Mississippi is a favorite punch line of comedians whenever they need to point to a state that is the worst in terms of almost any social measure such as poverty, teen pregnancies, education, and so on. But interestingly, Mississippi has the highest vaccination rates. How did it get that way? Melissa Bass and Austin Vitale explain how a state that is usually last came to be first in something good.

As a poor, rural state in the hot, humid south, Mississippi historically has been more prone to infectious disease outbreaks than many other states and less prepared to address them through private-market health care. As a result, the state has a century-long history of public health efforts to combat the spread of communicable diseases, supported by the state health department and the state legislature.

In line with this history, when states began passing legislation in the early 1970s requiring children to be vaccinated before attending school, Mississippi passed a particularly strong law: it required children planning to attend public or private school to have the required vaccinations, allowed for medical exemptions only when the local health officer determined that the exemption would not cause undue risk to the community, and had a strict religious exemption policy. Only parents who were “bona fide members of a recognized denomination whose religious teachings require reliance on prayer or spiritual means of healing” could qualify, with a statement of support from an officer of the church.

This restriction that exemption would only be granted on the basis of rigorously documented religious beliefs was challenged by a parent who wanted to expand the exemption to people who had other philosophical exemptions to vaccinations, arguing that it should be a matter left to the personal beliefs of parents, the kind of expanded view of exemptions allowed in 20 other states. The father lost the case in the lower court and the case ended up being appealed to the state Supreme Court with a surprising result. In 1979, not only did the state Supreme Court uphold the law, they went further and struck down the religious exemption too, stating that people, even parents, do not have the right to take risks with children’s health.

The court decided that the law’s religious exemption was itself unconstitutional. First, they determined that the exemption was not required by the First Amendment, asking, “Is it mandated by the First Amendment to the United States Constitution that innocent children, too young to decide for themselves, are to be denied the protection against crippling and death that immunization provides because of a religious belief adhered to by a parent or parents?” and answering no.

The courts then went on to say that it was wrong to expose vaccinated children to unvaccinated ones, using the 14th Amendment’s Equal Protection Clause to justify its decision.

Second, they found that the exemption violated the 14th Amendment, “which provides that no state shall make any law denying to any person within its jurisdiction the equal protection of the laws, in that it would require the great body of school children to be vaccinated and at the same time expose them to the hazard of associating in school with children exempted … who had not been immunized.”

With that decision in 1979, Mississippi – one of the nation’s most religious states and one in which equal protection has too often been denied – became one of only two states to disallow religious, as well as personal belief, exemptions (West Virginia is the other).

The state of Mississippi went further and instituted polices to give their vaccination program real teeth.

Mississippi backed its mandate with policies that made vaccinations available to all, regardless of income, race, or location. The head of the state’s Department of Health, Alton Cobb, made vaccination accessibility a top priority, and he held his post for 20 years, from 1973 to 1993.

Mississippi deserves praise for making sound public health decisions.