THE RIGHT TO VACCINATE
In 1901-2, a wave of smallpox
swept through the northeastern U.S., from which Boston suffered particularly. To
control the accelerating epidemic the Boston Health Department, among other
measures, instituted compulsory vaccination. Squads were dispatched to poorer
areas to vaccinate tenants in cheap
apartments and lodging houses. Many
received the vaccine against their will, as did many whose employers had
required it. Massachusetts law authorized compulsory vaccination when a city
deemed it appropriate, and refusal of vaccination carried a $5 fine. Exemptions
for schoolchildren, but not for adults, were obtainable with a physician’s
signature (often granted freely).
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| Smallpox victim, 4th day of eruption |
Close to 85% of
Boston inhabitants took the vaccine. Many refused, however, usually from fear
of side effects and complications. The newly formed Massachusetts
Anti-Compulsory Vaccine Society (MACVS), along with other anti-vaccination
groups, led the opposition. The MACVS, which included some physicians, contended
that compulsion constituted an infringement on personal liberty, though the
group understood the risk of smallpox.
Fears of side effects
were not without grounds. The vaccine didn’t always take, children with certain
skin disorders developed generalized vaccinia, vaccination sites developed
erysipelas, and stories circulated of deep ulcerating lesions at vaccination
sites. Most alarming were verified cases of tetanus after vaccination.
Vaccine manufacture
was not yet standardized. Jenner’s
original cowpox virus had been lost. New
vaccines, derived from cowpox or from smallpox inoculated into cattle whose
lymph was harvested, found acceptance. Preservation of vaccine lymph was another
problem. Person-to-person transfer of vaccine assured some purity but lost
favor after cases surfaced of syphilis transmission by that route. Lymph
directly from cows could carry bacterial contamination. Glycerin was tried as
an antiseptic and preservative, but it worked slowly and inactivated virus
along with bacteria. Use of dried lymph on ivory “points” could also carry
bacteria. And vaccination techniques varied from doctor to doctor. All these
variables contributed uncertainty to vaccination results.
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| Edward Jenner (unknown artist, Wikipedia) |
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| Ivory "points". Dry vaccine on the tips was scratched into the skin. (Wellcome Library) |
The epidemic had two
important consequences.
The first grew out of
fears of vaccination sequelae. Clusters of tetanus cases had emerged in Camden,
NJ and Philadelphia, with smaller numbers from other sites. Suspicion fell on
contaminated glycerinated vaccine, though full proof was lacking. The lymph was
usually harvested in a barn, a good source for tetanus contamination. When the
Massachusetts State Board of Health mentioned it might make its own vaccine the
larger manufacturers lobbied the U.S. government to introduce licensing
instead, to assure quality in established manufacturers (and keep them in
business). The result was passage by Congress of the Biologics Control Act in
1902, authorizing the Laboratory of Hygiene, part of the Public Health and
Marine Hospital Service (and later to become the NIH), to establish standards
and issue licenses to producers of biologics. This Act was the first step in
biologics regulation and was a forerunner to the 1906 Pure Food and Drug Act.
The second important
consequence of the epidemic was a legal one. Anti-vaccinationists sought a test
case to challenge the Massachusetts compulsory vaccination law. Reverend
Henning Jacobson, who had refused vaccination, was arrested and fined $5 and
appealed his case to the State Supreme Court. Jacobson was minister to the
Swedish Lutheran Church in Cambridge, a small congregation of 364 members. His
arguments centered on possible ill effects of the vaccine, and he sought
protection under the fourteenth amendment (prohibition against depriving a
citizen of life, liberty, or property without due process of law).
The State Supreme
Court held against Jacobson, arguing that the compulsion law was
constitutional, the result of deliberation by the legislature, and established
to protect the general public. Jacobson appealed his case to the U.S. Supreme
Court.
John Marshall Harlan
(born into a slaveholding family and later known for his defense of black civil
rights) wrote the 7-2 Supreme Court opinion. It too recognized that in the
public interest there
were necessary restrictions on individual freedom. The
Court declined to interfere with properly deliberated State legislation, but
did suggest that refusal of vaccination was allowed if the health of the
individual indicated a likelihood of harm. The Jacobson v Massachusetts decision, thinking of the public interest,
was cited later in upholding a Virginia law authorizing forced sterilization of
inmates of a State institution for mentally retarded, thus establishing the
basis for sterilization programs elsewhere.
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| John Marshall Harlan (Wikipedia) |
How relevant is the Jacobson v Massachusetts decision today?
There’s no space here for that, but it is discussed in the American J Public
Health, 2005, in the light of changes in the nature of infectious diseases and
civil rights legislation.
SOURCES:
Walloch,
Karen L. The Antivaccine Heresy.
2015. U of Rochester
Press.
McFarland,
Joseph. “Tetanus and Vaccination: A Study of 95
Cases of the Complication. Lancet, 1902,
Sept 13, pp 730-5
Willson,
Robert N. “An Analysis of 52 Cases of Tetanus
FollowingVaccinia,
with Reference to the Source of Infection”.
JAMA
1902; 19:1222-31.
American J Pub Health 2005, 95(4); 571-590. (3
articles on the
historyand
significance of Jacobson v Massachusetts)
Liebenau,
Jonathan. Medical Science and Medical
Industry: The
Formation of the American
Pharmaceutical Industry. 1987. J
Hopkins U Press.
(covers relation of tetanus to contaminated
vaccine, and 1902 Act)
