In 2000, measles was declared eliminated from the United States following a successful, national vaccination program — transmission of the disease had ceased within America, but even now, measles has yet to be eradicated worldwide. The continued spread of measles in other countries and lapses in America’s vaccination rates leaves the country vulnerable to outbreaks like the one happening in Texas right now. The ongoing outbreak has so far claimed two lives, with cases increasing due to the incredibly high transmissibility of measles and low vaccination rates in the affected areas.
In this adapted excerpt from his book Booster Shots (Penguin Random House, 2025), pediatrician and infectious disease specialist Dr. Adam Ratner looks at a historical measles outbreak in Texarkana, a city at the border of Texas and Arkansas. In the outbreak, the side of the state line people happened to live on determined their fate.
True to its name, Texarkana straddles the border between the states of Texas and Arkansas. In the 1960s, about two-thirds of the population lived in the part of the city that was in Bowie County, Texas, with the remainder residing in Miller County, Arkansas. The division did not generally affect the day-to-day workings of the city, with residents of both counties attending the same local businesses, churches, and events.
However, separate public schools and public health departments were maintained on either side of the state line. Texarkana was a natural laboratory to understand how policy choices could dictate health.
In late June 1970, a 5-year-old Texarkana boy who had traveled out of the area was diagnosed with measles. He represented the first recognized case in an outbreak that would last more than six months and involve more than 600 people, mostly children. That isn’t the remarkable part — measles outbreaks were becoming more frequent everywhere.
What made Texarkana different is that State Line Avenue separated two jurisdictions with quite different approaches to measles vaccination. Texas had no requirement for measles vaccination prior to school entry and generally eschewed mass vaccination campaigns.
Fewer than 60% of 1- to 9-year-olds on the Texas side were immune to measles either through vaccination or prior illness. In contrast, Arkansas maintained a school mandate and had held mass immunization campaigns for preschool- and school-aged children in each of the two years prior to the outbreak. An estimated 95% of their 1- to 9-year-olds were immune.
The result was striking. A political division, not a physical one, determined who got measles and who didn’t. Of the 633 Texarkana measles cases, 606 (nearly 96% of the total) occurred in people who resided in the Texas portion of the city. This disparity in rates occurred despite significant contact between residents from the two sides. The messages were clear — vaccination had protected children who happened to reside on the Arkansas side of town, and community campaigns and school mandates were highly effective in preventing measles spread.
Related: Measles deaths jumped over 40% from 2021 to 2022, CDC reports
The Texarkana story is frequently cited in public health circles and is used as a teaching case for students of epidemiology. The lesson that is sometimes missed is that in addition to showing that vaccination protects against disease, the Texarkana measles outbreak also provides a stark reminder that political decisions about funding for public health, acceptability of school mandates, and myriad other issues can have real and lasting effects on the health of populations.
Today, Texarkana’s unusual geographic and political arrangement continues to instruct us about the deeply intertwined nature of politics and health. Under the Patient Protection and Affordable Care Act (ACA, also known as Obamacare), which was passed in 2010, states were required to expand Medicaid coverage to nearly all adults with incomes up to 138 percent of the federal poverty level, with coverage going into effect in 2014.
A 2012 Supreme Court decision (National Federation of Independent Business v. Sebelius) made states’ acceptance of the ACA’s Medicaid expansion funds optional rather than mandatory. Arkansas accepted Medicaid expansion; Texas did not. Jonathan M. Metzl, author of “Dying of Whiteness,” has chronicled how states’ political decisions, including accepting or refusing Medicaid expansion, can change the health — and even alter the life expectancy — of its citizens. It is hard to imagine a place where that line is so sharply drawn as in Texarkana.
A 2023 report from Public Health Watch [a nonprofit news organization] detailed a “widening divide in health care access” between the two sides of Texarkana on the basis of those decisions. Despite the demographic similarities between the Texas and Arkansas sides of the city, after nine years of Medicaid expansion, the differences were stark. More non-elderly adults uninsured, more hospitalizations for life-threatening conditions such as diabetic ketoacidosis, worse access to care — these are the legacy of Texas’s refusal to accept the ACA’s Medicaid expansion.
Just as the 1970 measles outbreak made clear, in Texarkana, living on the wrong side of State Line Avenue can be hazardous to your health.
From “Booster Shots“, by Adam Ratner, MD, MPH, published on February 11, 2025, by Avery, an imprint of Penguin Publishing Group, a division of Penguin Random House LLC. Copyright © 2025 by Adam Ratner, MD, MPH.
