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Negative attitudes toward vaccination are not a recent phenomenon. Medical and political leaders have had to respond to these attitudes for hundreds of years. The precursor to smallpox vaccination, variolation with smallpox inocula, was introduced from the Ottoman Empire into the United Kingdom by Lady Mary Montague in the first quarter of the eighteenth century.1 Within Europe and the New World, it quickly faced religious and philosophical objections suggesting variolation countered God’s will in determining who was sick and who was healthy. Pamphlets produced by political and religious leaders, such as Cotton Mather, were important in countering negative sentiments and popularizing the spread of variolation in the American colonies.2

The physician Edward Jenner developed the first vaccine in 1796, using a cowpox inoculum to protect against smallpox. Although this vaccination did not have the serious adverse effects associated with the smallpox inoculum,2 it was almost immediately followed by the establishment of antivaccination societies and misgivings about the vaccine. Figure 91-1 displays an exaggerated belief that the vaccine would turn vaccinees into cows. Many antivaccine advocates still relied on arguments grounded in religious and personal liberty.3 However, the U.S. Supreme Court affirmed in Jacobson vs. Massachusetts in 1905 that “upon the principle of self-defense, of paramount necessity, a community has the right to protect itself against an epidemic of disease which threatens the safety of its members.”3 The era of the government instituting vaccine mandates had begun.


James Gillray. 1802. The Cow Pock or the Wonderful Effects of the New Inoculation. (Source: Library of Congress Prints and Photographs Division [LC-DIG-ds-14062].)

The development of vaccines against diphtheria, tetanus, and pertussis (DTP) in the 1920s and 1930s4,5 and against polio in the 1950s, were seen as further milestones in the medical world. The roll out of these vaccines, however, was not entirely without incident. In one major vaccine production problem—the Cutter Incident of 1955—eight lots of polio vaccine were improperly inactivated, resulting in the paralysis of 196 individuals and 10 deaths.6 At the time, this incident did little to dampen enthusiasm for the vaccine. Many parents had seen polio first-hand or read extensive news about polio,7 and their concern about contracting the disease was greater than concerns about the safety of the vaccine.

By the time parents in high-income countries were making vaccination decisions for their children in the 1990s, they were already one or two generations removed from the most widespread lived experiences of vaccine-preventable disease. It was in this environment, in which people largely lacked first-hand experience with vaccine-preventable diseases, that Andrew Wakefield published a report in The Lancet linking measles-mumps-rubella (MMR) vaccination with neurodevelopmental issues, and, by implication, autism.8 Although problems with the report were immediately discovered, coauthors were slow to distance themselves from the ...

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