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American Journal of Public Health logoLink to American Journal of Public Health
. 2018 Jun;108(6):741–747. doi: 10.2105/AJPH.2018.304348

Mistrust in Medicine: The Rise and Fall of America’s First Vaccine Institute

Tess Lanzarotta 1,, Marco A Ramos 1
PMCID: PMC5944868  PMID: 29741934

Abstract

In 1813, the American government passed An Act to Encourage Vaccination, the first federal endorsement of a medical practice in American history. The law tasked a federal agent with maintaining a supply of the smallpox vaccine and distributing it nationwide. James Smith, a well-respected physician and proponent of vaccination, was appointed as vaccine agent. Smith was skeptical of claims that only well-trained physicians should be allowed to perform vaccination; he felt it was a simple procedure that should be available to all American citizens. In 1822, he made a tragic error that caused several deaths and left him vulnerable to criticism from political opponents and his medical peers. This ended Smith’s professional career and led to the repeal of the act itself. In this article, we use the rise and fall of James Smith to provide a historical perspective on contemporary debates surrounding delayed vaccination schedules. We explain how physicians—in the 19th century and today—have worked to build public trust in vaccination in an American culture suspicious of medical expertise.


In The Vaccine Book: Making the Right Decision for Your Child, Robert Sears proposes two vaccination schedules that depart from the guidelines endorsed by the American Academy of Pediatrics and the Centers for Disease Control and Prevention.1 These “alternative” schedules spread out or delay the administration of vaccines to children. They have enjoyed wide attention and support from parents who fear the risks of frequent vaccinations in the first few years of their child’s life.2 The medical community, however, has heavily criticized Sears’ approach to vaccination. Prominent physicians have argued that alternative vaccination schedules endanger public health3 and have implicated Sears in recent disease outbreaks, including the 2015 measles outbreak at the Disneyland Resort in Anaheim that prompted the passing of a California bill eliminating vaccine exemptions on personal and religious grounds.4 Others have called Sears a “quack,”5 questioned the (lack of) evidence and research behind alternative vaccine schedules, and defended the science that supports the safety and efficacy of official guidelines.6 Most recently, in September 2016, the Medical Board of California accused Sears of “gross negligence” for prescribing no vaccines for a two-year-old child without adequately examining the patient’s medical history. If Sears is found guilty of negligence, he may lose his medical license.7

Although the mainstream medical community has largely rejected Sears’ delayed vaccination schedule, large studies have shown that the majority of children in the United States are not currently vaccinated on schedule and that parents who delay or refuse vaccine doses are more likely to have vaccine safety concerns.8 To understand the appeal of delayed vaccination for parents today, it is important to situate Sears within the context of an American public that, since the 1970s, has become increasingly skeptical of medical experts. As historian Elena Conis points out in her recent book Vaccine Nation: America’s Changing Relationship With Immunization, current concerns about vaccine safety are a minor theme in a longer story of mounting mistrust of the medical profession. The patient rights movement, for example, demanded informed consent for medical procedures, including vaccination, in the early 1970s, and criticized ethical abuses in medical research that violated patients’ trust. Contemporary consumer movements have similarly called for a voice in national health care policy in the name of consumer protection.9 Mistrust surrounding vaccination, then, is more than mistrust of the technology of vaccines themselves. Vaccination implicates an entire community of medical professionals whose legitimacy is being called into question—compelling physicians like Paul Offit to plead for “people [to] trust their experts” during a recent 60 Minutes episode on vaccine safety.10 In this context, Sears’ delayed vaccination schedule offers a provocative middle ground between official guidelines and the outright rejection of vaccination that animates the “anti-vaxxer” movement today. Although his delayed schedule endorses the efficacy of vaccines as a technology, it also acknowledges, at least implicitly, the validity of growing mistrust of medical authority in American society and provides an option—misguided or not—for patients and parents who desire increased autonomy in their health care.

graphic file with name AJPH.2018.304348f1.jpg

An Address to Mothers, From James Smith’s Vaccine Institute.

Source. This reprint is from an image that originally appeared as part of ProQuestâ American Periodicals product. Reprinted with permission from digital images produced by ProQuest LLC.

In this article, we turn to the 19th century and the figure of James Smith, the first and only federal vaccine agent in American history, to explore how physicians have struggled—then and now—to establish trust in vaccination in a culture suspicious of medical experts. Smith was eventually deposed from his position and ostracized by his peers, largely for calling into question physicians’ singular authority to determine who should be able to vaccinate. Smith had criticized doctors’ “vain” (conceited, not futile) attempts to establish exclusive control over the practice of vaccination, and argued instead that vaccination should be freely available to the public.11 “Any intelligent citizen,” he had claimed, could learn to perform vaccination.12 Smith’s efforts to “democratize” the practice of vaccination tapped into public mistrust of medical authority—much like Sears’ delayed vaccination schedule does today—and chafed an emerging community of elite physicians. Rather than sharing Smith’s desire to expand access to vaccination, elite practitioners wanted exclusive authority over this new technology.

We draw parallels between Smith and Sears. In both cases, concerns about vaccine safety were and are inseparable from questions of professional legitimacy. Physicians’ appeals to vaccine safety in the early 19th century reflected and reinforced the idea that the elite medical community should be in charge of vaccination, to the benefit of their professional status and economic interests. Their insistence on singular control over this new technology stemmed from concerns about the safety of allowing untrained practitioners to administer vaccines, as well as the recognition that vaccination provided an opportunity to augment their authority in a competitive medical marketplace.

THE RISE OF THE VACCINE INSTITUTE

On April 10, 1822, physician James Smith, from Baltimore, Maryland, received a letter informing him that President James Monroe had dismissed him from his position as the United States’ vaccine agent.13 This news probably came as little surprise to Smith. Two months earlier, he had accidentally sent smallpox scabs to Tarboro, North Carolina, instead of cowpox, the bovine virus used as a vaccine against smallpox. Under the 1813 Act to Encourage Vaccination, Smith had been maintaining a supply of vaccine matter, which he distributed through the mail to facilitate vaccination across the country. Smith’s error resulted in 10 deaths in Tarboro and irreparably damaged his professional reputation.14

After Smith’s dismissal, a debate arose in Congress over whether the Act to Encourage Vaccination should be repealed. Few in Congress would admit to doubting the efficacy of vaccination. One representative even pleaded with his colleagues to “pause and reflect, before they decide under the excited feelings of a moment, to lessen public confidence in the efficiency of a remedy against the greatest scourge which was ever visited upon the human family.”15 Despite such protestations, Congress voted to repeal the act on April 29, 1822, marking the end of the first American experiment into federal promotion of vaccination. As we discuss in the next sections, Smith’s dismissal and the repeal of the act seem, at first glance, to be solely the result of Smith’s tragic error. However, we argue that his dismissal also reflected the professional and economic significance of vaccination for elite physicians in the 19th century.

Smith was a member of the well-educated medical elite. In the early 19th century, the American medical marketplace was characterized by a diverse range of practitioners with various levels and forms of education and training. However, some physicians, particularly those who had attended medical school in the United States or abroad, actively attempted to distinguish themselves as elites by disparaging their competitors, who had merely apprenticed or forgone training altogether.16 In an effort to create firmer professional boundaries that excluded the unqualified and recommended the elite, these educated physicians had successfully pushed for licensing legislation and formed state medical societies.17

Smith had attended medical school classes at the University of Pennsylvania, studying under Benjamin Rush.18 He began vaccinating in Baltimore in 1801, and other local doctors and politicians applauded his efforts.19 For instance, the mayor of Baltimore publically expressed his support for Smith’s work and for the “liberal and humane views therein contained.”20 The state of Maryland appointed him director of their Vaccine Institute in 1809, a program that, at least temporarily, led to the eradication of smallpox in Maryland.21 Vaccine institutes usually consisted of a single individual tasked with preserving and transporting vaccine matter. Despite their small scale, these establishments tied the physicians who ran them to local and state governments, granting them some measure of authority through political endorsement.

The cowpox virus used to generate the vaccine was relatively rare, and efforts to inoculate American cows with the virus had consistently failed, which left American vaccinators dependent on English suppliers or the generosity of their better-connected colleagues. To send vaccine matter to America, English physicians sent dried cowpox lymph pressed between plates of glass.22 Once they had a supply of vaccine, physicians then switched to arm-to-arm vaccination, which involved scraping fluid from the cowpox lesion of one patient and applying it to an incision in the arm of another patient, leaving physicians reliant on their patients’ bodies to store their vaccine supply. If patients returned at the wrong time, or not at all, physicians could apply for fresh vaccine matter from a vaccine institute and begin vaccinating again immediately.23

In 1809, early in James Madison’s presidential term, Smith wrote to him suggesting the creation of a vaccine institute at the federal level. Smith, whose efforts to distribute the vaccine in Maryland had been so successful, was the logical choice to serve as vaccine agent. In his new role, Smith would send vaccine matter and instructions to applicants who paid a small fee. However, he also took responsibility for encouraging vaccination. This meant not only enabling physicians to consistently practice vaccination but also ensuring that the general population trusted the practice. Smith was cognizant of this additional responsibility. When he first wrote to Madison, Smith suggested that smallpox might be entirely eradicated within the United States, “if the Confidence of the people can be preserved, and sufficient attention is paid, to keep up a free, and general distribution of the vaccine Matter among them.”24 Maintaining the public’s trust in vaccination, Smith knew, was as important as maintaining a vaccine supply; one could not survive without the other.

graphic file with name AJPH.2018.304348f2.jpg

An Address to Fathers, From James Smith’s Vaccine Institute.

Source. This reprint is from an image that originally appeared as part of ProQuestâ American Periodicals product. Reprinted with permission from digital images produced by ProQuest LLC.

In early national America, newspapers played a prominent role in reporting on and generating political culture by publishing congressional debates and notifications of new legislation.25 Unsurprisingly, then, newspapers nationwide reported on the creation of the vaccine distribution service and the naming of Smith as vaccine agent.26 Newspaper editors, powerful figures in shaping popular opinion, reported favorably on the widespread adoption of vaccination as a sign that a nation’s citizens were liberal-minded and enlightened. Media reports expressed particular admiration for European nations that offered free vaccination, even praising those that enforced compulsory vaccination, a measure thought too extreme for the American federal government to undertake.27 Physicians, Smith included, used similar language and insisted that vaccination was a sign of political and cultural progress.28

In addition to newspaper articles, the Vaccine Institute sponsored poetry that tied vaccination to the values and responsibilities of American families. For example, the poem “An Address to Mothers” played on mothers’ love of and concern for their children. Lines such as “And wilt thou through neglect expose/The lovely child to future woes?” made a child’s vaccination a matter of maternal duty.29 A similar poem addressed to fathers positioned vaccination as the solution to parental anxiety concerning the loss of a child to smallpox.30 Such fears would have been very much on the minds of American parents in the early 19th century, when most would have known someone whose child had died from the disease. “Thou shalt feel thy spirits cheer,” the poem read, “for vaccination saves the child!” Interestingly, the poem directed fathers not to seek out vaccination for their children themselves, but rather to “urge then each mother to embrace [vaccination]/Urge them to save the human race.”31 Both of these poems made clear that the responsibility for sparing children from smallpox rested on the shoulders of mothers, whose children would “thank a mother’s care/That saved its little face so fair.”32 Vaccination, according to Smith, was both an urgent matter of parental responsibility and a general public good.

VACCINATION, INOCULATION, AND PROFESSIONAL STATUS

For elite, educated physicians, vaccination became a tool for professional and economic advancement. They were quick to recognize the potential professional benefits of vaccination after 1800, when physician Benjamin Waterhouse, from Boston, Massachusetts, performed the first smallpox vaccinations on American soil. In fact, Waterhouse initially tried to maintain a monopoly by frequently refusing requests to share vaccine matter with his colleagues. This effort was largely economically motivated, but it also reflected Waterhouse’s genuine concern that incompetent vaccinators would tarnish the reputation of a new and valuable technique.33 He complained of “vagrant quacks” that were strolling “about the country, inoculating for half dollar a head.”34 Although they may have resented his attempts to maintain a monopoly, many of Waterhouse’s peers agreed that vaccination needed to be protected from ignorant, unskilled practitioners.

American physicians used newspapers to communicate medical information in ways that affirmed elite physicians as experts, singularly qualified to assess the efficacy of vaccination and practice it safely. In 1803, 31 doctors in Philadelphia, Pennsylvania, including Benjamin Rush and other prominent medical figures, signed a public notice expressing their confidence in vaccination and recommending it for general use.35 Physicians in South Carolina made a similar announcement, insisting that the safety of vaccination had been “demonstrated by evidence sufficient to satisfy every candid mind.”36 Newspapers also warned the public against vaccination by poorly trained practitioners: “Your lives are in danger if you are vaccinated . . . by ignorant pretenders who are unable to tell decisively whether you . . . have been, affected with spurious or genuine [cowpox].”37 Such articles sent a strong message that vaccination was only safe when practiced by physicians with the necessary expertise to evaluate whether the procedure had been successful. Elite physicians found political allies who shared their insistence that vaccination should be under medical purview. New Hampshire Congressman Charles Atherton worried that vaccination would fall into “disrepute” at the hands of “rash and unskilful [sic]” practitioners, unless it was restricted to well-trained physicians.38

Physicians tried to discredit not only their “ignorant” competitors but also those who continued to practice inoculation. Since the 1720s, medical practitioners had inoculated their patients by giving them a mild case of smallpox, leaving them immune. Inoculation was a risky practice—those undergoing it were contagious and sometimes developed serious cases of the disease. Nonetheless, it enjoyed a strong reputation for efficacy. Inoculation also provided economic opportunities for medical practitioners, some of whom became specialists in the practice, and for women who nursed and ran quarantine houses for patients undergoing inoculation.39 For some physicians, inoculation comprised their single largest source of income.40 Inoculators, like vaccinators, had “treated the procedure as though it were an advanced technique only to be performed by the most skilled hands.”41 Because inoculators both profited from inoculation and used it to secure professional prestige, it is easy to imagine that they might not have willingly abandoned the practice, especially if they found themselves excluded from the professional networks where vaccine matter circulated.

Editorials in medical periodicals attacked inoculators with vitriol, deriding them as “irregulars” who “infested” American cities, driven by the “most debased and selfish motive,” a self-interested desire to preserve the income they derived from inoculation. These inoculators were a grave threat, determined to “shut their eyes against the light of truth, and to extend that intellectual blindness to others.”42 Henry Ducachet, a member of the Medico-Chirurgical Society of the University of the State of New York, wrote pointedly in a medical journal article: “In most European countries it is highly penal to inoculate for small-pox.”43

Smith, too, was concerned about the persistence of inoculation. Nathanial Potter, one of Smith’s mentors and a professor at the University of Maryland, wrote to him to insist (quite correctly, as it turned out) that lasting immunity could only be conferred through repeated vaccinations. Smith, however, was skeptical of Potter’s opinion and was concerned that patients would “rather have the inoculated smallpox at once” than be vaccinated multiple times.44 He rejected any claim that vaccination was anything other than a safe, straightforward, and simple technique. Elite physicians’ insistence that successful vaccination required specialized knowledge struck him as detrimental to the overall cause of promoting the practice. “The true vaccine process is always harmless, and so completely effective,” he explained, “that it requires no aid or interference . . . [only] to be let alone.”45 Smith had staunch “republican principles” and a strong belief in “the voice of the people” to direct political matters. However, he had much less confidence in “the voice of the Doctors,” which he felt was “oftentimes as remote from the truth as the North Pole is from the South.”46 This opinion would prove central to Smith’s fall from professional grace.

DOWNFALL OF SMITH AND REPEAL OF THE ACT

Much changed between 1813, when the act was passed, and 1822, when Smith was removed from his post. In the early 1820s, a new medical marketplace was emerging, shaped by the growing public mistrust of formal education, credentials and licensing, and professional monopolies that would characterize the Jacksonian Era. Groups of populist medical practitioners who refuted the authority of elite physicians had grown substantially. As historian John Harley Warner explains, these practitioners “challenged both the regular profession’s claims to intellectual and therapeutic superiority and its economic well-being.”47 Although these groups were still nascent, physicians were aware of mounting opposition. Within a decade, these groups, particularly a branch of botanical healing called Thomsonianism, would launch attacks on many conventional medical techniques and successfully advocate for the repeal of medical licensing laws.48 Such laws had been mostly honorary and rarely enforced, but they had nonetheless identified licensed physicians as “singularly legitimate.”49 In this context, Smith’s position and his beliefs began to appear outright threatening to his elite medical colleagues and to the political establishment that had supported his work.

When repealing the Act to Encourage Vaccination came up for debate, its supporters expressed concern about potentially damaging the public’s faith in the safety of vaccination. Pennsylvania Representative John Tod worried, “Were there not some doctors, or quacks, who pretend that vaccination is wholly useless?” By repealing the act, Tod argued, the legislature would play into their hands, weakening public confidence in a health measure that had saved many lives.50 Even John Ward, the physician in Tarboro who had received Smith’s smallpox scabs, opposed repealing the act. American citizens, he argued, should not “languish in the consequence of one fatal mistake.”51 Smith pled with Congress that “some other person, in whom the public may have greater confidence . . . be appointed in my stead.”52 But it was the opponents of the act who would win the day.

Massachusetts Democratic-Republican William Eustis urged that the Vaccine Institute be abolished because he felt that it granted Smith an unfair monopoly, which, he argued, stunted the healthy competition of the medical marketplace.53 The well-documented backlash against monopolies during the early 1820s probably made this a particularly effective line of argument.54 North Carolina Democratic-Republican Weldon Edwards commented on the “despotic” power European governments used to coerce or obligate their citizens to undergo vaccination. In contrast, he remarked that the American government had to respect the Constitution and “let the people, who are both able and willing, take care of themselves.”55 After the repeal of the act, Niles Weekly Register, a popular national paper, applauded the move, implying that appointing a “Vaccine Agent” had been misguided from the beginning. “High sounding titles will do nothing with the small pox,” the article insisted, “it is genius, diligence and care that must combat and destroy it . . . direct responsibility is the best security that can be afforded in things of this nature.”56

In this political climate, Smith’s insistence that anyone could perform vaccination bore a striking resemblance to the Thomsonian motto: “To make every man his own physician.”57 Smith and Potter argued about this issue; “Mankind can only be protected from the smallpox,” Potter remarked, “by vaccination confined to the enlightened physician.”58 It took training, he continued, to distinguish the effects of vaccination from those of a failed vaccine, chickenpox, or smallpox itself.59 Smith insisted that this stance was erroneous and dismissed it as an example of “the quackery and vain boasting of our profession.”60 Vaccination, he argued, was the same process whether it was performed by “an ‘enlightened physician’ or some ‘ignorant agent.’ ”61 He also quarreled with Waterhouse, whom he believed had criticized and undermined him out of professional jealousy. “I have had battles enough to fight with the enemies of my institution,” Smith wrote to Waterhouse, including physicians who were willing to reject “any method of practice that threatens to interfere with their business, or lessen the profits of their profession.”62 Elite physicians felt that their professional authority and status were under serious threat, and Smith’s sharp criticisms of their self-interested behavior made him unpopular.63

Smith had suspected for several years that powerful members of the medical profession were working against him. In 1817, he had petitioned Congress to provide funding for the Vaccine Institute, so that he could forgo charging a distribution fee for vaccine matter. He was sure that Waterhouse’s efforts, “as well as the influence and authority of many other respectable physicians,” had pressured Congress to reject this request, which would have made vaccine matter more widely accessible.64 Smith’s sense of opposition was so great that he would later insist that some “malicious and designing person” had sabotaged him by switching the vaccine matter he had meant to send to Tarboro with smallpox scabs, to ruin his reputation and destroy the institution he had worked so hard to build.65

Deposed from his federal post and in open conflict with his professional colleagues, Smith launched a campaign to rehabilitate his reputation and ensure that the public did not lose confidence in vaccination. Hoping to find a sympathetic audience, he published documents relating to the Tarboro incident in The Vaccine Inquirer; or, Miscellaneous Collections Relative to Vaccination. However, Smith never regained much ground. In fact, he quickly found himself in an argument with the Baltimore Board of Health, because he had publicly disparaged their proposed smallpox quarantine regulations. One of the board’s members wondered why Smith chose to “hang about small pox patients, like a preying vulture?”66 The easiest way to ensure the spread of smallpox, according to the board, was “by the unnecessary and presumptuous interference of Dr. Smith.”67 Smith, probably exhausted by his string of defeats, quietly retired from medical practice and from public life.68

CONCLUSIONS

There are important differences between James Smith in the 19th century and Robert Sears in the 21st. For one, despite medical research that has demonstrated the safety of vaccination, Sears today is far more skeptical about vaccine safety than Smith ever was. In contrast with Sears’ concerns about the practice of bundling multiple vaccines, Smith’s faith in vaccination as “always harmless” was unwavering and unqualified. However, differences aside, Smith’s democratic approach to vaccination and Sears’ delayed program both insisted on providing patients with increased autonomy over their health care. This, as their medical peers pointed out, caused both Sears and Smith to neglect important concerns about safety: Sears has largely ignored or dismissed evidence that delaying vaccinations leaves children at risk for disease,69 and Smith flatly rejected reasonable claims that a one-time vaccine did not prevent the development of smallpox over a lifetime.70

It is also important to acknowledge today that we live in an age in which vaccines are arguably safer than they ever have been. Next to the consistent demonstration of vaccine safety in medical research, persistent doubts among American parents have proven to be perplexing and frustrating for physicians, who often attribute vaccine resistance to public ignorance. This article, however, demonstrates that the story is far more complex. For more than two centuries, debates about vaccination have been shaped by broader American values of self-reliance and independence. In the case of Smith, physicians’ efforts to maintain exclusive control of vaccination ran up against popular mistrust of elite titles, professional authority, and monopolies. And today, Sears’ delayed program plays into the deeply ingrained belief that Americans should take responsibility for their own health.71 The upshot is that providing patients with this increased autonomy almost inevitably clashes with the professional interests of the medical elite. Whereas Smith believed in promoting trust in the smallpox vaccine, his colleagues wanted to develop trust in a narrower and ultimately successful vision of vaccination, which could only be provided safely by a member of their profession.72 Sears’ delayed schedule provides an option for parents who—like Smith—believe in the efficacy of vaccines, but who question the authority and intentions of the medical establishment in their efforts to control the practice of vaccination.

ACKNOWLEDGMENTS

This work was supported by National Institutes of Health Medical Scientist Training Program grant TG 2T32GM07205.

We thank Catherine Mas, Melissa Grafe, John Harley Warner, Naomi Rogers, and Jason L. Schwartz for their generous and insightful feedback on this article. We thank the Journal’s anonymous reviewers for their helpful comments and suggestions.

Footnotes

See also Rusnock, p. 715.

ENDNOTES

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  • 66. Quoted in Bell, The Colonial Physician, 144.
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