As educators work to help vaccinate students against COVID-19, the history of schools’ involvement with past inoculation efforts shows how teachers, principals, and others in the K-12 world can have a significant influence on the views of parents and others.
But the current cultural atmosphere—rife with partisan conflict and distrust in public institutions—also has many public health experts worried that what worked in the past faces a far higher lift in the current pandemic.
In fights against diphtheria and polio in the 1920s and 1950s, respectively, schools played a central role. They hosted information sessions, coordinated with local civic groups and the media, and commanded trust in their communities. Experts saw the influence of teachers, principals, superintendents, and other educators not just as helpful, but crucial.
“Schools have been critical sites for where public health officials for generations have thought about the importance of high vaccination rates,” said Jason Schwartz, an associate professor of public health at Yale University who studies the history of medicine and serves on a COVID-19 vaccine advisory group for Connecticut Gov. Ned Lamont, a Democrat.
But a precipitous decline in trust in government since the 1950s, skepticism or outright hostility toward vaccines in recent decades and a fragmented media environment where a blizzard of influencers and outlets compete for attention, are among the potent forces that—separately and combined—have changed the landscape for school leaders and others now facing an unprecedented test of public health.
The time when schools as institutions participated eagerly in nationwide trials to assess the viability of newly developed vaccines also is long gone.
Students ages 12 and up are eligible to receive the Pfizer-BioNTech COVID-19 vaccine, and emergency authoritzation for that shot for children ages 5-11 is expected this fall. Different perceptions of COVID-19’s impact on children, compared to widely-feared diseases in the past, also play a role in the current debate; vaccination rates for eligible school-age children have lagged behind those of adults, although vaccines for those children have been authorized for less time.
Some recent polling has shown parents growing more comfortable with having their younger school-age children vaccinated, although other survey data indicates there’s a large share who oppose the idea.
Schwartz said educators who know how to build trust in local communities can still be valuable in boosting vaccinations. But there’s also concern that current conditions will continue to make things difficult.
In the era when the polio vaccine was developed, and even before, “people generally trusted public health officials. They trusted the government, the pharmaceutical industry,” said Dr. Paul A. Offit, the director of the vaccine education center at Children’s Hospital of Philadelphia. “It’s a much more cynical, much more litigious time.”
Court rulings and New York City schools served a key role
The roots of requiring vaccines to attend schools go back to the 19th century. In 1827, Boston required students to show proof that they had received the smallpox vaccine in order to attend public schools. It is considered the first U.S. city to adopt such a mandate. Smallpox vaccine requirements for schools spread at roughly the same time that states began adopting basic requirements for public education services.
In a landmark 1905 ruling in Jacobson v. Massachusetts, the U.S. Supreme Court upheld the right of the state to implement penalties for those who did not receive the smallpox vaccine. By 1915, according to research by public health expert J.J. Hanlon, 21 states had adopted laws or rules empowering local jurisdictions to implement vaccine mandates, while nearly half the states had adopted vaccination requirements for school attendance by the start of the 20th century, the CDC has reported.
And in its 1922 Zucht v. King ruling, the Supreme Court upheld a San Antonio, Texas, ordinance requiring all schools in the city to publish lists of teachers and students and whether they had complied with a mandate to get the smallpox vaccine.
But the year before that ruling, another significant development took place in the history of schools and vaccines when William Hallock Park led testing of treatment that might confer immunity from diphtheria on 50,000 students in New York City schools. Although there was significant parent resistance to the idea, Park’s partnership with educators proved crucial to the effort, which required parental consent.
Principals wrote letters to parents emphasizing the importance. When teachers handed out permission forms to students, it implied that they (and the schools) backed the effort. Park said at the time that success or failure “depends largely” on educators’ backing.
“School officials’ active support for the trial was so valuable that Park reported obtaining consent from three-fourths of the parents when principals and teachers were enthusiastic about it, but only one-fourth when they were not,” Will Schupmann, a doctoral student in sociology at the University of California, Los Angeles who has studied the history of vaccines and schools, wrote in a 2018 analysis of the diphtheria trial.
Such actions presaged schools’ later involvement in vaccination campaigns.
Broader circumstances helped the effort as well. It was a time when signature Progressive Era reforms impacted schooling. Educators, as well as doctors employed by schools, helped diagnose student ailments, and schools were seen as crucial in the fight against communicable diseases.
“Schools held a great deal of power in communities, especially in the early 20th century, as laws mandating attendance were adopted and strengthened nationwide,” Schupmann wrote, even though there was notable resistance to Park’s work.
And the early 20th century was what Patrick Radden Keefe has referred to in the book Empire of Pain as “the golden age of American medicine … when the efficacy of medicine—and the credibility of the medical profession—were greatly enhanced by new scientific discoveries.”
How schools used obligation and partnerships to promote the polio vaccine trial
Perhaps the most famous instance of schools’ involvement with vaccines is the case of the polio vaccine, which underwent a trial involving more than 1.8 million children in 1954, and which eventually led to a nationwide vaccination campaign. It’s an often cited example of how public health officials can successfully cooperate with educators and the general public.
Yet the success of that trial and the subsequent ways in which schools aided polio vaccinations doesn’t necessarily translate into easy and relevant lessons for educators today.
Researchers and others settled on schools as the most logical and large-scale solution to put Dr. Jonas Salk’s new polio vaccine to the test. When the polio vaccine trial got under way, schools worked with institutions in several ways to promote the vaccine trial, and also relied on the social respect for educators. And they stressed how the trial represented a community effort.
The National Foundation for Infantile Paralysis, which eventually became the March of Dimes, distributed leaflets with information about the trial to parents, a source that was especially important to parents who consented to their children’s participation. Since it was established in 1938, the group had worked to find a cure for and raise awareness about polio for more than a dozen years before Salk developed the vaccine.
The foundation also pushed for the trial to take place in schools with strong public-health infrastructure already in place, as well as in communities that had already indicated an interest in being part of a trial.
Schools collaborated with county health officers, parent-teacher associations, and politicians, among others, to promote the effort. A famous picture features a teacher in her classroom near a blackboard with the message: “We are among the first children ever to be given Polio shots. So we are really making History today.” Trailers in theaters promoted the effort.
And consent forms sent to parents were framed by schools as a “request to participate.” That language underscored the idea that people were taking part in a positive endeavor with broad benefits, rather than an unwelcome imposition. In addition, experts found that schools often relied not so much on direct coercion as a “pervasive sense of obligation” among parents.
A December 1954 study of parents in Virginia schools that participated in the polio vaccine trial found that among mothers who attended “orientation” sessions at schools about the trial, 75 percent subsequently gave consent for their children to participate, while only 41 percent of mothers who did not attend those sessions gave consent.
“Schools, in that era, were both a focal point in generating the knowledge that the vaccine worked, and sites for where the vaccine was made available following its approval,” said Schwartz.
Media organizations often played a major role in promoting the trial, both as local institutions as well as in their coverage. When Randall Kerr became the first child to get the vaccine as part of the trial at a school in McLean, Va., in April 1954, his picture was featured prominently in newspapers across the country. Media outlets and others also promoted the children who participated in the trial as “polio pioneers,” as well as touting the vaccine’s efficacy.
“The press reported some controversy over the use of the Salk vaccine, but was preponderantly favorable,” three researchers reported in the 1954 study.
Parents’ willingness to have their children participate was also correlated with their educational attainment. The same Virginia study found that consenting mothers were much more likely to have attended college than those who withheld consent.
Factors that affected the polio vaccine trial are different today
All of that aside, some long-standing factors that contributed to polio vaccination efforts, and corresponding community trust in them, might have less relevance for schools’ efforts to increase COVID-19 vaccinations.
The National Foundation for Infantile Paralysis, over many years, used its network of local chapters to generate energy, excitement, and donations through tactics like the nationwide “Mothers’ March.” Celebrities and cultural icons ranging from Helen Hayes to Mickey Mouse were enlisted to promote the work, a strategy that continued after the vaccine trial to highlight polio inoculations through public figures like Elvis Presley. And the foundation had the prominent backing of President Franklin D. Roosevelt, himself a victim of polio.
Another factor in earlier efforts was parents’ acute fear of polio’s impact on children in particular. The disease inspired enough dread for parents to keep their children indoors and away from facilities like swimming pools and playgrounds. A polio outbreak also closed Chicago schools in 1937. The fact that COVID-19 has largely affected adults, especially the elderly, has created a different environment for parents when weighing the risks of the virus.
Still, the media environment in previous eras was not wholly free of misleading or baseless claims about the vaccine.
In April 1954, the national columnist and broadcaster Walter Winchell warned his audience that the polio vaccine undergoing a trial might be a “killer,” and that it had killed several monkeys. Winchell was misleading his audience.
Nevertheless, fearful that the message would disrupt the trial, Salk—with the help of his local newspaper, the Pittsburgh Post-Gazette—immediately rebutted Winchell’s claim, which did not ultimately halt or dramatically affect the trial and subsequent vaccination campaigns.
In the 1950s, the anti-vaccine movement was at a relatively low ebb, and did not have the weight it does today. And though Winchell was influential, “social media and the internet can help theories, hypotheses, and doubts find a sympathetic audience far more quickly” now than during the polio era, Schwartz said.
That’s not to say the rollout of the polio vaccine proceeded without problems, or tragedy. In the “Cutter Incident” in 1955, 10 children died and hundreds suffered paralysis after receiving a defective version of the vaccine. That ultimately did not scuttle the inoculation campaign itself, although it had long-term consequences concerning vaccine production and lawsuits.
Not all diseases and vaccines spur the same reaction among parents
The CDC has noted that despite state vaccine mandates, enforcement of them was “uneven” in the 1960s. The measles vaccine and the public’s reaction to it demonstrate how the public’s response to vaccinations can be difficult to predict.
The first measles vaccines were approved in the U.S. in 1963. Yet many parents at the time and in subsequent years were less eager to have their children vaccinated against measles than they were nearly a decade earlier, when the polio vaccine became broadly available.
“Measles was seen as part of childhood, and not as dangerous” as polio, even though measles did (and still does) have serious effects on children, Schupmann said. “It didn’t have the same fear associated with it as polio did. As a result, public health officials had a more difficult time encouraging vaccine uptake.”
To a certain extent, that matches reactions among some parents who believe their children don’t have a huge need for the COVID-19 vaccine, and indeed might be harmed by it.
Yet measles outbreaks continued to present a serious health risk in places like Los Angeles for years after the first vaccines came out. And the different approaches between neighboring school communities in various states could lead to very different consequences.
The city of Texarkana, which straddles the Arkansas-Texas border, experienced a measles outbreak for several months beginning in 1970. Experts who studied the disease there in children ages 1-9 found that in Texarkana, Ark., the rate of infection was far lower than in Texarkana, Texas; roughly 95 percent of cases were in Texas. They estimated that 99 percent of children on the Arkansas side—where there had been robust measles-vaccination campaigns for children in school and preschool—had been vaccinated, compared to 57 percent on the Texas side, where no such efforts had taken place.
In response to such outbreaks and lagging vaccination rates, states, with the support of the federal government’s 1977 Childhood Immunization Initiative, pushed to dramatically expand vaccinations for students for measles and several other communicable diseases, in conjunction with mandates tied to school attendance.
But vaccine hesitancy and refusal continue to keep measles outbreaks as a notable problem for public health.
Schupmann also noted that health officials have pushed to vaccinate students against rubella with the specific purpose of protecting not just those children, but pregnant women. Congenital rubella syndrome can result in serious birth defects among infants, as well as miscarriages and stillbirths.
In the same way, COVID-19 vaccinations among students are promoted in large part to help protect vulnerable adults, in addition to children themselves.
Offit said long-standing and broad school vaccine mandates in states like Mississippi, which for decades has not allowed for religious or philosophical exemptions, have shown that “you can compel people to do the right thing.”
Whether that carries over to COVID-19 vaccine mandates is very much an open question. Mississippi Gov. Tate Reeves, a Republican, has indicated his opposition to mandating the COVID-19 vaccine for students (at least until it progresses beyond emergency use authorization) in his state, which in September became the state with the highest COVID-19 death rate.
At the same time, Schwartz said vaccine-education efforts by school nurses as well as other staff have proven crucial to sowing support and reducing resistance to the vaccines, well in advance of official vaccine approvals and subsequent mandates. In short, the influence educators have demonstrated in the past might not have vanished completely.
“It’s those sorts of one-on-one, trusted sources of information that have been shown to be a really important way for people who have concerns or anxieties about vaccines [to] have those concerns addressed,” he said.