It took a small town chiropractor named Charles Brown to help vaccinate millions of kids for decades to come — all because he didn’t want to vaccinate his own.

It was 1979 in Houston, Mississippi, and Brown needed to enroll his 6-year-old son in school. But state law required the boy to be vaccinated against certain diseases, and Brown didn’t want to vaccinate his son. At the time, Mississippi had two exceptions to this law: medical exemption, for kids who had a medical condition that prevented them from receiving certain shots, and a religious exemption, but only for religious groups whose doctrines explicitly prohibit vaccination, such as Christian Scientists. Brown’s son wasn’t eligible for either exemption. So Brown sued.

Brown argued that by limiting the exemption to only certain religious groups, the law violated his First Amendment rights and ought to be expanded to include any religion. (The Browns were Christian, but not a sect approved for a medical exemption.) The case made it to the state Supreme Court where it spectacularly backfired. Rather than expand the religious exemption, the justices argued that having the exemption at all was a violation of the 14th Amendment because it put the rights of certain religious parents over the rights of other parents. The state court struck down the exemption altogether. 

With that decision, Mississippi became just the second state (after West Virginia) not to offer religious or personal belief exemptions to its child vaccination mandate. Mississippi now consistently has the country’s highest rates of vaccination among children entering school. 

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Mississippi’s childhood immunization rates are a sharp contrast to its COVID-19 vaccination numbers. As of Thursday, 44.5 percent of eligible Mississippians are fully vaccinated, making it 46th in the nation. In fact, Mississippi’s overall vaccination record — outside of kindergarteners — isn’t great: The state ranks much lower when it comes to vaccine rates for toddlers and teens, as the vaccination requirement only applies to students entering school for the first time.

It’s natural to wonder, then, whether Mississippi — and other vaccine-hesitant states — will expand their mandates to include the COVID-19 vaccine once it’s approved for kids as young as 5 years old. School mandates are one of the few tools states have to enforce vaccination, and they’re effective. Other jurisdictions are already considering, or have already enacted, such a mandate: California has announced plans to make the COVID-19 shot mandatory for grade school attendance, and school districts across the country have made it a requirement for extracurricular activities.

But adding COVID-19 shots to existing school mandates is not without risk. If an unpopular and highly politicized vaccine is added to the list, those opposed may begin to challenge all vaccine requirements. It’s already happening in other states, to some extent. In Ohio, statehouse Republicans introduced a bill that would ban all vaccine mandates, of any kind, for any vaccine, though it was never voted out of committee. And in Tennessee, Republican lawmakers pressured the state department of health into temporarily halting vaccine outreach to minors for any shot, not just the COVID-19 jab. It’s an idea that may be gaining popularity among Republican voters, too. The Economist/YouGov have historically surveyed Americans on whether or not they think “parents should be required to have their children vaccinated against infectious diseases.” In the past, and as recently as last year, the majority of both Republicans and Democrats answered yes, but in a new poll released yesterday, only 46 percent of Republicans agreed with the statement. This fight pits two very serious public health considerations against one another: Either keep the COVID-19 vaccine off the school mandate and risk leaving millions of children and communities at greater risk of the virus, or add it and risk the entire vaccine schedule falling under attack.

When it comes to childhood immunization, you simply can’t beat the Magnolia State. During the 2019-2020 school year, more than 99 percent of Mississippi kindergarteners were fully vaccinated, according to the Centers for Disease Control and Prevention, which tracks kindergarten vaccination rates in every state for the MMR (measles, mumps and rubella), DTaP (diphtheria, tetanus and pertussis) and chickenpox vaccines. While childhood vaccination rates in the U.S. are generally high, Mississippi is exceptional — it has a more than 99 percent coverage rate for all three shots. Other state rates for kindergarteners ranged as low as 84 percent (for the DTaP vaccine in Indiana). The second-highest rate (in West Virginia, also for DTaP) was 98.8 percent. Childhood vaccine mandates have always been political, but they have typically not been partisan. The modern anti-vax movement has prompted fights surrounding the mandates and their exemptions, but as I’ve previously reported, the anti-vax movement has long been a bipartisan affair. As a result, childhood vaccination rates don’t fall along partisan lines the way COVID-19 vaccination rates do — red states are just as likely to have high childhood immunization rates as blue ones.

Like most states, Mississippi has had its share of pushback from anti-vaccine groups over the mandate (and in particular its lack of exemptions). But these efforts haven’t amounted to much beyond a few proposed bills that died in committee. Among the general public, the mandate has largely been tolerated as a fact of life, according to James Colgrove, a sociomedical science professor at Columbia University who studies public health policy.

“I haven’t found evidence that there was any widespread resistance,” Colgrove said. “The evidence we have for its acceptance is mostly negative evidence: the absence of lawsuits and controversy.” 

When measles outbreaks have occurred in recent years, Mississippi has been spared due to its high vaccination rates, even when outbreaks hit neighboring states. These outbreaks remind the public of just what vaccines protect them from and can be helpful for passing or upholding vaccine law. Consider California, which leveraged a measles outbreak to do away with its personal belief/religious exemption in 2015.

But Mississippi has not embraced the COVID-19 vaccine in the same way. Government agencies and nonprofits have worked together to reduce barriers to accessing the vaccine — efforts that helped the state close its early racial gap. But nearly half the state’s eligible population remains unvaccinated, and the politicization of the pandemic has undoubtedly played a role. It’s reductive to suggest all of the vaccine hesitancy is simply due to Mississippi being a red state (Republicans are less likely than Democrats to be vaccinated for COVID-19), but there is a correlation: Counties with a higher voter share for Trump have some of the lowest vaccination rates in the state. 

“We often get reduced to backwoods, ignorant people who don’t know how to think. It’s much more nuanced than that,” said David Buys, the state health specialist at Mississippi State University Extension. “We have a lot of rugged individualism that serves us quite well. That’s not altogether bad. We want people to be critical thinkers. In this case, we do want people to rely a little bit more on the expertise of our public health officials.”

That politicized tension makes the notion of mandating a COVID-19 vaccine for all school kids, once it’s available, much less likely in the state. Though state law grants authority to the State Health Officer to specify which vaccines are required to enroll in school, new shots are rarely added. The most recent shot, for chickenpox, was added by the state department of health in 2002, with little fanfare. But the vaccine against HPV — another politicized vaccine — was never added (this is true for most states), despite it being recommended by the CDC. The state department of health refused to answer a request for comment.

Increasing COVID-19 vaccination rates in Mississippi, whatever the means, will undeniably reduce the spread of the virus, but this vaccine is different from the ones currently required for school children. Aside from the politicization, COVID-19 is not a disease that primarily impacts kids the way measles, mumps, or pertussis do. Though the vaccine reduces the risk of infection, the risk of a severe infection or death from COVID-19 is already quite low for children. This would make adding it to the school mandate an even harder sell in a state resistant to the jab. 

And then there’s the concern that drawing attention to a law can have unintended consequences. (Just ask Charles Brown.) Given the COVID-19 vaccine’s heightened politicization, adding it to a school mandate could draw unwanted attention to the other mandated vaccines, and risk politicizing those as well. Some public health experts have even warned against including the COVID-19 vaccine in school mandates for this precise reason.

“Health officers are creatures of the state and the health officer is probably keenly aware that trying to go that route could lead to political backlash,” said Dorit Rubinstein Reiss, a vaccine law expert at the University of California, Hastings. “I’d be surprised if, in a state with this level of hesitancy, this would happen.”

Mississippi isn’t alone in facing down this dilemma. As COVID-19 vaccines gain approval for kids aged 5 to 11 — which they’re expected to in the coming weeks — every state will need to grapple with whether or not existing school mandates ought to include COVID-19, or if the risk of drawing negative attention is too great. As Brown learned in his crusade to change the religious exemption, sometimes efforts to alter a law can wind up destroying it altogether.

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