Faith, Law, and the Needle: A History of Religious Exemptions to Vaccination in the United States

On the morning of February 7, 1991, a nine-year-old girl named Caryn Still died of measles in North Philadelphia. She was a third-grader at the Faith Tabernacle Congregation school, where none of the two hundred students had been vaccinated against anything. Three days later, her classmate Monica Johnson died the same way — a rash, then unconsciousness, then cardiac arrest. Her parents never called a doctor. That was church doctrine. Illness was God's business, and medical care was interference.

Over the next ten days, . By June of that year, nine children were dead and more than 1,400 people had been infected across Philadelphia. The city was the epicenter of the worst American measles epidemic in a generation. And the outbreak had a legal shield: Pennsylvania, like nearly every state in the country, allowed parents to opt their children out of vaccination for religious reasons. That shield had been on the books for a little over ten years.

The story of religious exemptions in the United States is not, as many people assume, a story that began with the founding of the republic. It began in the 1960s. But the arguments that produced it — the arguments between a person's faith and a community's safety — are much older, and they are still being fought. This post walks through where those exemptions came from, how courts have handled them, what has happened when they collided with an outbreak, and what public health workers have learned about talking with the people who claim them.

In 1721, a smallpox epidemic tore through Boston. The Puritan minister Cotton Mather, who had learned about a folk practice called variolation from an enslaved West African man named Onesimus, urged the city's physicians to try it. Variolation was crude — you took pus from a smallpox pustule on a sick person and rubbed it into a small cut on a healthy one, provoking a milder case that usually left the patient immune. It worked. It also killed some of the people who received it.

Mather was pilloried. A bomb was thrown through his window. Local ministers preached that inoculation was a rebellion against divine providence — that if God had sent smallpox, then it was not humankind's place to intervene. A pamphleteer named John Williams wrote that inoculation was "bidding defiance to Heaven itself." That charge — that vaccination usurps God's role — is the same charge you can still read on anti-vaccine websites today.

Nearly a century later, when Edward Jenner's cowpox vaccine crossed the Atlantic, the argument came with it. In 1798, an anti-vaccination society formed in Boston, made up of physicians and clergymen. In 1803, the Reverend Dr. Ramsden preached against vaccination from a Cambridge University pulpit. But in the United States, no religious exemption to vaccination existed at the level of law. When Massachusetts became the first state to make school vaccination compulsory in 1855, there was no religious carve-out. If your child was not vaccinated, your child could not go to school.

The most consequential vaccine case in American law started with a preacher who had nothing against faith.

Henning Jacobson was born in a Swedish farming village in 1856 and vaccinated against smallpox at age six under his country's compulsory vaccination law. According to what he later told a Massachusetts court, the vaccination made him miserably ill for a long time — a bad reaction that shaped everything he later believed about the procedure. He emigrated to the United States around 1870, studied at a Swedish Lutheran college in Illinois, and in 1892 founded the Swedish Evangelical Lutheran Augustana Church in Cambridge, Massachusetts, where he served as pastor for the rest of his life.

In 1902, smallpox was again moving through Cambridge. The Board of Health ordered that every adult who had not been vaccinated in the past five years must be vaccinated or pay a five-dollar fine. On March 15, the chairman of the board came to Jacobson's home. Jacobson refused the vaccination. He cited his own childhood suffering and a similar bad reaction one of his sons had suffered. His objection was medical and personal, not religious. He was charged, convicted, and fined.

He appealed all the way to the Supreme Court of the United States, arguing that the Massachusetts law was "hostile to the inherent right of every freeman to care for his own body and health in such a way as to him seems best." On February 20, 1905, the Court ruled 7–2 against him. Justice John Marshall Harlan wrote the majority opinion.

Read it once, because it still governs American vaccine law more than a century later:

"The liberty secured by the Constitution of the United States does not import an absolute right in each person to be, at all times and in all circumstances, wholly freed from restraint. There are manifold restraints to which every person is necessarily subject for the common good."

A few pages on:

"The rights of the individual in respect of his liberty may at times, under the pressure of great dangers, be subjected to such restraint, to be enforced by reasonable regulations, as the safety of the general public may demand."

Jacobson paid his five dollars. He kept preaching in Cambridge for another twenty-five years and died in 1930. The case that bears his name — — became the foundation for every American mandatory vaccination law that followed, and it did so without any religious exemption at all. That is worth pausing on. The country's most famous vaccine case was brought by a Lutheran pastor whose objection was medical, and theCourt'ss answer was that public health authority does not stop at the doorstep of individual conscience.

Seventeen years later, in , the Court applied Jacobson to schools: a child could be barred from attending public or private school if she was not vaccinated. And in , in a case that was actually about a Jehovah's Witness child selling religious literature on the street, Justice Wiley Rutledge wrote a line that has been quoted in every religious exemption case since: "The right to practice religion freely does not include liberty to expose the community or the child to communicable disease."

For most of the twentieth century, that was the American legal position. Vaccination was compulsory. Religion did not exempt you.

If you had asked a public health lawyer in 1950 whether the states had religious exemptions to school immunization, the answer would have been almost universally no. If you ask that same question today, the answer is that 46 states and D.C. have one.

The story of how that happened is detailed in a  by legal scholar Dorit Rubinstein Reiss. Religious exemptions to school vaccination laws first appeared in New York in the 1960s. They were not written to shelter a general population of religious objectors. They were written for one specific group: Christian Scientists.

The Church of Christ, Scientist, founded by Mary Baker Eddy in 1879, teaches that disease is an error of the mind, healed through prayer rather than medicine. Christian Scientists did not use hospitals, doctors, or vaccines. As states in the 1960s began tightening school vaccination laws, Christian Science families found themselves cornered. New York wrote a narrow exemption for them. Other states followed.

Then the federal government pushed the process forward. In the early 1970s, the CDC and the Department of Health, Education, and Welfare began linking federal funds to state school immunization laws, driving a nationwide wave of new mandates. Many state legislatures added religious exemption clauses alongside the new requirements to make them politically easier to pass. By the early 1980s, almost every state had a religious exemption on its books.

Two court cases shaped what those exemptions could look like. In (Massachusetts, 1971), the state's highest court struck down an exemption that was limited to "members of a recognized church or religious denomination," ruling that it discriminated among religions. After Dalli, most states rewrote their exemptions to require only a "sincerely held religious belief," which no longer required a parent to belong to any particular church. In (Mississippi, 1979), the Mississippi Supreme Court went the other direction. It held that offering a religious exemption at all would discriminate against non-religious families whose children were not similarly protected. Mississippi, therefore, refused to have one, and for the next four decades it was one of only two states in the country — the other was West Virginia — that offered no non-medical exemption of any kind.

So the practical modern picture emerged in a very short historical window: from no religious exemptions at all before 1960, to a nearly universal patchwork of them by 1985. In 1990, the Supreme Court decided , a case about Native American religious use of peyote. The ruling had nothing to do with vaccines, but it established a principle that has shaped every religious vaccine case since: a neutral law that applies generally to everyone does not violate the Free Exercise Clause just because it burdens someone's religious practice. In plain language, the Constitution does not require any state to offer a religious exemption to a vaccine mandate. Every religious exemption that exists today exists because a state legislature chose to write one — and, as we'll see, any legislature can also choose to take one back.

Because religious exemptions have been widely available, and because sincerely held religious belief cannot be examined too closely without violating the First Amendment, they get used. Sometimes by families who genuinely have theological objections. Sometimes by families who use the religious language as a legal shortcut to opt out. When enough of those opt-outs cluster in one community, that community loses herd immunity. Then somebody travels, brings home an infection, and the outbreak begins.

The pattern shows up early. In 1972, a poliomyelitis cluster occurred in a Christian Science school in Greenwich, Connecticut. In 1985, , a Christian Science-affiliated school in Elsah, Illinois. Christian Science communities have accounted for a modest but consistent share of vaccine-preventable disease clusters in the United States since the middle of the twentieth century.

The Philadelphia outbreak that opened this post is the most heartbreaking case of what happens when religious exemption meets a virus with a 90-percent secondary attack rate.

Measles arrived in Philadelphia in April 1989, brought back by a teenager who had traveled to Spain and attended a concert at the old Spectrum arena. Cases spread through underimmunized neighborhoods over the following year. By late 1990, two children unrelated to any church had died of measles — the city's first measles deaths in twenty years. The health commissioner, Dr. Robert Ross, declared an emergency.

Then, in mid-January 1991, Ross's office got an anonymous call from a woman whose granddaughter attended the school at the Faith Tabernacle Congregation, in a rundown block of North Philadelphia. The caller said children at the school were sick. The school had about 200 students. Not one of them was vaccinated. The congregation, along with its offshoot, the First Century Gospel Church, believed that all medical treatment — vaccines, antibiotics, hospital care — was forbidden. Illness was to be met with prayer.

Caryn Still, nine years old, died on February 7. Monica Johnson, also nine, died three days later. Nancy Evans, five, and Linnette Milnes, fourteen, died on February 14. Tina Louise Johnson, thirteen, died the next day. Nineteen-month-old James Jones died on March 8 of measles encephalitis. Three more children would follow. Six of the nine dead belonged to the two churches. The others were in unvaccinated families in the neighborhoods where the outbreak had already been circulating.

Dr. Paul Offit, then a young infectious disease physician at Children's Hospital of Philadelphia and today the director of the hospital's Vaccine Education Center, as "a major epidemic. Parents were scared to death in this city. The city became a feared destination. It was a nightmare." Children arrived at hospitals in the late stages of pneumonia because their parents had waited. "They were profoundly of the belief that Jesus would protect their children," Offit said. "They said Jesus was our doctor."

Ross asked the pastor of Faith Tabernacle, Charles Reinert, to allow the children to be vaccinated. Reinert refused. Ross closed the school. Then, with Mayor W. Wilson Goode's support, he went to Philadelphia's Family Court and obtained court orders compelling medical treatment and vaccination for the sickest children over their parents' religious objections. Three appellate courts upheld those orders. The ACLU declined to represent the church. Their reason, per Offit's retelling: parents are free to martyr themselves for their faith. They are not free to martyr their children.

Inside the two churches, the than in the surrounding city. The case-fatality rate reached one in thirty-five children — worse than the case-fatality rate for measles in the developing world. All of it, Offit later wrote, would have been prevented by a shot that cost less than the fine Henning Jacobson had refused to pay in 1902.

The Philadelphia outbreak did not change Pennsylvania law. The religious exemption stayed on the books. And the same denomination is still tied to preventable child deaths today: in April 2026, in the death of their newborn from an untreated illness the coroner said was survivable. The church, founded in Philadelphia in 1897, has been associated with dead children in nearly every decade since.

In the spring of 2014, four unvaccinated young Amish men from Knox County, Ohio, traveled to the Philippines on a mission trip. The Philippines was in the middle of a major measles epidemic. The men came home infected. The virus moved through their tight-knit, largely unvaccinated communities, spreading to nine counties. By July, , the largest single measles outbreak in the United States since measles had been declared eliminated in 2000. The Amish are not doctrinally opposed to vaccination — plain-community elders in Ohio actively cooperated with public health officials, and vaccination clinics run through Amish community networks helped end the outbreak in weeks rather than months. But the routine vaccination rate had drifted low enough that the virus, once it arrived, had nowhere to stop.

By the fall of 2018, a large measles outbreak was underway in Israel, particularly in ultra-Orthodox neighborhoods of Jerusalem, where first-dose MMR coverage had fallen to about 78 percent. That October, an unvaccinated child returned to New York from Israel and brought measles into Orthodox Jewish communities in Rockland County and in the Williamsburg and Borough Park neighborhoods of Brooklyn.

The New York outbreak became the largest and longest sustained measles event in the United States since the disease was declared eliminated. Rockland County recorded 312 confirmed cases before the outbreak was declared over in September 2019. New York City recorded 649. Vaccination rates in some yeshivas had fallen to as low as 60 percent, against a statewide average above 92 percent. On April 9, 2019, in four Brooklyn ZIP codes, mandating MMR vaccination for everyone over six months old and threatening $1,000 fines for noncompliance. Nearly 34,000 doses were administered in Williamsburg and Borough Park in the months that followed.

An important point about this outbreak: it was not driven by rabbinic teaching. Anti-vaccine activists — some outside the community, some within — had produced a slick, misinformation-laden pamphlet called The Vaccine Safety Handbook and circulated it through Orthodox communities. Mainstream Orthodox rabbinical authorities pushed back publicly and forcefully. Rabbi Dr. Aaron Glatt, chairman of the department of medicine at South Nassau Communities Hospital and a practicing pulpit rabbi, plainly: "There's not a single opinion that says vaccination is against Jewish law." A 2021 found that across the Orthodox rabbinical spectrum — Haredi, National Religious, Modern Orthodox — the overwhelming majority endorsed vaccination for both children and adults.

Two months after the Brooklyn emergency declaration, the New York State legislature repealed the state's religious exemption to school vaccination. It happened on June 13, 2019. A found that vaccination rates in the affected ZIP codes climbed to between 97.95 percent and 99.15 percent after the exemption was removed.

In late January 2025, the South Plains Public Health District in West Texas notified state health officials of a suspected case of measles in a young child from Gaines County, a rural stretch of oil-country prairie about 90 minutes southwest of Lubbock. By January 30, two PCR tests had confirmed it. By early February, the case count was climbing daily.

Gaines County is home to a Low German–speaking Mennonite community that traces its migration through Mexico back to religious persecution in Europe. Kindergarten vaccination coverage in the county sat at about 82 percent — well below the 95 percent needed to keep measles from taking hold. Nearly one in seven local students had a filed conscientious exemption to at least one required vaccine.

On February 26, 2025, an unvaccinated six-year-old girl died at a Lubbock hospital. She had been ill for three weeks. She was, according to the state, otherwise healthy. It was the first measles death in the United States since 2015. On April 3, an eight-year-old girl named Daisy Hildebrand died of "measles pulmonary failure" in the same hospital. She was also unvaccinated, also from the Mennonite community, and also otherwise healthy at the time she was infected. An unvaccinated adult in Lea County, New Mexico, also died. By the time , the state had recorded 762 confirmed cases, 99 hospitalizations, and two dead children. Chihuahua state in Mexico, where the virus spread through a related Mennonite community after a Mexican resident visited Gaines County, went on to record . Ontario became the measles center of the Western Hemisphere for much of the year.

The full 2025 U.S. total reached — the highest annual measles count in more than thirty years. As of mid-2026, cases are already running ahead of the 2025 pace.

The Mennonite piece of this outbreak deserves a careful look, because it is easy to get wrong. Mennonite theology does not prohibit vaccination. There is no doctrine against it. Tina Siemens, who runs a small Mennonite museum in Seminole documenting her community's history of religious persecution, : "It's not for religious reasons. Because they were self-sustaining, they did not visit the local doctor for everything; they had home remedies." Siemens translated Texas Department of State Health Services vaccination materials into German for her neighbors. She said she was mostly ignored. Pastor David Klassen, of a mostly Mennonite congregation in the outbreak area, told the same reporters that his church took no position: "We left it to the mothers to decide."

The exemption most families used was Texas's broadly available "conscientious exemption" — legally categorized as a personal-belief exemption, but on paper looking indistinguishable from a religious one. In Texas, as in most states with such an exemption, a parent simply signs an affidavit. There is no external verification. There is no doctrinal statement. And for a community that has kept its own schools, its own language, and its own remedies for generations, the affidavit is the paperwork that comes with a much older cultural reflex: outsiders, especially outsiders from the state, do not tell us what to put into our children.

In December 2025, the Texas Tribune returned to Gaines County. Their reporters found that attitudes had . Two children were dead, hundreds had been sick, the national press had come and gone — and the community's answer, in the aggregate, was that they felt blamed, unfairly targeted, and no more interested in vaccinating their kids than they had been a year earlier. One community member named Friesen told the Tribune what he thought had gone wrong with the public health response: it "fell short because it came across as orders." He suggested "a better approach is to teach people how vaccines work and invite questions" rather than issue directives.

That single sentence is the hinge of this entire history. It is where public health, having won at Jacobson and lost at Faith Tabernacle and won at Brooklyn and lost, so far, in Seminole, has to figure out what to do next.

For fifty years after the modern religious exemption emerged, the trend line moved in the same direction: more exemptions, easier to obtain, in more states. Around 2015, that reversed for a while.

The Disneyland measles outbreak of December 2014–January 2015 spread to seven states and infected 147 people, most of them Californians. California's response was legislative. In June 2015, Governor Jerry Brown signed , which eliminated both the religious and personal-belief exemptions to school vaccination. California became the first state in more than a generation to repeal an existing religious exemption. Kindergarten vaccination rates rose statewide.

New York followed in 2019, in the middle of the Brooklyn outbreak described above. Maine's LD 798, also signed in 2019, took effect in 2021 and eliminated both religious and philosophical exemptions. Connecticut repealed its religious exemption in 2021, grandfathering only currently enrolled K–12 students. As of this writing, — over 97 percent of schoolchildren — and Connecticut posted the country's highest kindergarten measles vaccination rate as of the 2024–2025 school year.

But that trend line has now bent the other way. In January 2025, West Virginia Governor Patrick Morrisey issued an executive order directing state schools to grant religious exemptions to vaccine mandates, despite the state's decades-old statute permitting only medical exemptions. Within months, multiple lawsuits were filed — some to block the order, some to defend it. In July 2025, a lower court granted in the governor's favor, and by December 2025, the West Virginia Supreme Court had agreed to review the case. Mississippi, the state that had refused to grant any religious exemption for 40 years following Brown v. Stone, added one around 2023. Robert F. Kennedy Jr., the current U.S. Secretary of Health and Human Services, has publicly endorsed Morrisey’s position.

So the map that had reduced the four "no exemption" states down from six a decade ago — California, Connecticut, Maine, and New York — now sits at four in the middle of a live legal battle over whether it will stay that way. The historical direction of the exemption regime is contested again for the first time in a generation.

If the last century of religious exemption law tells one story, the last twenty years of clinical research on vaccine hesitancy tell another one alongside it. Public health cannot argue anyone into a shot. And yet a good conversation, done in the right way, changes vaccination decisions more often than any court order.

Four evidence-based approaches keep coming up in the literature.

The presumptive opening. In 2013, Dr. Douglas Opel and colleagues at Seattle Children's published that recorded how pediatricians actually talk about vaccines with parents. They found that when a provider opened the conversation with a "participatory" question — "What do you want to do about shots today?" — parents were 17.5 times more likely to resist the recommendation than when the same provider opened with a "presumptive" statement — "Well, we have to do some shots today." Opel put it more bluntly to a reporter: "There isn't a choice here. There's no other medically accepted option." The pediatricians in the study who kept recommending vaccines even after initial parental pushback got 47 percent of the initially resistant parents to agree by the end of the visit.

Motivational interviewing. Motivational interviewing, or MI, is a communication technique originally developed for substance-use counseling that has been adapted specifically for vaccine hesitancy. It rests on four practical steps: engage the parent without judgment; understand what actually matters to them under the hesitancy; offer information using an "ask-offer-ask" pattern, so the information you provide is what the parent has asked for; and clarify by acknowledging their autonomy over the final decision. A delivered MI-style vaccine conversations to mothers during their postpartum hospital stay and produced a 15 percent increase in vaccination intent among hesitant mothers. A large randomized controlled trial in 2025, published in , tested a hybrid of empathetic refutation and MI and found measurable improvements in vaccine readiness and confidence.

The CASE method. Developed by Alison Singer and the Autism Science Foundation, the is a one-page script that any pediatrician, nurse, or pharmacist can memorize in ten minutes:

• C — Corroborate. Start by acknowledging what the parent has said and finding something in it you agree with. If a parent is worried that some vaccines contain small amounts of aluminum, agree that vaccine ingredients are worth understanding, and thank them for reading the insert.
• A — About me. Say a sentence or two about your own training and how you came to your position. The goal is not authority. It is to let the parent see that a specific person with a specific background is in the room with them, not an anonymous institution.
• S — Science. Explain what the evidence actually says, in ordinary language. Numbers help. Comparisons help more.
• E — Explain and advise. Give your recommendation. Own it. Do not hedge.

Trusted messengers. The single most consistent finding in the recent literature on religious vaccine hesitancy is that the effective persuader is usually not a public health worker. It is a person the community already trusts. During the Rockland County outbreak, mainstream Orthodox rabbis were the most credible voices pushing back against the anti-vaccine pamphlet. In Gaines County, succeeded in reaching families that the state health department's clinics never quite could. A large IMA World Health field project that trained clergy to deliver "faith and science" sermons and health talks measured drops in vaccine hesitancy from ; roughly 11 percent of the 2.7 million vaccinations delivered through the project were directly attributable to a faith leader's endorsement. A 2025 reached the same conclusion for COVID-19 vaccination: engaged religious leaders build trust, counter misinformation, and increase uptake, and their silence or opposition does the reverse.

What ties these four techniques together is that none of them is an argument about faith. All of them respect the person you are talking to as someone whose "no" is worth understanding rather than overriding. The 2025 qualitative study on faith-based vaccination interventions : "Interventions to increase vaccine uptake among faith groups need to focus on building trust and inclusivity, rather than on religious beliefs." Because when religion is offered as a reason for refusal, it is very often not the reason. It is the language available for the reason. The reason itself is usually some combination of prior bad experience with the medical system, misinformation from someone the person trusts, and a well-founded historical suspicion of being told what to do by outsiders.

The doctor who acknowledges all three of those things — and then still, calmly, recommends the vaccine — is the doctor who moves the needle.

Three points, in the order I would want a reader to remember them.

First, religious exemptions to vaccination in the United States are much younger than most people assume. They are not a founding-era protection. They are a mid-twentieth-century accommodation, invented for Christian Scientists and expanded through political compromise as the country moved toward universal school immunization. What legislatures created, legislatures can end. California, New York, Maine, and Connecticut have shown that; West Virginia is showing the reverse. There is nothing inevitable about the current map.

Second, the Constitution does not require any state to hand out a religious exemption. Jacobson stands. Prince stands. Smith stands. A state that decides to have one is making a policy choice, not obeying a constitutional command. That is worth remembering the next time a bill to repeal one comes to a floor vote in a state legislature.

Third — and this is the hardest one — the history of religious exemption in the United States is not a story of religion versus medicine. It is a story of trust. When faith communities have felt lectured at, they have hardened. When they have been engaged as partners, with their leaders trained, their language respected, and their questions taken seriously, they have shifted. The Faith Tabernacle families in 1991 Philadelphia and the Mennonite families in 2025 Seminole reached the same refusal by very different routes, and the successful responses in Brooklyn and in Andrews County reached the same acceptance by very different routes, too. In both cases, what worked was not louder public health messaging. It was a specific person, known and trusted inside the community, saying: This is safe. This is what I would do for my own child. Come talk to me if you have questions.

Nine children died in Philadelphia in 1991. Two more died in West Texas in 2025. Every one of them died of a disease we have known how to prevent for six decades. The exemption laws that shelter that death toll are neither ancient nor untouchable — they are recent, they are contested, and they were written by people. They can be rewritten. And in the clinic room, in the meantime, the conversation that changes a parent's mind is not the one that starts with the law. It is the one that starts with listening.