Vaccinated America is frustrated with the unvaccinated. Stories regularly go viral about covid-19 patients sending messages of regret and contrition about their vaccination hesitancy. Accounts also come from burned-out health-care workers, remorseful loved ones, even funeral directors and embalmers — all desperately, even angrily, begging the vaccine-skeptical to reconsider.
A prominent subset of stories and social media chatter is specifically focused on the sufferings of anti-maskers, anti-vaxxers, QAnon influencers, conservative politicians and numerous right-wing talk radio personalities (some notorious for having celebrated AIDS deaths). Many of these discussions adopt a tone that goes beyond the feeling of schadenfreude. They seem to ask: What if the unvaccinated cannot be persuaded? Will hospitalizations and deaths accomplish what reasoning, encouraging, pleading, bribing, shaming and mandating cannot?
These and other questions demand urgent reflection, since policymakers and health providers are confronting distressing choices around crisis standards of care. How might pent-up frustration and anger influence assessments for medical rationing? What are the ethics of expecting the disease itself to sway the vaccine holdouts?
SARS-CoV-2 may be a novel virus, but these quandaries, including frustration at the stubbornly unvaccinated, are not new. Vaccine resisters in the 19th century significantly stymied public health efforts, and the anger felt by health officials shaped their responses — not always for the best.
When Victorians talked about vaccination they meant immunization for smallpox, a deadly and often disfiguring viral disease. Britain introduced compulsory infant vaccination in 1853, significantly suppressing the prevalence and visibility of smallpox.
But anti-vaccination then exploded as a movement, churning out popular literature that challenged vaccine efficacy and warned of injuries to children. Fueled by resentment toward the fines and jail sentences used to compel compliance, Victorian anti-vaccine sentiment took hold in clusters in places such as the English towns of Leicester, Gloucester and Keighley.
The doggedness of anti-vaccine fervor frustrated vaccine proponents, who worried that it raised the threat of epidemics. A key figure was John C. McVail, health officer for the Scottish town of Kilmarnock. His 1887 “Vaccination Vindicated” provided a meticulous response to the claims of the leading vaccine opponents, delivered in a snarky style not unlike some social media posts today. McVail recognized the difference between anti-vaccine ideologues and the merely vaccine-hesitant, but above all he was worn down by the sheer magnitude of misinformation he had to repeatedly debunk.
Despite McVail’s confidence in the evidence for vaccination, his book had a surprisingly pessimistic conclusion: It was useless to argue with the typical vaccination skeptic, and perhaps the only option was to await the real-world consequences of vaccine resistance. “When the catastrophe does come,” McVail warned, the government should be ready to publicize smallpox’s high toll on the unvaccinated.
This sort of fatalistic attitude grew common among British doctors who watched nonvaccination rates climb in the 1890s. “If ever a disease may be said to punish the guilty,” one declared, “smallpox is that disease.” Some criticized the high cost of caring for unvaccinated victims and questioned why the vaccinated majority had to foot the bill. Others advocated socially shunning the defiantly unvaccinated and the politicians who seemed to support them.
Upping the ante, McVail threw down a challenge: Send a group of vaccinated doctors and anti-vaccine activists to mingle with patients in a smallpox isolation ward. People unable to understand statistics, he wrote, “might perhaps be convinced of the advantages of vaccination if they could see for themselves the different results.” The Canadian doctor Sir William Osler envisioned a similar test and grimly vowed to arrange for the funerals of the unvaccinated participants he expected would die as a result.
It seems no doctor undertook such a trial, but many expected that immediate experience with smallpox, brought on by falling vaccination rates, would teach the same lesson.
During an 1892 smallpox outbreak in Halifax, the local health officer reported that it was no longer difficult to enforce vaccination. Owing to the horrific sight of badly disfigured children, whole families came to him with their sleeves already rolled up. “Smallpox has persuaded them without me,” he testified.
When a severe smallpox epidemic in 1896 killed more than 400 people in poorly vaccinated Gloucester, the local health board tried to put a silver lining on the tragedy, reporting that three times as many residents were induced to be vaccinated during the epidemic than in the previous decade.
In an editorial published in the British Medical Journal, McVail reflected on how these flare-ups provided useful “object lessons” to the public. The “man in the street” normally thought little about smallpox or vaccination; he “does not read much history, and when he does start to it he tackles the French Revolution or the Battle of Waterloo, so that his knowledge of what smallpox used to be remains practically nil.” It was preferable that he be properly instructed in the value of vaccination, McVail wrote, but given the malicious influence of anti-vaccine activists, this “man in the street” might need to have his “ignorance of history atoned for by latter-day knowledge.”
If not epidemics, then perhaps gruesome photographs of smallpox victims would help refamiliarize people with the disease. Physician Jay Frank Schamberg of the Municipal Hospital of Philadelphia preferred side-by side views of vaccinated and unvaccinated patients, reproduced widely in American and British health literature. The Leicester health officer carried around with him photographs of his vaccinated wife and two young children sitting next to a horribly affected patient in the local smallpox hospital. For persuading the unvaccinated, he felt these were more useful than any lecture or statistic.
Vaccination advocates leaned on fear-based tactics because the government was unwilling to enforce universal vaccination. In fact, a new law in 1898 further eased mandates. The Scottish surgeon Joseph Bell (real-life inspiration for Arthur Conan Doyle’s fictional Sherlock Holmes) feared that the legislation would allow anti-vaccine activists to go on preparing a “terrific experiment in murder,” but he thought it “may be needed to open the stupid eyes of men apparently impervious to reason or argument.” Another doctor wrote that “a few more wholesome epidemics” might be the only thing to change minds.
McVail ultimately disagreed with this type of spiteful noninterference. “Natural laws work slowly,” he cautioned, “and it is not always the custom of the gods to cause the lightening to descend forthwith on the man who openly defies them.” Moreover, it was frankly unethical not to do everything possible to avert infections and suffering.
Besides, the belief that disease itself significantly or lastingly altered opinions on vaccination was mostly wishful thinking. The notoriously anti-vaccine town of Leicester suffered a smallpox surge in 1892, but opposition to the procedure remained firm there. Although people in Gloucester had embraced vaccination during the epidemic, just months later they voted heavily for anti-vaccination politicians. And in 1901, the worst smallpox outbreak in London in two decades bolstered anti-vaccination sentiment, with continued declines in immunization rates.
A few years later, Parliament further weakened vaccination rules, and health officials nationwide were vocally disappointed when this was not immediately followed by devastating smallpox outbreaks.
The problem continued to be that there were few civil-society or governmental efforts to publicly explain what the vaccine was, how it worked and why it was important. Instead, the condescending tone of McVail and his peers did the opposite of engendering trust. Then, as now, vaccine hesitancy was more tied to cultural and political factors than to ignorance of science or inexperience with disease.
If any disease should have terrified people into getting vaccinated, it was smallpox. Yet there was no clear relationship between fear and vaccine-readiness; thinking otherwise might be little more than a reflection of the exasperation and annoyance felt by vaccination advocates.
At least 1 in 500 Americans have died of covid-19 so far. Since the rollout of the new vaccines, the virus’s impact has fallen disproportionately on the unvaccinated, yet hesitancy and resistance in a core group remain tenacious. It is quite possible that as the acute phase of the delta variant eases, vaccine reluctance and opposition to mandates will rise further, in turn permitting continued spread. That dynamic might be terribly frustrating, but history shows it should not tempt us into thinking that disease ought to work out its own lesson.