Article by Carsten Timmerman, Academic Lead for the Museum of Medicine & Health.

Why would I not want to get vaccinated? Here is why some Victorians were sceptical about smallpox vaccinations

I received my first COVID shot a few weeks ago and am happy that I did. As far as vaccinations go, this was a pleasant experience. The large, temporary vaccination site at the Manchester Tennis and Football Centre was an incredibly slick operation, involving lots of friendly volunteers, and the whole experience was really quite exciting (you can tell how much – or how little – is happening in my life at the moment). I had minimal side effects: a slight headache the next morning, which was gone after breakfast and might have been caused by anything, and a slightly sore upper arm. Added bonus: I cycled to the vaccination centre near the Stadium, which was nice, as I don’t get to cycle much these days: I normally use my bike mostly for commuting, and that is not happening at the moment, as we all work from home. It did not occur to me to turn down the vaccination opportunity. But some people do refuse to be vaccinated. Why?

At a time when vaccines are tested systematically and transparently in large-scale clinical trials, when they come to us highly pure and, in the case of the BioNTech-Pfizer vaccine, frozen at minus 20 degrees, when side effects are mostly mild and sometimes moderate (some people I know suffered from flu-like symptoms following the shot), we sciency types may find it difficult to understand why some people are reluctant to get vaccinated. Looking at the history of vaccinations and the resistance to vaccination campaigns may help us with this.

Smallpox is a terrible disease, caused by the variola virus, which has killed scores of people, disfigured about three times as many as it killed, and caused unbelievable suffering for many centuries: scars observed on Egyptian mummies suggest that they were suffering from the disease 3000 years ago. We also have ancient descriptions from China that seem to match smallpox, dating back to around 1000BC.

Comparison between smallpox and cowpox pustules on the 10th and 11th day after inoculation. Chromolithograph, 1896, after George Kirtland. Source: Wellcome Collection

However, smallpox is also at the core of one of the great success stories of modern medicine: vaccination. Thanks to a series of successful vaccination campaigns, there have not been any recorded cases of smallpox anywhere on the planet since 1977: for all intents and purposes, the disease appears to have been eradicated.

Let’s think about what vaccination used to involve. The term vaccination derives from British country doctor Edward Jenner’s eighteenth-century observation that pus taken from the suppurating lesions of a person infected with cowpox (the Latin for cow is vacca) protected children from contracting smallpox. Famously, Jenner performed an experiment on a young farm boy in 1796, who he inoculated with pus from a milkmaid who had caught cowpox, after hearing tales that dairymaids were immune to smallpox.[1] This would be considered a reckless human experiment today, and would never be approved by a modern research ethics committee.

A Weir vaccinator was used to introduce cowpox lymph material into the body via scratches made by scarification, 1831-1870, Science Museum Group

Let’s talk about some other terms and practices. Variolation or inoculation, that is, the transfer of a small amount of liquid from the pustules of a patient suffering with smallpox to a healthy person, into a small wound created for that purpose, was a fairly well-established practice in Europe well before Jenner’s experiment. It had most likely been in use outside Europe, in parts of Asia and Africa for much, much longer. Traders brought back reports of these practices from the Ottoman Empire around 1670. While variolation may have prevented epidemics, it was also risky, however: two to three out of every hundred people who were thus treated died from smallpox as a consequence, and more developed the disease. In  fact, some local outbreaks may have been caused by variolation. Clearly, these kinds of risks are unacceptable today.

Vaccination with cowpox pus was not as risky as variolation, and a little less messy, but it was still understandable that there was concern. Imagine watching pus from a pustulating sore being transferred into a wound created for that purpose in the arm of your child. And there was the added challenge that this was pus associated with an animal. Would the animal matter change the nature of the humans into whose arms it was transferred? Contemporary cartoonists certainly had fun with this idea, but at a time when mechanisms of inheritance were not understood to the same degree as they are today, it is not fair to dismiss these fears too easily.

Cow-pox sore from An enquiry into the causes and effects of variolae vaccinae, Edward Jenner, ref 179813709.3, UoM Libraries Special Collections.

Of course there was no danger whatsoever that cowpox vaccine would turn you into a cow. But it is perhaps not surprising there are resonances with recent conspiracy theories suggesting that the AstraZeneca COVID vaccine turns you into a monkey. It uses a modified, harmless chimpanzee adenovirus (let’s call it a castrated virus) as a vehicle for inserting viral RNA into human cells. Once the modified adenovirus delivers its RNA load, these cells produce Coronavirus surface proteins and this, in turn, triggers an immune response to COVID without COVID infection – that’s what vaccines are meant to do. And strictly speaking we are all primates already, of course, but that’s a different issue.

After initial scepticism, Jenner and his followers had persuaded most experts that vaccination was both more effective and less risky than invariolation with smallpox. They were so persuasive that by the mid 1840s, state sponsored vaccination campaigns were considered a good idea. The UK government had taken on an increasingly interventionist role in these matters over the previous decades, and in 1853 Parliament passed the Vaccination Act, which made vaccination of all babies mandatory by the age of four months. If parents refused, they were landed with fines or faced prosecution. Nevertheless, mortality rates from smallpox increased. The second Vaccination Act in 1867 intensified pressure on parents with increased, cumulative fines and even the threat of imprisonment if they failed to have their children vaccinated.

As the pressure on parents grew, there was also increasing resistance to vaccination, involving organisations such as the British Anti-Vaccination League, founded in 1853, the same year in which the Vaccination Act was passed. The publications of the anti-vaccination organisations challenged the ethics of the procedure, pointing to the permanent scars it left after arm-to-arm vaccination, which they compared to the branding of lifestock. There were also concerns over the safety of the procedure: while the upper and middle classes paid a private doctor to vaccinate their children, a public vaccinator inoculated the children of the poor, often with reused vaccine material, using a single sample of material on hundreds if not thousands of patients.

Part of the problem was symbolism: compulsory vaccination was associated with pauperism; the government relied on the administrative structures of the New Poor Law to organise the vaccination campaigns, linking vaccination to the stigma associated with the Victorian workhouse. To the objectors, refusing vaccination was a rational decision. All this led to impressive demonstrations of mistrust and opposition. In Leicester, in 1885, between 80,000 and 100,000 protesters took part in a march against the prosecution of those who refused to have their children vaccinated. [2]

Attitudes towards vaccination as one of the most important achievements of modern medicine changed in the late 1800s and early 1900s. This was partly due to the success of other new interventions such as the diphtheria antitoxin, from the 1890s, which provided dramatic relief for children suffering from that bacterial disease. Such successes generated trust. But the elimination of the harsh penalties following the report of a Royal Commission appointed after the Leicester protests also helped, and a succession of new vaccination acts leading to the effective end of compulsion. Over the course of the twentieth century, faith in the power and benevolence of modern medicine continued to grow, in light of other successes such as Penicillin or the vaccination campaigns against polio, and not least the eradication of smallpox. Vaccinations in Britain today are associated with the NHS, an institution with strong positive connotations, rather than the Poor Law and the workhouse. However, while resistance to vaccination may appear irrational to most of us today, it is important to try to understand the reasons for continuing distrust in state campaigns, including vaccination. Victorians who did not trust the smallpox vaccine felt they had good reasons, and declaring their concerns irrational would not have persuaded them otherwise. All that said, did I mention that I am happy to have received my first COVID shot?

[1] Stefan Riedel, ‘Edward Jenner and the History of Smallpox and Vaccination’, Proceedings (Baylor University. Medical Center) 18, no. 1 (January 2005): 21–25.

[2] Nadja Durbach, ‘“They Might as Well Brand Us”: Working-Class Resistance to Compulsory Vaccination in Victorian England’, Social History of Medicine 13, no. 1 (April 2000): 45–62. DOI: 10.1093/shm/13.1.45

Related