A 300 year old lesson from history: Smallpox

The following is the story of the eradication of smallpox from the world. The story has many twists and turns over the centuries that still have direct bearing on vaccine hesitancy even today.

Vaccine hesitancy is not a new social phenomenon. It’s beginning dates back to the 18th century and smallpox outbreaks in New England. Tracing the eradication of smallpox from the world is instructive for us to understand vaccinations as a whole and why we do them. It is also instructive on issues in vaccination that we face today, such as vaccine hesitancy discussed above. In taking a very small risk in vaccination, a much larger risk of death and disability from a dangerous infectious disease is avoided. This is the time honored lesson of smallpox eradication.

The eradication of Smallpox from the world

The year was 1721, April 22nd, Boston, Massachusetts. A dreaded disease had just arrived aboard the passenger ship HMS Seahorse commanded by Captain Wentworth Paxon inbound from Barbados. Several sailors aboard the ship had just survived smallpox. The severe form of this disease named variola major, routinely killed 30% to 35% of those who contracted it. Another form of smallpox called variola minor was 20% fatal.

After an incubation period of about 10-14 days, people with smallpox suddenly developed a flu like-illness with fever, fatigue, severe back pain, vomiting and headache. A few days later, a terrible rash appeared. Flat spots all over the body became blisters which gradually became filled with pus. This process  left severe scars. Many of those who survived the disease were severely scarred, many losing appendages such as earlobes and noses, marking them for life with disfigurement and disability. Women would dread the scars of severe pox-marks of the face.

One sailor aboard the HMS Seahorse became ill just one day after arrival in Boston. He had been exposed on the ship and in turn exposed others on land. 

Upon arrival, the ship had bypassed the harbor hospital and docked. When Boston customs officials finally inspected the ship, two or three additional cases of smallpox were found. The ship was ordered to leave the harbor. 

The ill sailor was quarantined to the home where he was staying. Nine other seamen were quarantined to Spectacle Island near Boston in a lodging house in an effort to prevent spread of the disease. Despite these efforts, smallpox entered the Boston community. Cotton Mather, a Boston Puritan minister wrote the following in his journal dated 26 May 1721, “The grievous calamity of the smallpox has now entered the town.”

Before modern times, smallpox and other communicable diseases cyclically devastated communities worldwide. This pattern had persisted for thousands of years, affecting various civilizations, including the Egyptian pharaohs, the Chinese, and peoples across Africa, Europe, and later the American colonies. 

Native peoples of the Americas did not experience smallpox outbreaks until the exploration of the New World, as they had never been exposed to the disease. Consequently, they had no immunity to smallpox. As a result, waves of smallpox epidemics brought from Europe severely impacted Native American populations, leading to staggering losses. When the Pilgrims landed at Plymouth Rock in 1620, they settled on land that had once been part of a thriving Indigenous culture, the Wampanoag people, which had been largely decimated by smallpox which was introduced earlier by European explorers.

Cycles of smallpox epidemics covered the globe. It was common for entire communities to be affected by the disease once it arrived, with survivors developing permanent immunity. The spread of infectious diseases was often facilitated by travelers. In the case of Boston, the last smallpox epidemic occurred in 1703, leaving an 18-year period for the population to grow through births and immigration, creating a vulnerable population susceptible to smallpox. Therefore, the conditions were favorable for a smallpox epidemic in Boston in 1721.

Cotton Mather played a significant role in combating smallpox outbreaks in the American colonies. His story begins in 1707. Mather received an enslaved West African man as a gift from his congregation, naming him “Onesimus” after a slave in the Bible. 

Onesimus revealed that he had undergone a procedure now known as variolization, which involved deliberately exposing oneself to smallpox in a controlled manner to gain lifelong immunity while limiting the risk of death. This technique involved introducing dried smallpox scabs or fluid from the pustules of an infected individual into scratches made on a non-immune person’s skin. Contracting the smallpox virus in this way avoided infection through the nose, mouth, and lungs, reducing the severity of the disease.

The purpose of variolization was to provide protection against the deadly natural smallpox infection by inducing a milder form of the disease. In 1721, this method was commonly referred to as inoculation.

While the mortality rate for natural smallpox was around 30% to 35%, those who underwent variolization during this time faced a mortality rate of approximately 2%. With further improvements in the procedure, this rate would eventually decrease to about 1 in 500 inoculations.

Mather, who had a keen interest in public welfare, was particularly influenced by a letter from Dr. Emanuel Timoni, a physician and the British ambassador to Turkey. This letter, which described the practice of variolization, was presented to the Royal Society in London in 1714 and later published in the Philosophical Transactions of the Royal Society. Mather also learned about variolization firsthand from his enslaved man, Onesimus, who had undergone the procedure himself. To further explore and understand variolization, Mather corresponded with the Royal Society.

When the smallpox outbreak hit Boston in 1721, Mather urged local physicians to combat the disease by using variolization. Only one physician, Zabdiel Boylston, agreed to act on Mather’s request. Boylston, who received his medical training through apprenticeship, including one with Hiram Cutter, a prominent physician in Boston, successfully inoculated his six-year-old son, his 36-year-old slave, and the slave’s two-year-old son. They all survived. 

Encouraged by these early successes, Boylston proceeded to inoculate 247 more people, with only 6 fatalities, resulting in a mortality rate of 2%. Boylston inoculated 15 individuals at Harvard university. All of those individuals survived as well, leaving the student body and faculty fascinated by the procedure.

Then politics intervened. The Boston Selectmen, the Boston city council, moved to restrict Boylston from further inoculations thus ending his smallpox prevention experiment despite its success in reducing morbidity and mortality. A Harvard tutor, Thomas Robie, inspired by the new research and findings, continued to inoculate non-immune individuals on Spectacle Island near Boston.

Among these volunteers in the medical experiment on Spectacle Island was Nicholas Sevier, another Harvard tutor who showed up at Harvard 16 days later, alive and well after the procedure. These events galvanized the faculty of Harvard university in favor of inoculation.

Not everyone in Boston was so easily convinced. On the contrary, what followed was a divisive societal debate, often escalating into violence, concerning inoculations and smallpox. Mather believed that inoculation was a divine gift to spare the majority of the population from death by smallpox. Boylston, as a physician, felt it was his God-given duty to protect the population from this dreaded disease, advocating for variolization as the preferred method to prevent death from smallpox.

However, there were those in Boston who saw the procedure as flawed, dangerous, and even immoral. James Franklin, the brother of Benjamin Franklin, established The New England Courant, a newspaper in Boston, during the smallpox epidemic. In the very first issue, an article was published that criticized those who were carrying instruments of inoculation and intentionally infecting willing participants with smallpox, asking, “Can any man infect a family in the morning, and pray to God in the evening that the disease will not spread?”

Other physicians in Boston also spoke out against Boylston’s work and refused to join him. Dr. William Douglas, one of the few formally trained physicians in Boston, made derogatory comments, referring to Boylston as a “quack”. These remarks were regularly published in Boston newspapers, including The New England Courant.

Fellow clergymen distanced themselves from Mather quoting scripture about “not murdering thy brother.” Eventually a few of the clergy, including Mather’s father, a man named Increase Mather, the president of Harvard University, supported inoculations and Boylston was able to resume his work. 

This resumption of inoculations led to physical attacks against Dr. Boylston by riotous mobs with death threats. Boylston went into hiding for two weeks to avoid attack. The mob violence then turned to Mather. 

After inoculating his nephew Rev. Walter, Mather offered to have Rev. Walter stay at his home while recovering from the milder form of inoculated smallpox. This offer resulted in a mob hurling a crude bomb with a lighted fuse into the window of the room where Rev. Walter was staying. The bomb did not explode. A note was attached to the bomb which read, “Cotton Mather, I was once of your meeting, but the cursed lye you told of - you know who, made me leave you, you dog, and damn you, I will inoculate you with this, with a pox on you.”

Thankfully, by February 1722 smallpox was on the decline in Boston with no new cases. Out of Boston’s 1721 population of 10,700, it is recorded that 5,889 people contracted smallpox by February 1722. 

It is important to understand that many in Boston were already immune to the disease from previous outbreaks. This means that the vast majority of those who were susceptible to the disease in the city contracted smallpox by February 1722. Of those who contracted smallpox, it is recorded that 855 died, which is about 15% of those who contracted the disease, or one in six people. There were possibly more deaths in the city due to smallpox that were not recorded at the time. Of Boylston’s 247 inoculated patients, six had died with a 2% death rate versus the 15% death rate that was recorded in naturally acquired smallpox. These facts were noted and published in the colonies.

In 1723 Dr. Boylston would eventually be honored in London by King George for his work of inoculation. While there, he published his work entitled, An Historical Account for the Smallpox Inoculated in New England. 

Lady Mary Wortley Montagu would be involved in similar experiments during a simultaneous outbreak in London which further corroborated his results. Inoculations were effective in preventing smallpox deaths.

In the months and years that followed the outbreak, the young 16-year-old publisher of The New England Courant, Benjamin Franklin would print words to mock Cotton Mather and Dr. Boylston for their positions on the prevention of smallpox deaths. Those words would sell their newspaper but would later haunt Franklin. Ben Franklin would remain at The New England Courant only 18 months more, fleeing his brother’s physical abuse. He would move to Philadelphia.

Many years later, Benjamin Franklin wrote the following in his autobiography: 

“In 1736 I lost one of my sons, a fine boy of four years old, by the smallpox taken in the common way. I long regretted bitterly and still regret that I had not given it to him by inoculation. This I mention for the sake of the parents who omit that operation, on the supposition that they should never forgive themselves if a child died under it; my example showing that the regret may be the same either way, and that, therefore, the safer should be chosen.” (source: Franklin’s Autobiography)

Franklin eventually came to believe that he made the wrong decision to forgo smallpox inoculation for his son, Francis “Franky” Folger Franklin in 1736. He would live to regret this decision for the rest of his life.

As time went on, the results of this and other research, the continued smallpox death toll and the academic power of Harvard University in the colonies would come to bear. Inoculation would eventually be firmly established in England and in the colonies as the primary way to prevent smallpox death and disability.

Smallpox inoculation would also play a role in the American Revolution. On 5 Feb 1777, George Washington wrote to inform John Hancock of Congress of his intent to inoculate the entire Continental Army against smallpox. Here is the part of the text of that letter.

“The small pox has made such Head in every Quarter that I find it impossible to keep it from spreading thro’ the whole Army in the natural way. I have therefore determined, not only to inoculate all the Troops now here, that have not had it, but shall order Docr Shippen to inoculate the Recruits as fast as they come in to Philadelphia. They will lose no time, because they will go thro’ the disorder while their cloathing arms and accoutrements are getting ready.” George Washington

The final draft of the letter to Hancock is printed above. However, George Washington’s aide-decamp Tench Tilghman wrote the following draft beforehand. It was eventually crossed out and reworded as the decision to inoculate became firmer In Washington’s mind.

“The small Pox is making such Head in every quarter that I am fearful it will infect all the Troops that have not had it. I am divided in my opinion as to the expediency of inoculation, the Surgeons are for it, but if I could by any means put a stop to it, I would rather do it. However I hope I shall stand acquitted if I submit the Matter to the Judgment and determination of the medical Gentlemen.”

It is clear that Washington had tremendous ambivalence about what to do about the smallpox threat. Should he inoculate his troops or not? We can see him waffling back and forth on this issue, striking out words already dictated. Why would he use the word “acquitted” in his deliberations and writings about the procedure? 

At this time, many states had enacted laws prohibiting inoculation for fear of spreading smallpox. Washington’s hopes of acquittal were justified. Certain laws were in place which placed him in legal danger if he had his troops inoculated. There was no national consensus on what to do to control this dread disease and state and federal governments had conflicting laws about inoculations. It is no wonder that Washington was concerned about acquittal. He stood in legal jeopardy. 

75% of the Continental Army at that time were non-immune to smallpox. The British army, on the other hand, was mostly immune to the disease because they had been either inoculated or had the disease as a child.

George Washington, during the height of the American Revolutionary War, took on smallpox, inoculating (variolization) his entire army with this decisive action. This was clandestinely done in 11 hospitals over the entire country in 1777 and at Valley Forge in the bleak winter of 1778. Not one regiment under his command was incapacitated due to smallpox during the entire war, even though smallpox raged through the American colonies during this time. His troops were immune. This success was crucial to winning the American Revolutionary War.

Let us fast forward to 1796, and Edward Jenner, born in Berkeley, Gloucestershire, England. Edward was orphaned at 5 years of age. Raised by his brother, he developed a keen interest in science and nature. After being inoculated with smallpox as a young boy and surviving, Jenner became interested in preventing smallpox. At 13 years of age, he was apprenticed to a country surgeon and apothecary in Sodbury near Bristol. It was during his apprenticeship that he heard a milkmaid say, “I shall never have smallpox for I have had cowpox. I shall never have an ugly pockmarked face.”

Cowpox is a disease in cows that is genetically very similar to smallpox, causing blisters and illness in cows. Other similar pox viruses also exist in nature such as horsepox, monkeypox and dolphinpox.

[Note: In recent years, Monkeypox has spread outside of Africa where the disease has been more commonly found in the past. This development has raised global health concerns as more and more cases have been identified in humans. Monkeypox symptoms resemble those of smallpox, including fever, headache, and a characteristic rash, although it is generally less severe than smallpox. Effective vaccines and treatments, such as the smallpox vaccine, which offers cross-protection, can help control outbreaks. Public health measures, including surveillance, isolation of cases, contact tracing, and vaccination, are essential to prevent its spread and protect human populations from this emerging disease.]

Milkmaids who milked cows that had current cowpox infections were susceptible to getting a mild human form of cowpox that would cause blisters on the hands and arms with some mild general symptoms like fatigue and anorexia. The illness was almost always mild in humans in contrast to smallpox. Milkmaids who got cowpox were subsequently protected from smallpox infection.

Jenner concluded that the development of a mild cowpox infection in humans—a process known as zoonosis—provided protection against the more deadly smallpox. Zoonosis refers to any disease or infection that is naturally transmissible between animals and humans. He would explore and utilize this phenomenon as a preventive measure against smallpox.

In May 1796, Edward Jenner found a young milkmaid named Sarah Nelms, who had fresh cowpox lesions on her hands. On May 14, 1796, he inoculated an 8-year-old boy named James Phipps with material recovered from Sarah Nelms’ cowpox lesions. The boy developed cowpox lesions with some mild symptoms like anorexia for a few days but recovered nicely. 

Subsequently, two months later in July 1796, Jenner inoculated the boy again, this time with material from a fresh smallpox lesion. Amazingly, no smallpox illness developed in the boy, despite the exposure. Jenner concluded that Master James Phipps was immune and protected from smallpox. A preventative cure for smallpox had been discovered! 

Jenner decided to call this new procedure “vaccination”. The Latin word for cow is vacca, and the latin word for cowpox virus is vaccinia. Hence the word “vaccination” at that time meant intentionally giving a human being the zoonotic disease, cowpox in order to prevent smallpox. The meaning of the word “vaccination” would change over time and be applied to all infectious disease preventing interventions.

Jenner would go on to promote vaccination against smallpox for the rest of his life. He tirelessly worked to get this fact recognized by the medical society of the UK. To his credit, Jenner did not seek to profit from his discovery. His only goal was to protect as many people as possible from smallpox.

In 1800 Jenner sent vaccine material to Benjamin Waterhouse, professor of physics at Harvard University. Waterhouse introduced vaccination in New England and persuaded Thomas Jefferson to try it in Virginia. Thomas Jefferson proved to be influential in promoting vaccination in America. Jefferson appointed Waterhouse as vaccine agent in the National Vaccine Institute, an organization set up to implement a national vaccination program in the US. Because of the problem of scale, it would take years for this practice to reach the majority of the US population. 

For about 80 years after Jenner’s discovery of vaccination in 1796, the main strategy used to disseminate and maintain the smallpox vaccine supply was human arm-to-arm vaccination with vaccinia strains (cowpox virus). This was also known as Jennerian vaccination. However, this strategy had two major disadvantages. The first was the co-transmission of other infectious diseases from person to person with arm-to-arm transmission, including syphilis and strep infections. Both of these diseases at that time were untreatable and possibly deadly. 

Another challenge was that the effectiveness of human-to-human transmission of the vaccinia virus (cowpox) in preventing smallpox seemed to decrease with each arm to arm transmission. It appeared that the virus changed and became less effective when transmitted between humans. As a result, a direct source of the vaccinia virus from cows was needed.

After a lengthy studious process, inoculation with material directly from cowpox lesions in young calves gradually replaced variolization in the prevention of smallpox. 

The need for a large amount of high-potency, uncontaminated cowpox virus material from cows for smallpox vaccination led to the creation of vaccine farms. These farms repeatedly grew the same strain of cowpox in newborn calves. The process of “animal vaccination” began in Naples, Italy in 1840 by Giuseppe Negri and was later shared with French medical student Ernest Chambon in 1860.

Chambon convinced his friend Gustave Lanoix to visit Naples and learn the technique. Lanoix returned to Paris with a heifer that had been inoculated with Negri’s cowpox virus strain. In 1864, Chambon and Lanoix established the Institute of Animal Vaccines in Paris. The Italian vaccinia virus strain used at the institute was later replaced by a French strain of cowpox, known as the “Beaugency lymph”. This mixture was obtained from spontaneous cases of cowpox in cows discovered in the French city of Beaugency in 1866.

To maintain the continuous line of the cowpox virus, young calves were successively inoculated with the Beaugency lymph material. When the cowpox lesions on the calves were ready, the pulp was obtained and ground in a mortar and pestle. It was then suspended in a solution called “vaccine lymph”.

This method allowed for the consistent production of high-quality vaccine material to protect against smallpox. Animal vaccination was rapidly adopted around the world. The “animal vaccine” concept was introduced in the United States in 1870 by physician Henry Austin Martin of Boston. Dr. Martin obtained the vaccinia virus strain from Dr. Jean-Anne-Henri Depaul, the Director of the Vaccination Services of the Paris Academy of Medicine. Depaul supplied Martin with vaccine from the 258th, 259th and 260th passage of his continuous series of cowpox lesions from the heifer of Beaugency. This “animal vaccine” arrived in New York in September 1870 and was immediately used to inoculate more calves.

The resulting vaccine was used exclusively in the Unites States for the next six years.

Many “vaccine farms” were established in the U.S. after the Civil War and began producing large quantities of “animal vaccine”. By 1897, there were at least 14 main vaccine farms in the US supplying vaccine.

These efforts resulted in many variants or different strains of the vaccinia virus vaccine in use. Modern sequencing technologies are being used to understand the origins of several of the available vaccina virus variants that eventually emerged during this time from the various vaccine farms. Some variants that were produced on the farms were closer to horsepox than cowpox. Still, the vaccine was effective in preventing smallpox.

The Biologics Control Act of 1902 was made by Congress in response to contamination issues in the vaccine farms. It led to the US Secretary of the Treasury requiring licenses to produce and sell vaccines and other biologicals in the US. The initial biological licensees eventually evolved into most of the current major American industrial vaccine manufacturing companies now in existence.

There would eventually be three generations of smallpox vaccines for control of the disease. First-generation smallpox vaccines were developed using the method known as cowpox vaccination described above.

Second-generation smallpox vaccines were developed using a modified form of the original cowpox-based vaccination. Instead of using the live vaccinia virus, scientists utilized a strain called Modified Vaccinia Ankara (MVA), which had been further attenuated (weakened) to ensure safety while still offering protection against smallpox. This vaccine was less likely to cause complications, although it still did carry a small risk of severe disease and even death from cowpox.

Third-generation smallpox vaccines, known as modern or recombinant vaccines, were developed using advanced biotechnology. These vaccines use non-replicating DNA strands to trigger an immune response by introducing vaccinia virus genes into a harmless virus or DNA. Examples include MVA-BN and ACAM2000. These vaccines are extremely safe and carry a very low risk compared to their live virus predecessors.

Routine smallpox vaccination is no longer recommended since the disease was eradicated in 1980. Vaccines are kept for potential outbreaks due to bio-terrorism, monkeypox, or research. The smallpox virus is stored in two authorized labs: the CDC in the U.S. and the VECTOR Institute in Novosibirsk, Russia.

During the battle against smallpox, politics played a major role in efforts to control the disease. Anti-vaccination forces developed during the smallpox battle and were very active over the years. 

Here are the highlights of the battle for the eradication of smallpox:

• 1721 – Cotton Mather and Dr. Boylston inoculate 247 people with 6 fatalities. The rest survive. 
• 1796 – Edward Jenner discovers vaccination with the mild cowpox virus prevents smallpox.
• 1853 –Smallpox vaccination is made compulsory in the UK
• 1866 –Anti-compulsory Vaccination League is formed in the UK
• 1879 –Anti-Vaccination League of America formed
• 1885 –Compulsory smallpox vaccination law is repealed in the UK
• 1905 –Jacobson v Massachusetts, US Supreme Court Case that upheld the authority of states rights to enforce compulsory vaccination (against smallpox). The Court’s decision articulated the view that the freedom of the individual must sometimes be subordinated to the common welfare and is subject to the police power of the state.
• 1922 Zucht v. King, US Supreme Court Case that upheld the authority of states and the school district of San Antonio, Texas, to exclude un-vaccinated students from attending the schools in the district.
• 1971 routine smallpox vaccinations stopped in the US
• 1975 -The last wild human case of smallpox due to variola major occurred in Bangladesh. This happened after a large outbreak that killed thousands of people in India in the early 1970’s. Rhima Banu was two years old at the time when she contracted variola major (severe smallpox) and made a full recovery, although she was scarred for life.
• 1977 - Ali Maow Maalin was the last person to have naturally acquired smallpox caused by variola minor, a milder form of smallpox. On October 12, 1977, Ali, a hospital cook, rode with two smallpox patients in a vehicle. He contracted the disease. Massive smallpox containment efforts would be employed around him by workers of the WHO. He would recover and smallpox would spread no further.
• 1978 - Janet Parker was the last known person to die of smallpox. In 1978, Parker was a medical photographer at England’s Birmingham University Medical School. She worked one floor above the Medical Microbiology Department where smallpox research was being conducted. She became infected somehow while working in the medical school building. She would pass away from smallpox. 

In summary, smallpox was the very first infectious disease that was successfully eradicated in human history with a vaccine, preventing millions of deaths and millions more who would have survived disfigured and disabled. The accomplishment was made with stiff societal objections.

Some observations:

Smallpox posed a significant threat with mortality rates of 14-35%. Initially, variolization reduced the risk of death, though it still involved significant danger. As vaccination with the vaccinia virus (cowpox virus) was developed, it further minimized these risks. People accepted the smaller risk of vaccination to protect against the much greater risk of death from natural infection. This concept—accepting a minor risk to prevent a larger one—remains central to modern vaccination strategies.

There was a spirited public debate, both individually and in the media, about inoculation and later vaccination. Medical pioneers faced ridicule, mockery, and even physical attacks during the smallpox eradication efforts.

There was no vaccine efficacy proof and little reliable information on the safety of inoculations at the outset of the battle to eradicate smallpox.

The most medically educated were the ones who were the quick adopters of the procedure. Many at Harvard took the vaccine themselves and gave it to their families and colleagues. Harvard University has a long and distinguished track record in the eradication of smallpox.

• The media spread false and misleading information, while unprecedented profit-driven media coverage surrounded the smallpox inoculation and vaccination story, often vacillating on vaccination's merits over the years.
• Many people refused the vaccine, leading to regret for some, like Benjamin Franklin, as their loved ones died without the protection of inoculation.
• Inoculation and vaccination mandates were repeatedly enacted and repealed in our country, creating a legal quagmire. Despite some laws against inoculation, George Washington took considerable legal risks to inoculate his troops during the Revolutionary War. There was forced quarantine to control the disease.
• Court battles erupted over the state's authority to enforce vaccinations, levy fines, impose quarantines, and mandate vaccinations for school attendance and employment. Vaccination became a major political issue.
• Despite resistance, the dedicated efforts of researchers, vaccine producers, contact tracers, and public health workers, combined with global cooperation, led to the eradication of smallpox in 1977.
• A virology lab accident resulted in the release of material that killed the last person to die from smallpox. The surrounding immune population and effective quarantine contained the disease, preventing its spread.

Does any of this history sounds familiar?

Summary:

In the 300 years since the 1721 Boston smallpox outbreak, humanity achieved the monumental eradication of this dreaded disease. Smallpox is the only illness completely eliminated from the world through vaccination, significantly improving global safety. Historically, smallpox was devastating, claiming half of all children and 25% of the population, though this accomplishment is now largely forgotten.

While the eradication of smallpox is a monumental achievement, the story of every vaccine in use today shares a similar narrative: a once-dreaded disease that posed significant risks of death and disability has been brought under control through an effective vaccination program. This process involves the development of a vaccine, widespread adoption, government mandates for school attendance, and ongoing utilization, all contributing to the successful management of these diseases. 

However, if herd immunity diminishes due to vaccine hesitancy, every disease we vaccinate against could resurface. Vaccinations are crucial for protecting against life-threatening illnesses. By valuing and supporting vaccines, we not only protect ourselves but also safeguard future generations from past threats, preventing the reopening of Pandora's Box.