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smallpox in the United States. Between 1921 and 1930, the United States reported nearly 400,000 cases of smallpox, with a case-fatality rate of less than 1 percent. During the next decade, 108,000 cases were reported, with a case-fatality rate of just .38 percent. As smallpox continued to lose its lethal force, Americans remained ambivalent—or apathetic—about smallpox vaccination. Health departments relied on school mandates and voluntary action to maintain vaccination levels. But by the 1930s, only nine states had compulsory vaccination laws on the books, and four states had laws banning compulsion. During the 1930s, public health experts voiced the old refrain that “the United States lags behind other civilized countries in vaccination protection.” And they were right. With 5,000 to 50,000 cases still occurring each year, health officials estimated that only one in two Americans had ever been vaccinated.3

The antivaccination movement had continued to challenge the authority of American public health officials. As the Birmingham, Alabama–based Southern Medical Journal lamented in 1921, “All the fools are not dead yet.” Since the Supreme Court’s ruling in Jacobson v. Massachusetts, antivaccinationists had relentlessly railed against school vaccination requirements. They would continue to do so even after the Court, in a 1922 opinion written by Justice Louis D. Brandeis, dismissed a constitutional challenge to a local school vaccination mandate, stating that the Jacobson ruling had effectively decided the question.4

Time and again, however, when malignant variola major reared its head, the American people bared their arms. As Assistant Surgeon General R. C. Williams of the U.S. Public Health Service commented in 1946, “When you get a scare, everyone within 100 miles gets vaccinated.”5

In 1947, when a traveler on a bus from Mexico City carried smallpox to Manhattan, more than six million New Yorkers lined up in a single month to get vaccinated. In dramatic contrast to the 1901–2 epidemics in the city, the New York City Health Department did not resort to compulsion and force, instead reaching out to the public through the radio and newspapers, while using the full agencies of the local government to trace cases and contacts. In the end, the city suffered only twelve cases and just two deaths.6

By the time of the New York outbreak, smallpox had grown scarce in the United States. America’s last confirmed outbreak struck Hidalgo County, in the lower Rio Grande Valley of Texas, in 1949.7

At the time, few American states mandated smallpox vaccination. Beginning in the late 1930s, nine states and the Territory of Alaska enacted the first laws mandating immunization for another deadly childhood disease—diphtheria. The discovery of the polio vaccine and the ensuing national vaccination campaign during the 1950s changed everything, turning compulsory immunization from a political liability into a popular cause. Between 1958 and 1965, all fifty states enacted new legislation requiring schoolchildren to undergo vaccination for smallpox and other diseases. By 1969, twelve states had mandated a full slate of childhood immunization shots that included smallpox, measles, polio, diphtheria, pertussis, and tetanus. And more states were jumping on board each year. A new era of compulsory immunization had begun.8

With no reported cases of smallpox in the United States in more than twenty years, the annual tally of six to eight deaths from complications of vaccination became increasingly unacceptable. In 1971, the United States Public Health Service, the agency that seventy years earlier had sent C.P. Wertenbaker across the South to help communities fight smallpox, recommended that routine childhood vaccinations against smallpox be discontinued. Within three years, every American state had repealed its smallpox vaccination mandate for schoolchildren.9

As of 1967, smallpox still killed 2 million people every year across the globe. The World Health Organization—leading an unprecedented international campaign—launched an offensive to wipe