In Alfred W. Crosby’s seminalstudy of the 1918 influenza pandemic, America’s Forgotten Pandemic (1989), the late historian noted the puzzling fact that, despite its profound toll on individuals and communities throughout the United States, the episode rarely appears in historical accounts of the era. Outbreaks of deadly contagious disease, it seems, have a curious way of fading from public memory once the immediate danger has subsided.Footnote ¹

Kim Tolley’s timely study of compulsory school vaccination over the course of two hundred years reflects a similar pattern: periodic epidemics of childhood diseases induce widespread public support for mandatory vaccination, followed by complacency after vaccine-induced “herd immunity” lowers the immediate risk to children and public awareness of danger fades, leading to a renewed interest in vaccination when immunity wanes and outbreaks affecting children once again increase societal concern. Schools played a key role in this narrative, representing key sites for both spreading and containing childhood illness and functioning as centers of local community engagement with prevention efforts. Tolley’s precise focus provides a limited but nevertheless illuminating lens through which to examine Americans’ broader historical experience with contagion. Her well-supported analysis also demonstrates the crucial role played by mandatory school vaccination in diminishing the threat posed by once-deadly childhood diseases.

The book’s eight chapters are divided into two chronological sections centered on smallpox and polio, respectively. Chapter 1 traces school vaccination laws as they emerged in the mid-nineteenth century in the context of periodic disruptions caused by smallpox epidemics and the equally disruptive attempts by local authorities to contain them. At a time when costly quarantines and the forced isolation of the sick provided the most effective means of curtailing contagion, vaccination seemed to offer a promising alternative. The first school vaccination law was enacted by Massachusetts in 1855, followed by laws in other northeastern states where, significantly, both state boards of health and compulsory school attendance laws were also in place. (An ineffective federal vaccine program lasted only nine years, from 1813 to 1822.) Over the next decades, other states followed suit, usually in direct response to local smallpox outbreaks, and by 1910 thirty-five states had made vaccination mandatory for school attendance.

In chapter 2, Tolley turns her attention to those opposing vaccination in the nineteenth and early twentieth centuries. Led by various organizations over the decades, such efforts had ideological ties to various schools of thought challenging the ascendancy of mainstream (“regular” or “allopathic”) physicians and promoting alternatives to the germ theory of contagion. As germ theory became more widely accepted among both medical practitioners and the public, vaccine opponents shifted their focus to asserting individual medical liberty, including the rights of parents to refuse compulsory vaccination for their school-aged children. Tolley argues that, because they were adept at both grassroots organizing and promoting their views through the popular press, anti-vaccinationists enjoyed an influence that belied their relatively small numbers.

Chapter 3 traces the many, often protracted, legal challenges to school vaccination at the turn of the twentieth century. While courts overwhelmingly recognized states’ authority to enact and enforce public health measures, they also worked toward a “reasonableness standard” to balance states’ police powers with the rights of students to receive a public education. In 1922, the US Supreme Court upheld the validity of mandatory vaccination laws in Zucht v. King, rejecting the claim that school authorities in Texas had violated a student’s constitutional rights by requiring smallpox vaccination at a time when the disease was not present in the community. With mandatory school vaccination solidly affirmed, opponents shifted their efforts to carving out religious and philosophical exemptions for individuals within state laws.

Chapter 4 concludes the book’s first section with a discussion of opposition to vaccine mandates by school administrators pushing back against the authority of public health officials. Such mandates, the administrators argued, clashed with their core responsibility of educating children. A case study from California in the early twentieth century reveals administrators’ concerns about keeping schools open and functioning adequately, responding to demands from anxious parents about the safety of vaccines, and the loss of state funding tied to school enrollments. By the 1930s, decades of controversy over smallpox vaccination led to hesitation among health officials in requiring vaccination against diphtheria, a disease with high morbidity and mortality rates that spread easily in school settings. “For better or worse,” Tolley notes, “persuasion became the health board’s last remaining tool” (p. 140).

Such complacency ended abruptly when epidemic polio made its terrifying appearance in the mid-twentieth century, and the author turns her attention to a “sea change” in attitudes toward school vaccinations in Part II. Chapters 5 and 6 examine the breadth and speed of efforts, both public and private, in support of discovering, producing, and distributing vaccines against polio. Schoolchildren raised funds for the March of Dimes and even participated as test subjects in the (ethically dubious) vaccine trials known as Operation Polio. Schools served as key community sites for distributing information about polio vaccines and as clinics for the procedure itself. Tolley asserts that the groundswell of popular support for anti-polio campaigns provided a ready environment for mandatory school vaccination, and the number of states enacting such statutes tripled by the 1960s. In the most successful public health campaign in American history, the number of polio cases fell to zero in 1979. Chapter 6 examines the “age of eradication,” in which confidence in the effectiveness of polio vaccines increased public support for childhood immunization programs targeting measles, diphtheria, pertussis, and tetanus. Despite these successes, however, vaccines also carried undeniable risks, and opposition to their use, while latent, never went away entirely.

Chapter 7 addresses the reemergence of anti-vaccination sentiment in the 1960s and 1970s, an era of “growing public criticism of government institutions, science, and technology” (p. 199). Parents objected to the number of inoculations now being recommended by the Centers for Disease Control, and new fears arose about the safety of vaccines, including unfounded but persistent claims connecting them to autism. In an era that stressed individual rights, the dangers of environmental toxins, and distrust in a male-dominated medical system, exemptions to compulsory school vaccination found renewed support, and several states broadened them to include personal choice as well as religious and philosophical objections.

The book’s final chapter explores the reemergence of measles and pertussis in the early twenty-first century, when both herd immunity and the public memory of these once-deadly childhood diseases had faded. Tolley notes that schools had also become complacent about contagious illness, turning their attentions to other health concerns such as physical activity, nutrition, mental health, and the abuse of drugs and alcohol. New childhood disease outbreaks led states to rescind personal exemptions to school vaccination, which in turn engendered a fresh round of controversies over individual medical liberty. In a concluding section, Tolley warns that Americans’ recent fraught experience with COVID-19—marked by the partisan politicization of public health and the spread of medical misinformation on social media—signals serious potential challenges to safeguarding children’s health.