closed swimming pools, movie theaters, amusement parks and other places associated with summer vacation.

The highly infectious disease spread through contact with infected feces, often when children didn’t wash their hands correctly, according to the University of Rochester Medical Center.

The polio vaccine, created by Dr. Jonas Salk at the University of Pittsburgh, was proven safe and effective in 1954 after the largest clinical trial in the nation’s history, which included about 1.8 million children.

Although millions of children were inoculated in schools, recreation centers and hospitals, public health officials never made the vaccine mandatory.

“What public health officials found is that they didn’t have to mandate it because parents were so scared of polio that they were just vaccinating their kids,” Hart said.

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Persons handling international travelers at Pier 88 in New York City are shown Jan. 12, 1962, inoculating disembarking passengers against smallpox, after the arrival of the north German liner Bremen.

Parents saw frightening images of paralyzed children in iron lungs and were eager to get their own kids vaccinated, even before the trials found it was safe and effective.

Experts say a national vaccination campaign helped convince parents who were hesitant at first. The National Foundation for Infantile Paralysis – now called the March of Dimes – enlisted the help of some of the most famous celebrities at the time such as Lucille Ball, Desi Arnaz, Marilyn Monroe, Louis Armstrong, Grace Kelly and Elvis Presley.

“Public health has known for a long time that they can’t do the job all by themselves, they have to work with other people,” Kehoe said. “The vaccines for polio were a huge benefit to vaccines’ public image.”

Childhood vaccines: 1970s

By the 1970s, efforts to eradicate smallpox were largely successful and the vaccine was no longer recommended for use after 1972. The polio vaccine cut cases of paralysis from about 15,000 in the 1950s to about 10 by the 1970s, according to the CDC. 

But public health faced new challenges as other childhood vaccines became required to enter school. 

In 1977, the federal government announced the Childhood Immunization Initiative, aiming to increase vaccination rates in children against seven diseases: diphtheria, tetanus, pertussis, measles, mumps, rubella and polio.

Even though the polio vaccine was already widely accepted, parents began pushing back on other vaccines as anti-vaccine movements took hold.

The government didn't have to mandate the polio vaccine because polio was seen as a very serious disease, Hart said. The same was not true for others.

"The concern by parents was to why the government was mandating a vaccine that in their mind are (for diseases) that aren't particular serious," she said.

This idea gained momentum as other social movements – advocating for women’s health, patients’ rights and consumers’ rights – began emerging in the U.S.

“All of those movements are kind of questioning whether the government always has our best interest,” Hart said. “Parents have been kind of trained by some of these social movements to question, ‘Well, what’s in the vaccines? What are you giving my child?’”

Some people claimed childhood vaccinations would cause Guillain-Barré syndrome – a rare disorder where the body’s immune system damages nerve – after a batch of swine flu vaccines were linked to increased reports in 1976, Kehoe said. Such misinformation was amplified through modern media.

“It was a lot of people adding two and two and getting five,” she said. “And so that’s where education really comes in … The government needed to convey to people that they were taking all the necessary measures to make sure that the vaccines are safe.”

COVID-19 vaccine: Today

As public health education improved, more parents accepted childhood vaccinations as a natural part of a child’s life before entering school.

States revamped immunization laws, making them more consistent throughout the country, said James Colgrove, professor of sociomedical sciences at Columbia Mailman School of Public Health and author of “State of Immunity: The Politics of Vaccination in the Twentieth-Century.”

“Pre-COVID, the momentum in states seemed to be in favor of making vaccination laws more strict,” he said. “Five years ago, I might have said we were going to go in that direction, but now, COVID has thrown all of that into question.”

Public health officials face many of the same challenges seen in previous disease outbreaks and immunization initiatives – fear, distrust and misinformation – but they're now confronted with politicization, too.

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COVID-19 vaccine acceptance is sharply divided by party lines. As of Sept. 13, 52.8% of people in counties that voted for Biden in the 2020 election were fully vaccinated, compared with 39.9% people in counties that voted for Donald Trump, according to a Kaiser Family Foundation analysis.

This is uncharted territory, Colgrove said, and public health officials are still figuring out how to overcome this hurdle.

“The sharp mapping of vaccination attitudes onto party affiliation is really new,” he said. “It has become a matter of identity at this point and we know from psychological research that those beliefs get very hard to change.”

Follow Adrianna Rodriguez on Twitter: @AdriannaUSAT. 

Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.