In December 2021, Francis Collins, the outgoing head of the $45 billion federal National Institutes of Health declared himself utterly flummoxed. “I never imagined,” the walrus-whiskered Collins told PBS, “a year ago…that we would still have 60 million people” resisting vaccines.

Fifteen months later, no one is surprised about widespread refusal of vaccines—even those vaccines, like measles, that the American public universally embraced 20 years ago. As vaccination rates decline, the vaccine resistance movement, once the butt of jokes, has become a major rallying point for conservative movement politics.

At the grassroots level, vaccine resistance attracts new recruits and reinvigorates true believers even as it promotes a broadly unpopular, and dangerous, political agenda. Across the country, thousands of true believers flock to churches hosting the ReAwaken America Tour, where anti-vax entrepreneur Clay Clark and retired three-star Army Gen. Michael Flynn weave together an apocalyptic culture-war fable that enlists evangelical Christians as a righteous saving remnant, defending God against stolen elections and genocidal vaccination campaigns. And at the top of the party, rising star Ron DeSantis pads his presumptive presidential run with anti-vax rhetoric assailing the “biomedical security state,” while his biggest rival, Donald J. Trump (who oversaw the creation of the vaccines and had earlier promoted them) insults DeSantis as someone who “loved the vaccines.”

How did we get here?

In reality, Francis Collins shouldn’t have been surprised. The anti-vaccine train now hurtling across the deranged landscape of our Covid-battered republic first eased out of the station decades ago. Propelling it forward was an unlikely alliance between two fringe groups: the New Age–minded merchants of bizarre unscientific medical treatments, and libertarian lobbyists. Back then—in the early aughts—the worst thing about being in the anti-vaccine movement was that there was no longer an anti-vaccine movement to speak of.

Sure, every time a new vaccine was rolled out, it sparked fresh public fears, but the problem was the dang things kept working. Over decades, the vaccines racked up victory after victory—polio, smallpox, diphtheria, tetanus, pertussis, all wiped out by successful public vaccination campaigns. In the 1950s, roughly a third of Americans were vaccine hesitant. But now? The anti-vaxxers watched glumly as the most recent childhood vaccination campaign, pushing measles, mumps, and rubella shots, achieved a 97 percent coverage rate, which resulted in zero cases of measles in the Untied States in the year 2000.

Without any serious financial resources behind the anti-vaccine message, about the only people still refusing vaccines were owners of composting toilets, a sprinkling of parents who kinda-sorta heard they caused autism, and fringe members of minority religious groups like the Amish. The chief problem was that the anti-vax movement relied on tired old arguments. People simply didn’t think vaccines were unsafe, or bad for the environment, or sacrilegious. But then something wonderful happened for the scattered and dispirited anti-vax activists—a call to arms at a West Coast alternative health conference.

In 2005, Los Angeles hosted an alternative-healing expo—one of those events where attendees pay a few dollars to wander rows of booths rented by sellers of organic lip balm, hypnotism services, dietary supplements, and healing crystals. These sorts of gatherings happened all the time, especially in New Age–friendly California, but this particular one was the brainchild of an Indiana-based supplements manufacturer named Wendell W. Whitman. Whitman was a graduate of the unaccredited Clayton School of Natural Healing, and in an effort to advance the prospects of alternative healers in Washington, D.C., he had branded this event as the first-ever “Health Freedom Expo.”

The expo, organized by Whitman’s lobbying group, the HealthKeepers Alliance, featured a typical lineup of alternative-health speakers, including Hulda Clark (whose line of panaceas included a $350 “Zapper” to kill the parasites she believed caused all disease), Charlotte Gerson (whose cure-all Gerson Therapy cost up to $15,000), and Kurt Donsbach (who, among other dubious enterprises, ran an alternative hospital in Mexico for patients suffering from terminal illnesses).

But the lineup also included some atypical names: medical-freedom activists like attorney Diane Miller of the National Health Freedom Coalition, and Joan Vandergriff, leader of the Sunshine Health Freedom Foundation (and former seller of an audiocassette “pH Balancing plan,” which promised to correct various disorders of the digestive, glandular, nervous, intestinal, and immune systems ).

These activist speakers were there to bring a message to the alternative-healing community: The alternative health movement’s stock in trade—the fever dream of One True Cure for nearly any chronic malady you could name—could be made much more profitable through the idea of “medical freedom.” For years, the healers had been desperately trying to defend the crappy science behind their various One True Cures, but under the banner of medical freedom, the great question was no longer about the remedies’ efficacy in treating disease. It was about the consumer’s right to buy the treatment they wanted.

Medical freedom wasn’t an entirely new idea, of course, but the proliferation of One True Cures in the Internet age gave rise to a whole class of American entrepreneurs who had a vested financial interest in beating back the regulations that were designed to protect the public. Fueled by their raw energy, the Health Freedom Expo was an enormous success for all involved, spawning dozens of similar events across the country. In evolutionary terms, if the Internet caused the medical quack to become so immensely prolific that regulatory predators couldn’t keep pace, the medical-freedom activists now invited them to herd up and act as one for mutual protection and benefit.

Thanks to these sorts of grassroots actions, diverse sellers of One True Cures began speaking in a single voice. When the disgraced pH Miracle Diet guru Robert Young had a chance to meet President Barack Obama at an event, he didn’t start talking about the science of acid and alkaline diets. “Freedom is a God-given right,” he told the president. “It’s about the right to choose between complementary or alternative or conventional treatment.” Other alt-health entrepreneurs enthusiastically joined the chorus. Toby McAdam said he merely wanted to exercise his rights to sell supplements that he said could treat various cancers and prevent radiation poisoning ; Larry Lytle argued that the ability to purchase lasers to heal virtually any disease of the mind or body was “a private right”; and Pentecostals like Dale and Leilani Neumann began defending faith healing as an exercise of their constitutional religious rights.

As sellers of One True Cures were converted into medical-freedom advocates, a side effect was the creation of a political space that welcomed the fringe actors remaining in the anti-vaccine movement. They were, like alternative healers, eager to move on from scientific debates and instead talk about the rights of Americans to choose. And they were happy to point to One True Cures as solutions to the communicable diseases that vaccines were designed to prevent. Within two years, the speaker lineup at Health Freedom Expos had incorporated anti-vax activist leaders, including Dr. Joseph Mercola, who asserted in a 2006 New York Times bestseller that the avian influenza pandemic was government fearmongering ginned up to control the populace. Mercola was himself marketing a wide variety of health scare and wellness products with bogus health claims.

If alternative healers and anti-vaxxers were happy to have found a label to rally around, imagine how happy it made the people who had created the label in the first place. This was another fringe group—the ones who had already defined what medical freedom means in America: libertarians.

It’s hard to think of two cultures more different than a touchy-feely New Age alternative-healing movement that celebrates mindfulness, and the free-market, small-government libertarian capitalists who celebrate mind-your-own-businessness. But the medical-freedom label formed an unprecedented bridge between these two worldviews.

Libertarians had articulated a clear and comprehensive vision of medical freedom, one that went far beyond weakening federal vaccination programs and allowing unregulated sales of One True Cures. The 2000 political platform for the national Libertarian Party advocated for “a complete separation of medicine from the state. We oppose any government restriction or funding of medical or scientific research…. We support an end to government-provided health insurance and health care.” If the United States adopted this pure free-market approach to health care, it would be the first nation in the world to do so.

The Future of Freedom Foundation, a libertarian policy think tank, published an article that staked out this vision in more detail, blasting the National Organ Transplant Act of 1984, which ensures that donated organs are allocated according to medical need rather than financial resources.

“Why?” asked the article’s author, Laurence Vance of the Ludwig von Mises Institute (and the Libertarian Christian Institute and the International Society of Bible Collectors). “Why do Americans not have the medical freedom to buy and sell organs?”

Vance called for such lovely human rights as “the freedom to discriminate,” “a free market in medical devices,” and “a free market in ambulance services”—meaning that if you live in an area that can’t financially support ambulance coverage, you should pack your sorry, heart-attack-having ass into the car and drive to the hospital yourself. One useful pro-tip, though: Since medical-freedom activists also advocate for the right of an emergency room to refuse service for nonpayment, you’d better not forget your wallet.

The government’s responsibility for public health was cemented back in 1901, when the US Supreme Court ruled seven to two to uphold a mandatory vaccine program to combat a deadly smallpox epidemic; in its ruling, the court established the right of the government to use police powers to control epidemic diseases.

But in the libertarian vision of medical freedom, there are no medical-licensing laws, no Medicaid or Medicare, no federal grants for medical research, and no federal programs to combat public health threats like HIV/AIDS or Covid. To bring about this reconstitution of the American social order as a viral Petri dish by another name, they plan to shutter every federal laboratory in the country and abolish the FDA, along with the Department of Health and Human Services and the National Institutes of Health.

The guiding principle of medical freedom is that a person’s health and safety are the sole concern of the individual, not the government—a bit of ideological boilerplate that pretty much refutes the whole modern history of disease treatment and eradication. All you have to do is Google “Typhoid Mary” to grasp the real-world limitations of this fancy—it’s a simple fact of life that society has a significant stake in an individual’s health. In 1980, Massachusetts court stoutly affirmed this principle in a case involving mandatory helmet laws for motorcycle riders. “From the moment of the injury, society picks the person up off the highway; delivers him to a municipal hospital and municipal doctors; provides him with unemployment compensation if, after recovery, he cannot replace his lost job; and if the injury causes permanent disability may assume the responsibility for his and his family’s continued sustenance. We do not understand a state of mind that permits a plaintiff to think that only he himself is concerned.”

I suspect that targeted surveying would reveal that 100 percent of healthy libertarians proclaim their intentions to do without all these luxuries, while 100 percent of libertarians lying injured on the pavement admit that, yes, such societal services are kind of necessary, now that they think of it.

As the left-leaning New Age creators of universal energy, herbal cures, meditation, and pyramid pendants adopted the libertarian medical-freedom label, they paid a price for their newfound clout: Large segments of the alternative-health movement drifted away from their cultural and spiritual roots and embraced a more commercial version of healing. What they really wanted was the right to sell their products to the public; in advancing that goal, they were signing on to a much broader idea of medical freedom that wanted to dismantle key parts of the social safety net.

Meanwhile, as libertarians absorbed the political power of the alternative-healing industry, their calls for medical freedom gained sway with mainstream Republicans. Elected leaders who could not have been persuaded to endorse lasers or pH miracles in any circumstance suddenly rallied to the alternative-healing cause.

Perhaps Republicans got on board because of their long-standing vision of a more limited form of government. Or maybe it was because they had the same exact vested interest that the purveyors of the One True Cures did: product sales.

Protesters at a 2022 anti-vaccination demonstration in Los Angeles(Damian Dovarganes / AP Photo)

During the aughts, national politicians—almost exclusively Republicans—began monetizing the email lists of their campaign supporters by partnering with for-profit corporations to sell supplements. An exposé by journalist Ben Adler for The New Republic found that a typical mail-order transaction in this booming sector involved about a hundred dollars per one thousand names, allowing campaigns to pull down millions of dollars. (Democrats tended to monetize their mail-order lists in other ways, such as renting them to explicitly political causes and candidates.)

Because of this, tens of millions of rank-and-file Republicans were deluged with targeted, shady health-marketing claims from the presidential candidates they trusted. Herman Cain urged 330,000 supporters to buy TestoMax 200, a One True Cure for erectile dysfunction. Pat Robertson’s crowd was tempted with an age-defying protein shake. Ben Carson’s voters heard all about the Mannatech dietary supplement line. Mike Huckabee sold his followers heart disease fixes and a diabetes solution kit, while Newt Gingrich pitched a cancer cure that cost just 74 dollars per year, and Alan Keyes began hawking Prevennia, a supplement that could supposedly prevent the cell mutations behind 6,000 diseases. America had, quite by accident, created a real clusterquack.

For a century, doctors had rested on the bedrock of scientific surety fueled by empirical researchers; they offered the American public an evidence-based constellation of procedures and recommendations, including vaccines, that demonstrably led to a dramatic increase in the life span of the human organism. Standing on that bedrock, the medical profession took the public’s trust for granted—medical doctors routinely expected patients to accept extreme cures like mind-altering pills, anesthetization to allow strangers to rummage around in their insides, and the stabbing of their children with needles filled with tamed versions of deadly diseases.

A century of fringe One True Cures had failed to destroy this trust. But for most of that time, alternative healers were just a few small actors in an endless swamp of profit-driven medical misinformation. By 2011, it seemed clear that the medical establishment was getting its ass kicked by a shadow health empire that it barely knew existed. That year, for the first time in American history, more adults were taking supplements than not. The use of probiotics had quadrupled over the past decade. Roughly one in 200 Americans who boarded an international flight did so to receive health care in places like Costa Rica, often getting treatments that would be illegal in the United States. That translated to nearly a million people, a ninefold increase over 2003. More people were choosing not to go to their doctor, and a national survey showed that 60 percent of these off-grid patients never told their doctor about the alternative treatments they underwent, whether leeches, lasers, or the low-acid liquid diet.

The most heavily trafficked alternative-medicine website in the world in 2011 was mercola.com, run by anti-vaccine activist (and Health Freedom Expo speaker) Dr. Joseph Mercola, who in 2009 stopped practicing medicine, and in 2010 sold $7 million worth of supplements (such as “Dr. Mercola Vitamin K2,” which he did not adequately test for adulterants) and medical devices (including “telethermographic cameras,” about which he made unfounded medical claims). The website’s heated denunciations of Big Pharma appeared alongside articles pimping things like so-called horny goat weed for erectile dysfunction. That year, Mercola’s website drew 1.9 million visitors a month—as many as the website of the National Institutes of Health—many of whom came back multiple times a week.

The proliferation of One True Cures had serious consequences. In 2015 alone, 23,000 Americans went to the emergency department after taking bunk dietary supplements to lose weight or improve their sex lives or boost their athletic skills.

Meanwhile, it was clear that the FDA, formidable as it might be, was doing little to thin the vast flocks of quacks running amok. By 2014, nearly one in four Americans had purchased items from online pharmacies, and 36 million of them did it to get drugs for which they had no prescription.

Worse, academics and watchdog groups began to point out just how ineffective the FDA was, even when it had a violator in its grasp. Between 2007 and 2016, the FDA identified 746 brands of supplements that were laced with prescription drugs—but only 360 of them were recalled. The rest were still available for sale within the framework of the unstoppable juggernaut of America’s retail system.

In one study that was particularly embarrassing for the FDA, researchers took a closer look at hundreds of products that had been recalled between 2009 and 2012 and found that dozens of them were still available for sale a year after they had been recalled. The researchers bought and analyzed those products and discovered that two-thirds of them were still adulterated with the same ingredients that had prompted the recall. In 2014, one US congressman ruefully noted that penalties were steeper for counterfeiting a designer purse than a designer drug.

When events like the Health Freedom Expo successfully merged New Age healers with cutthroat medical-freedom values, it was as if they’d successfully brokered a wedding between Oprah Winfrey and the Grinch. The quacky offspring of this union raked in huge new revenues, some of which was inevitably diverted into efforts to undermine America’s regulatory system in the name of medical freedom.

That meant showering anti-vaxxers with cash. People like Mercola joined conservative political donors to fund grassroots organizations like Texans for Vaccine Choice or Oklahomans for Vaccine and Health Choice. Mercola, whose net worth ballooned to more than $100 million, funneled $4 million into the National Vaccine Information Center, which fought against vaccine mandates by arguing in part that they violated a Christian tradition of freedom or liberty.

The FDA and the medical establishment had been doing all they could to drop the hammer on One True Cures. It occurred to them belatedly that One True Cures might figure out how to drop the hammer on them.

Taking the fight to the medical establishment was the next evolution of the health-freedom movement. As these groups promoted all sorts of One True Cures (the primary qualification for which seemed to be that they were not vaccines), they successfully lobbied twelve states to pass laws weakening vaccine requirements. Between 2000 and 2015, measles coverage dropped from 97 percent to 92 percent of kids nationally; it became as low as 86 percent in some areas.

Several years later, a group of researchers from the University of Idaho would set out to learn why, during this time period, large numbers of Americans began rejecting vaccines that had been proven effective. Conventional wisdom was that people were individually losing faith in institutions and then banding together under the banner of medical freedom, which had been adopted by the Republican Party.

But in fact, their research proved the opposite: Political identity dictates vaccine opinions, not the other way around. This meant that liberals didn’t support vaccines because they loved science; it was because political influencers told them that vaccine support made them good liberals. And rank-and-file conservatives didn’t begin to rail against vaccines because they had an inherent distrust of doctors. They opposed them because a dense network of influential alternative healers, political leaders, and entertainment personalities told them that doing so made them good conservatives. It made little difference to them that those same healers, political leaders, and entertainment personalities were earning money from products—bogus supplements, fraudulent medical devices, and quack-informed wellness services—that sold better when distrust in mainstream medicine was rampant.

To make matters worse, the basic conditions that fomented all this distrust of the medical establishment was in no small part the handiwork of the medical establishment. In his 2019 book Ruined by Design, the designer and social critic Mike Monteiro argues that most of the problems that run rife through Big Tech and society at large—everything from toxic speech and harmful misinformation on social media platforms to disenfranchisement of poor and minority voters—should not be thought of as mistakes or free-floating problems. Instead, he says, they are the inevitable outcomes of systems that are designed to produce those effects, whether the system in question is Twitter or the Electoral College. If we took an ethical, thoughtful, and inclusive approach to designing (or redesigning) those systems, he writes, most of the problems would simply evaporate.

The proliferation of One True Cures is kind of like that: an inevitable product of poorly and inequitably designed systems. In this case, the systemic failures of the misinformation-friendly Internet, soft-on-supplements legislation, and the ineffectual FDA were compounded by another flawed system, one that was not so much an errant failure in the mission of American medicine as a direct byproduct of it—namely, the medical profession’s deliberate elevation of all the wrong values.

The basic story is told by the demographics of the anti-vax movement. Low vaccination rates and high use of alternative medicine are both associated with rural areas, where Americans tend to make less money, have fewer educational opportunities, and have less health insurance coverage than their urban counterparts.

These are the areas that need doctors most—yet they are the very places that suffer from chronic doctor shortages. As one 2000 study noted, about 20 percent of Americans live in rural areas, but only 9 percent of physicians practice in those communities. Roughly 25 percent of rural residents in the same survey reported that they had recently had trouble accessing medical services, either because of cost or because the services they needed were too far away. The problem has gotten worse since the turn of the century. Between 2005 and 2022, more than 10 rural hospitals closed each year, and only 1 percent of medical students say they want to practice in rural communities.

When medical professionals leave a territory, One True Cures and anti-vaccine messaging move into the vacuum that is left behind. And the absence of medical professionals in rural areas is not a fluke; it is an integral part of the field, as designed by the American Medical Association.

In the mid-1800s, soon after the AMA was formed, it ran doctors for state legislative positions across the country. Once elected, they worked to address what they saw as the profession’s biggest problem: too many doctors and not enough patients. By imposing stricter licensing requirements and preventing the chartering of new medical schools, they reduced the number of graduating doctors—a plan almost entirely based on the argument that reducing supply would increase demand, which would then increase their own wages. This was, perhaps, a defensible position when doctors carrying black bags on horseback to house calls could barely make ends meet, but the appetite for money well outlasted that era. No matter how high physicians’ salaries got over the next hundred years, the AMA continued to lobby to further narrow the pipeline of doctors.

This strategy has been strikingly effective. In 2020, the average self-employed physician earned more than $350,000. Today, the doctor supply is so small and poorly distributed that Mississippi had just 191 licensed doctors per 100,000 people, roughly half the ratio in New York, Vermont, Rhode Island, or Maryland. Even those states compare unfavorably to the 400 doctors per 100,000 enjoyed by the residents of the Russian Federation, or Italy—or, of all places, Kazakhstan. (Greece had 550 doctors per 100,000 people, and Cuba had 840, the most in the world.)

By making American doctors so precious, the AMA inflated the social and financial status of its members, which introduced another, unintentional obstacle to access: Credentialed doctors now comprise an intimidating elite culture, one that breeds mistrust and misunderstandings among underserved rural patients nearer the low end of the socioeconomic ladder. Had the health care model that the AMA so aggressively designed and sold to the public included an ample flow of doctors whose pay didn’t create a massive class gulf with so many of their rural patients, quackery would have lacked a friendly medium for its growth.

Today, we’re living through the brutal consequences of that growth, particularly in rural areas, where the MAGA rank-and-file have filled the vacuum with not only anti-vaccine sentiment but also a whole raft of science-lite ideas that threaten the well-being of their own bodies, and the larger body politic—notably, QAnon-directed narratives that claimed elite Democrats were harvesting the adrenaline of children, that the entire pandemic was a fiction orchestrated by Big Pharma, and that various prominent liberals are actually intelligent reptilians disguised as humans. And, of course, that the key to health is something like the veterinary deworming agent ivermectin, or the Miracle Mineral Solution—a supposed cure-all that is actually a diluted form of bleach.

Under the great dispensation of our new age of medical freedom, these disparate forces—ambitious Republican politicians, self-interested medical professionals, profiteering quacks, and nihilist visionaries—have melded to produce the libertarians’ cherished vision of a free market of medical ideas, administered by and for sovereign individuals. And just as that utopian design foretold, when it comes to evidence-based medical science, a disturbing number of Americans are not buying.