History of Medicine

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

Smallpox victim, 4th day of eruption

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).

     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

Edward Jenner (unknown artist, Wikipedia)

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

Ivory "points". Dry vaccine on the tips was scratched into
the skin. (Wellcome Library)

bacteria. And vaccination techniques varied from doctor to doctor. All these variables contributed uncertainty to vaccination results.

     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

John Marshall Harlan (Wikipedia)

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.

     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)