(ABC4) – They say history repeats itself, and it appears that many elements of the COVID-19 pandemic might not be exempt from this old adage. In March 2020, as we all know, COVID-19 swept the globe, sending the whole world into lockdown. COVID-19 vaccine distribution began in December 2020, and quickly became a source of both hope and controversy.

There was similar reverberation when it came to the smallpox vaccine, which was pioneered in the 1790s. Although smallpox, unlike COVID, was a disease that terrorized the world in epidemic proportions for centuries, public response to the vaccine followed a similar trajectory to that of the immunization for the modern-day coronavirus. And despite their differences, both viruses have prompted some degree of a vaccine mandate, too.

“The idea of a vaccine mandate is really old and dates to that first vaccine,” says Nadja Durbach, a University of Utah history professor who has written a book on the smallpox vaccine.

While, in current times, many states are fighting against attempts by the federal government to mandate the vaccine, after the smallpox shot was introduced, state governments in the United States, in addition to the central government in Britain, began to require the vaccine.

“In Britain, you had to get vaccinated otherwise you’d have to pay very, very steep fines or you could actually wind up in jail,” Durbach says.

Just like today, the enforcement of the vaccine mandate sparked opposition and spearheaded what we know as an “anti-vaccination movement.” And according to Durbach, the reasons for opposing the vaccine then were similar to now. Concerns pertaining to attacks on civil liberties, bodily autonomy, and questions about the science of the vaccine and how it might affect individual bodies were voiced by the public.   

So, what does this tell us about the way vaccine mandates might play out in the COVID-19 pandemic?

According to Durbach, history might be able to give us the right answer for how to proceed.

In 1898, nearly 50 years after the smallpox vaccine was introduced, the British government developed a system for vaccine exemptions in response to the vaccine opposition movement. Granting exempt status required those opposed to getting the vaccine to appear in a court of law to state their case.

Durbach says that this procedure caused people to think deeply about their reasoning for not wanting to take the vaccine, and going through a process similar to setting up a vaccine appointment in terms of time commitment and difficulty deterred people from the temptation to take the easy way out.

“What that did was actually bring an end to the anti-vaccination movement,” Durbach says. “The reason they required you to stand before a judge and make that statement was because that was about as difficult as getting a vaccine.”

But even though COVID has brought vaccine mandates and exemptions to the forefront of our cultural conversations, Rich Lakin, Immunization Program Director at the Utah Department of Health, notes that there were other modern immunization requirements in place prior to the coronavirus.   

“There are certain requirements to attend school,” he says. “Students have to get their MMR, they have to get the chickenpox vaccine, they have to get their TDAP, and a few others, as they go through the school system.”

Many schools are also instating COVID vaccine mandates, too. Durbach notes that, at the University of Utah, while there is a mandate, there is also an exemption option. In order to be granted this status, applicants are only required to check a box stating that they claim exemption.

But, unlike in turn of the century Britain, Durbach says vaccine exemptions processes for COVID are not consistent, which is an aspect of the protocol that she deems essential to the overall success of mandates.

“One of the lessons we should take away from older forms of anti-vaccination and government response is that you shouldn’t require someone to do something to their body that they object to, on the one hand, and you should allow for exemptions, but you need to make that exemption at least as difficult a process as actually getting a vaccination,” she says. “What you want to do is make sure that the people who are getting that exemption have thought it through and are not getting it because it’s easier to do so.”  

Even though history seems to be repeating itself in many ways during the present pandemic, there are several aspects of the coronavirus that are new. According to Durbach, restricting entry into public spaces is an element of our current pandemic situation that varies from those in the past.  

“What’s new is the idea of restricting access if you don’t have the vaccine,” she says. “It’s new because our scientific understanding of how vaccines work has evolved. In the 19th century, people didn’t understand that it’s not just about personal protection, it’s about creating a group immunity.”

The idea of variants is also different from public health understanding in the days of smallpox. Although the disease was caused by a virus, at the time, scientific knowledge was not advanced enough to know how or whether the virus was mutating.

According to Durbach, smallpox was epidemic and reappearing, and although the vaccine was effective, it wasn’t able to stop outbreaks from popping up in different communities. This type of spread is similar to how COVID is mutating now, although our global world puts this on an entirely different scale.

As far as how the future will play out, Lakin says it’s hard to know. It’s unclear how long proof of vaccination will last, and the time when we’ll be able to remove our vaccine card or negative test results from our wallets, might be as illusive as herd immunity itself.

Someday, he says, COVID will move from being a pandemic to an endemic, which is defined by Intermountain Healthcare as “belonging to a particular people or country.” This means that the disease is in control and, while outbreaks might occur, they are predictable and easier to navigate.

“At some point, the disease will become rarer due to vaccines, then you won’t need to require to see a proof of vaccination anymore because it’s not a pandemic,” Lakin says. “There’s not necessarily a hard line when you move from a pandemic to an endemic; it’s the point when it becomes more manageable and the disease burden is a lot less.”

The British government stopped mandating smallpox vaccines at the beginning of the 20th century and the disease was deemed eradicated in the 1970s. Of course, we’re all hopeful that COVID can be similarly – and hopefully more rapidly – eliminated, but, as it has been since the beginning of the pandemic, the past is set in stone and the future is still uncertain.