As recently as 20 years ago, measles was listed by the World Health Organization as one of the five leading causes of death in the world. But by 2000, the disease was declared “eliminated” in the U.S., largely credited to the success of statewide public health campaigns to make the MMR (measles, mumps, rubella) vaccine mandatory for children enrolling in public schools.

Since then, however, the number of parents requesting religious or philosophical exemptions to state rules has gone up, as have reported measles cases. In 2014, the CDC reported the highest number of cases in over a decade: 644 in 27 states, including one outbreak in an Amish community in rural Ohio infecting more than 300 people.

Not surprisingly, rates have increased fastest in states with the most lenient vaccination exemption rules. All but two states (Mississippi and West Virginia) allow for religious exemptions, and 19 states — California included — permit parents to opt out of vaccinating their children on personal or philosophical grounds. Many parents who do so, say they doubt the effectiveness of the vaccine or have concerns that it may cause autism or other major health problems, even as no medical evidence actually supports these theories.

So why this recent outbreak in anti-vaccination sentiment?

It's actually nothing new: anti-vaccination movements have a robust, storied history. Intermittent backlashes against compulsory government vaccination campaigns have arisen ever since the first series of inoculations were given more than 200 years ago.

Perhaps most interesting is the striking cultural similarities and motives of today's prototypical "anti-vaxxers" and their 19th Century forebears: both have been typically portrayed as affluent, well-educated and politically progressive, driven by strong distrust in the safety of vaccines and intensely protective of civil liberties and personal choice.

The First Vaccine Revolution

If you know little or care less about smallpox, Edward Jenner's the man to thank for that.

Among the most gruesome and deadly diseases in human history, smallpox terrorized the world for centuries, ravaging entire societies during its sporadic outbreaks and claiming millions of lives, particularly those of young children. Highly infectious, smallpox typically covers the skin in large oozing, pus-filled bumps.

In 1796, Jenner, a rural British physician, tested a locally shared theory that milkmaids who contracted cowpox were immune from smallpox. Similar to smallpox but far less severe, cowpox is generally found in animals, and can be transmitted to human handlers. Jenner extracted pus from a cowpox scab and inserted it into an incision on the arm of an eight-year-old boy. Although the child contracted a mild virus, he recovered quickly, developing antibodies that built up his immunity to both cowpox and smallpox.

[Source: Nuffield Dept. of Medicine, University of Oxford]

Jenner subsequently coined the term "vaccine," from "vacca," Latin for cow.

Although initially rejected by the British medical establishment, Jenner's findings were eventually published after subsequent successful trials, and the field of modern immunology was born. The discovery paved the way for vaccine breakthroughs over the next two centuries, including inoculations for polio, tetanus, influenza, rabies, diphtheria and, yes, measles.

The smallpox vaccine and its later iterations proved so successful that the World Health Organization in 1980 declared smallpox the first disease to be eradicated as a result of global vaccination efforts. To date, there is no cure or treatment for the disease; vaccination is the only means of prevention.

[Source: World Health Organization]

Birth of the Anti-Vaccination Movement

Protection from one of the most feared, miserable ailments in human history: who wouldn't raise a (sterilized) glass to that?

1887 illustration from an anti-vaccination flier. Included in the text: "This monster has been named vaccination; and his progressive havoc among the human race, has been dreadful and most alarming." — An illustration from an 1807 anti-vaccination flier. Included in the text: "This monster has been named vaccination; and his progressive havoc among the human race, has been dreadful and most alarming." (Courtesy of National Institutes of Health)

Turns out, lots of folks. As word of the procedure spread, Jenner was ridiculed by a host of angry critics, particularly members of the clergy, who charged that the idea of inoculating someone with pus from a diseased animal was not only revolting but blasphemous. Rumors abounded of vaccinated patients contracting bovine diseases and suffering grotesque reactions. Enough evidence, however, demonstrated the obvious advantages of the vaccination, and the procedure soon became widespread.

By the mid-1800s, in the wake of several smallpox outbreaks, the United Kingdom enacted a set of laws making vaccinations compulsory, initially for infants, but eventually for all children up to 14 years old. Cumulative penalties were imposed on violators.

The measures were met with staunch resistance and incited a series of riots. The unrest prompted the creation of the Anti-Compulsory Vaccination League in 1867, whose founders were primarily concerned with what they considered a blatant infringement of personal choice and liberty.

Notice of a demonstration at Andover Town Hall (England) in support of an anti-vaxxer on her release from imprisonment for refusing to allow her children to be vaccinated (date unknown). (Courtesy of MicroBiology Today). — Notice of a demonstration at Andover Town Hall (England); date unknown. (Courtesy of MicroBiology Today).

The group's seven-point mission statement, printed on the masthead of its newsletter, included the following pronouncement:

"As parliament, instead of guarding the liberty of the subject, has invaded this liberty by rendering good health a crime, punishable by fine or imprisonment, inflicted on dutiful parents, parliament is deserving of public condemnation."

By the 1870s and 1880s, even as smallpox vaccination techniques were rapidly advancing and helping to contain the disease's spread, anti-vaccination campaigns gained increased momentum in the U.K. and beyond. As propaganda literature proliferated and leaders of the movement adeptly tapped into the public's understandable anxieties about the still nascent procedure. some efforts were successful in temporarily lowering vaccination rates.

One of the largest demonstrations, in Leicester, England in 1885, drew upwards of 100,000 people, with props including a child's coffin and an effigy of Jenner.

An artist's depiction of the 1885 anti-vaccine demonstration in Leicester. (Courtesy of Immunize USA).

The rally prompted a government commission to investigate the protesters' grievances, which eventually concluded that the vaccine was safe and effective but, in a political move to pacify detractors, also recommended the abolition of penalties for violators. In 1898, the passage of a new national vaccination act removed penalties and included a "conscientious objector" clause, which allowed parents concerned with the safety of vaccinations to apply for an exemption certificate.

[Source: National Institutes of Health]

Anti-vaccination fever spreads to the U.S.

In the late 1800s, a series of smallpox outbreaks in the U.S. prompted local government vaccine campaigns and subsequent anti-vaccine advocacy, including a visit from prominent British anti-vaccinationist William Tebb. By 1879, the Anti-Vaccination Society of America was established, followed by the emergence of several local leagues, including the New England Anti Compulsory Vaccination League and the Anti-Vaccination League of New York City. A second national league was formed in the early 1900s. Activists waged court battles to repeal vaccination laws in a number of states, including California, Illinois and Wisconsin.

"Vaccination is the putting of an impure thing into the blood - a virus or poison -- often resulting in serious evil effects. In vogue for more than one hundred years, it has been received by most persons without question. Yet the time is passing when people will accept a medical dogma on blind faith."

-- From "The Fallacy of Vaccination," a 1911 essay by John Pitcairn, Jr., prominent Pennsylvania industrialist and president of the Anti-Vaccination League of America.

Inflaming tensions and helping to further cast vaccination campaigns as an affront to civil liberties, public health officials commonly resorted to heavy-handed, uneven enforcement tactics, often vaccinating immigrants and minorities against their will during outbreaks, notes University of Georgia history professor Stephen Mihm.

Fears were also legitimately stoked by the lack of oversight of vaccine production, which was primarily controlled by private industry and at times resulted in questionable product. In one of the worst incidents, nine children in Camden, New Jersey died after being inoculated with a batch of tetanus-contaminated smallpox vaccine. News of the tragedy prompted Congress to pass the Biologics Control Act of 1902, which required increased government oversight of the manufacturing process.

Following a smallpox outbreak in 1902, the city of Cambridge, Mass. mandated vaccinations for all residents. After one man refused to comply on the grounds that the law violated his right to care for himself, the city filed criminal charges against him. The case -- Jacobson v. Massachusetts - made its way in 1905 to the U.S. Supreme Court, which sided with the state. In its decision, the court ruled it within the power of the state to enact mandatory vaccine laws in order to protect the public in the event of a communicable disease. The decision marked the first Supreme Court case weighing in on state power in enacting public health law.

[Source: History of Vaccines, College of Physicians of Philadelphia]

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