By Anne Hardy
The declining mortality from infectious disease in Victorian Britain owed little to preventive medical procedures such as vaccination. One thing is certain: the modern anti-vaccine movement has recently brought great attention to the role of vaccines in reducing child mortality during the 20th century. And while this is particularly true for diseases like measles and polio, the reality is that the greatest decline in mortality from infectious diseases occurred well before the introduction of successful and widely used vaccines. It’s therefore important that we look at the history of infectious diseases and vaccines in context so that we can better understand the role of medicine, social change, and public health more generally in explaining how we got where we are today and what role compulsory vaccination might play in the future.
Infectious diseases have been a scourge of humankind at least since the hunter-gatherers formed settled communities, took up farming and domesticated livestock. For much of history the emergence and impact of these diseases on human societies went unrecorded, except in relation to such drastic events as the Great Plague of Athens, the Black Death, or the appearance of syphilis in Western Europe. It was only in the nineteenth century, when public health became a political and economic issue that the problem began to be documented numerically.
Britain was the first, and for a long time the only, country to put into place a dependable official system for recording deaths and causes of death (as well as births and marriages), from 1837 in England and Wales, from 1854 in Scotland. It was soon abundantly clear that infectious diseases exacted a high price in terms of death and morbidity, and that this was principally an urban problem. Britain’s great cities were hotbeds of infection, their death rates far outstripping those of the county boroughs and rural areas.
Tuberculosis, pneumonia, smallpox, scarlet fever, measles, whooping cough, and typhoid, with typhus before and diphtheria after 1870, were consistent indigenous killers in the middle decades of the century. Four epidemics of imported cholera hit the country between 1832 and 1866, the last affecting mainly London through contamination of the East London water supply. There were important outbreaks of typhus in Lancashire and London in the 1860s, of smallpox between 1850 and 1885, and in 1893 influenza emerged with a new epidemic virulence.
It was against these diseases that Britain’s public health administration was mobilised, first in London from 1855, then in England and Wales from 1872, and in Scotland from 1889. A range of approaches was adopted in a determined effort to bring down the death rates. Compulsory infant vaccination against smallpox was enacted for the first time in England in 1854; filtration of domestic water supplies began to be put into place at much the same time, isolation hospitals for infectious cases appeared from 1870 on. Issues around domestic overcrowding among the poor began to be addressed, local medical officers of health strove to address local problems, and numerous voluntary organisations sprang up, from the Bible women to housing charities and Ladies Sanitary Associations, engaged in projects of public education and sanitary reform. Regulatory legislation was enacted in 1848, 1855, 1872, 1875, and 1889.
As these various provisions were put into place, death rates began to fall. Disentangling the respective role of rising living standards and of sanitary reform after 1870 in effecting this new trend has provoked much historical debate, but that death rates from the major infectious diseases did begin to fall after 1870 is clear from the available statistics. Some, like typhoid and cholera, clearly responded to preventive interventions, others, like scarlet fever and later diphtheria, underwent natural processes of diminished virulence.
The declining mortality from infectious disease in Victorian Britain owed little to preventive medical procedures such as vaccination. Even smallpox was not eliminated because of the compulsory vaccination laws, but rather through targeted preventive interventions.
This did not mean that the British were uninterested in developing and using the new knowledge of vaccines. Cholera and typhoid, both serious obstacles to imperial ambitions, were among the first targets, with anti-typhoid vaccines used to immunise troops heading to fight in the Boer Wars around 1900, as well as missionaries and tea planters heading to India. Anti-typhoid vaccines played an important part in keeping British enteric deaths to a minimum in World War I. But Britain’s civilian health administration had been deeply scarred by the vigorous anti-smallpox vaccination campaigns waged in the closing decades of the nineteenth century, which resulted in the virtual repeal of compulsion in 1907.
No further attempts have been made to impose immunizations on the British population by compulsion, although a major diphtheria-preventive vaccination campaign was waged ahead of the planned emergency evacuation of children from London at the beginning of World War II. Worries over the safety of new American polio vaccines following the Salk incident in 1955, delayed Britain’s anti-polio campaign while the country developed its own vaccine.
Infectious diseases today bring relatively low mortalities, and while anti-vaccination sentiment still exists, especially among devout religious communities, these receive less public attention than those demanding new vaccines, as currently in Britain for meningitis B vaccine to be made available for all babies. If compulsion remains politically unacceptable in some countries like Britain, there is no denying that they have become very generally accepted, often welcomed, as almost invariably safe and certain preventives of a wide range of infections with potentially dangerous or damaging effects on human bodies.
Anne Hardy is Honorary Professor at the Centre for History in Public Health, London School of Hygiene and Tropical Medicine. She has written The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine (1993); Salmonella Infections, Networks of Knowledge and Public Health in Britain, 1880-1975 is published in 2015.