Public health has been given over ever more to individual citizens to vouchsafe. Democracy requires its participants to take responsibility for themselves, not be ordered about by a state. That applies primarily to chronic and lifestyle diseases, where the individual can have an effect. But epidemic diseases have not disappeared, though they are no longer as important in the industrialized world as earlier. To prevent pandemics, the state and its interventions are still needed. Because every infected person poses a threat to others, and no one wants to bear the inconvenience of preventive measures, statutory enforcement is required. This dilemma came out starkly in the coronavirus pandemic. In effect, the state held a third of humanity in house arrest during the spring of 2020. In other ways, it regulated its subjects drastically, with fines and even jail for violating pandemic restrictions. But not all violation of required behavior could be just made unlawful. To get people to wear masks, for example, passing laws and regulations was not very effective. Citizens had to buy-in to the need for masks and adopt them voluntarily. Much the same will hold for a vaccine, if and when one becomes available.

This chapter demonstrates how countries expanded vaccination programs following the invention of the smallpox vaccine and how anti-vaccination movements emerged.

Chapter 5 explores the early spread of vaccination in continental Europe. If news of Jenner’s discovery quickly spread abroad, the delivery of vaccine in a viable state proved a major challenge. Diplomatic and medical networks explain its early arrival in Germany and Austria. From 1799, Dr De Carro made Vienna a major centre for the spread of the practice, with the samples sent to Lord Elgin in Istanbul seeding the practice in Greece. The British military build-up in the Mediterranean opened new channels for the dissemination of English cowpox. By vaccinating sailors aboard ship, Drs Marshall and Walker brought fresh vaccine to Gibraltar and Malta and Marshall established vaccination in Sicily and southern Italy early in 1801. Dr Sacco’s discovery of a local source of cowpox in cattle in Lombardy in late 1800 led to important trials and, over the following decade, an impressive vaccination programme in northern Italy. In the interstices of war in Europe, the practice developed as an international enterprise with several important new hubs.

Chapter 3 focuses on Jenner and the discovery of vaccination, specifically his translation of the vague notion that cowpox prevented smallpox into a more precise body of knowledge which could distinguish between varieties of cowpox and be the basis for the development of protocols for its effective use. Given the rarity of cowpox, his use of humanised cowpox (vaccine), propagated on children, was to prove critical to the success and viability of the practice. Publishing his findings in 1798, Jenner had to wait a year for his new mode of prophylaxis to gain acceptance. Initially, London-based physicians – Woodville conducting clinical trials and Pearson distributing vaccine – made much of the running. Jenner, however, reasserted his leadership in the field and made championship of vaccination his principal occupation. After considering reports on Jenner’s discovering of cowpox inoculation and making it available to the world, the British parliament granted him a premium in 1802. The Royal Jennerian Society was established in 1803 to promote and support the practice.

Chapter 8 discusses the arrival of vaccination in Portugal and Spain. An early recipient of cowpox, Portugal proved barren ground until the Prince Regent promoted the practice. Given its long rejection of smallpox inoculation, Spain moved surprisingly rapidly to embrace the new prophylaxis, with the first vaccination at the end of 1800, with vaccine sent from Paris. During 1801, vaccination was established in Madrid and other major centres and there was a flurry of publications on the procedure, some original, others customised translations. Grandees patronised vaccination in the provinces and local initiatives led to good coverage in Barcelona and Navarra. In 1803, the Royal and Philanthropic Vaccine Expedition was organised to extend the practice through the Spanish empire, beginning in the Canary Islands. War and political upheaval frustrated measures to consolidate vaccination in Spain and Portugal, but the authorities, political and medical, and some communities retained their commitment to the practice.

Chapter 9 charts the fortunes of vaccination in the Russian empire. Emulating Catherine the Great’s patronage of inoculation, Dowager Empress Maria sponsored its introduction and establishment in the Foundling Houses in Moscow and St Petersburg in 1801. Early in 1802, Tsar Alexander commended the practice and supported a plan for a vaccine expedition through the empire, using children under vaccination to deliver vaccine from one district to the next. Projecting an image of paternalism and philanthropy, the expedition required local notables and medical men to assist in extending and embedding the practice. The Russian embassy to China in 1805–6 included a vaccination arm that helped to consolidate and further extend the practice in Siberia. By a variety of means, including promotional prints (lubki) addressed to the peasantry, pressure from the nobility and direct coercion in 1811, large numbers of vaccinations were achieved. The French invasion of Russia only briefly halted the progress of the practice. After the defeat of Napoleon, Tsar Alexander visited London, congratulating Jenner in person.

Chapter 4 discusses the expansion of vaccination in the British Isles during the Napoleonic Wars. The rapid extension of the practice from 1800, involving hundreds of thousands of people, represented a mobilisation of opinion and action that paralleled the mobilisation of the nation for war. Medical men took up vaccination with alacrity, seeking to make their name and serve their communities. Members of the aristocracy and gentry, with women often in the lead, accepted it in their families and supported it in their spheres of influence. Clergymen promoted it from the pulpit. Reckless practice led to adverse outcomes that encouraged anxieties about inoculating cowpox and provided ammunition for an anti-vaccination movement in London in 1805–7. Instructed to conduct an enquiry, the College of Physicians fully endorsed vaccination in 1807. After receiving the report, Parliament broke new ground in health provision by funding a National Vaccine Establishment to distribute vaccine and have oversight of the practice.

Chapter 7 discusses the spread of vaccination in northern Europe. Familiarity with smallpox inoculation, its disadvantages as well as its advantages, assured a strong constituency of interest in the Netherlands, Germany and Scandinavia and a generally positive response to the potential of the new prophylaxis. Medical men in Germany, well-networked professionally, conducted trials of the new prophylaxis, rapidly achieved consensus as to its value and collaborated in extending it nationally. They invested culturally in vaccination, celebrating the ‘guardian pox’ in festivals and promoting a cult of Jenner. In the Netherlands, most German states and in the kingdoms of Denmark and Sweden, rulers acted on the advice of their physicians to endorse and support vaccination. Government officials and the clergy, Catholic as well as Lutheran, needed little prompting to assist in establishing it in their spheres of influence. Vaccination put down strong roots across northern Europe, becoming compulsory in Bavaria in 1805, Denmark in 1810–11 and Sweden in 1816.

Chapter 13 completes the study of vaccine’s encirclement of the globe by examining its introduction in Mauritius, Cape Colony and New South Wales in 1804, Indonesia in 1804–5 and the Philippines and Canton (Guangzhou) in 1805. The seeding of vaccination around the Indian Ocean, in the southern latitudes and around the South China Sea reveals a complex pattern of movements, with vaccine from India brought to Mauritius and Cape Town, with carefully packed cowpox sent directly from London to Sydney and with Mexican boys going arm-to-arm with Filipinos. The spread of vaccination around this vast region rarely led to continuity of practice, except in European enclaves, in Mauritius and parts of the Indonesia and the Philippines, where enslaved or subject populations were available to maintain the vaccine supply. Vaccination nonetheless saved lives, helped to suppress smallpox in gateway cities, laid foundations on which the practice could be rebuilt and extended and show-cased the benefits and costs of colonial medicine.

Chapter 14 returns to Britain in 1814–15, with Jenner hoping that peace would bring new opportunities to advance the vaccination cause. The end of the Napoleonic Wars and the reopening of lines of communication, bringing further reports of vaccination around the world, provides a useful vantage-point to identify key developments in the global story. Although the early history of vaccination is one of the diffusion of know-how and biomatter along the lines of Europe trade and empire, the networks rapidly become more complex and multilateral, with the new prophylaxis constructed on a global stage, not least the management of the practice, its integration in systems of public health and in legislative and other forms of coercion. Above all, it is possible to see vaccination as a quiet revolution, an emancipatory force, the pointy end of increasing state power and a foundation for further breakthroughs in the struggle against disease.

Chapter 6 discusses how France, hesitant about smallpox inoculation, embraced cowpox inoculation and the Napoleonic regime provided strong support and direction. After the first successful vaccination in Paris in August 1800, vaccine was rapidly distributed through France. In 1803, the Minister of Interior instituted a central vaccination committee in the capital and instructed prefects to form subordinate committees to support the practice in the provinces. Napoleon himself was committed to the practice and the practice prospered under a regime that had no doubts as to its merits and potential contribution to the nation’s welfare and prosperity. In the context of large-scale military mobilisation, several million citizens were vaccinated before 1815. The French system, ill-funded but quite effective, was extended to the client states and annexed territories of the Napoleonic empire, providing further scope for Dr Sacco’s enterprise in Italy and laying firm foundations for the practice in the Netherlands.

Chapter 11 discusses the early vaccination in North America. Dr Benjamin Waterhouse pioneered the practice in Boston in August 1800, rebranded cowpox as kinepox and briefly enjoyed a monopoly of the practice. Aware of the hazards associated with smallpox inoculation, Americans welcomed the new prophylaxis. President Thomson Jefferson took up the lancet at Monticello and, largely in a private capacity, helped to entrench and extend the practice. Philadelphia emerged as a new hub of vaccination, seeding its establishment in the southern states and on the western frontier. Serviceable to individuals and communities, the new practice served to bind together the new nation, with slaves often among the first to be vaccinated and prophylaxis being offered, as opportunities arose, to Native Americans. The problem of maintaining a supply of good vaccine in sparsely populated districts and on the frontier appeared more urgent with the outbreak of war with Britain in 1812 and explains the Federal government’s unusual decision to fund a (short-lived) National Vaccine Agency in Baltimore.

Chapter 10 discusses the beginnings of vaccination in India. From Bombay in June 1802, the practice was extended to Ceylon (Sri Lanka), Madras and Calcutta by the end of the year. Medical men in the service of the East India Company made the running, but civil and military governors provided strong support for the establishment of the practice. Children under vaccination were often used to deliver the vaccine, Indians were trained and paid for their work in vaccinating and systems were devised to maintain the supply of vaccine. The new prophylaxis was taken up in the European enclaves, but won some acceptance, too, among the Indian and Sinhalese, especially in Madras. Intrusive measures caused resentment and arm-to-arm transmission raised concerns about pollution. Still, the tally of vaccinations probably reached one million in the first five years of the practice. By this stage, too, India was serving as a hub for the spread of the practice in all directions.

Chapter 1 introduces smallpox and, its ultimate nemesis, cowpox. At the beginning of the modern age, a more virulent strain of smallpox spread around the world. Observing that survivors did not take smallpox a second time, many cultures recognised that exposure to a mild case might prove advantageous. The practice of smallpox inoculation, first observed in Istanbul, was the focus of interest in western Europe and was introduced experimentally in the English-speaking world in the 1720s. Though not without risks, inoculation led to advances in understanding contagion and improvements in therapy. It also helped clarify the relationship between similar human and animal diseases. The expansion of inoculation in the eighteenth century revealed individuals whose resistance to smallpox infection was associated with prior cowpox infection. Jenner used inoculation to put the notion that cowpox prevented smallpox to the test. Familiarity with the old practice set the scene for the rapid introduction of cowpox inoculation, a milder intervention.