The supposed apathy shown towards diphtheria by certain sections of the British public was largely overcome by the 1960s – or, at least, immunisation rates had improved to such an extent that the Ministry of Health was no longer concerned about widespread diphtheria epidemics. Yet it did not have the same successes with smallpox vaccination. The problem of low rates of infant vaccination and childhood revaccination among the population remained a continual source of irritation for the Ministry. In the government's favour, the success of international vaccination and public health campaigns was making smallpox an ever-decreasing threat; but taking decisions about when the risk of disease had fallen below the risks posed by the vaccine itself proved to be a political and scientific minefield. Moreover, smallpox may have receded as a quotidian threat to British residents by the post-war period – but in the 1950s and 1960s a series of imported cases from abroad showed that the country was still at risk from foreign contagion.
Smallpox is a unique example of an infant vaccination programme that was shut down in Britain.1 This chapter explores the slow process of dismantling the British system of routine smallpox vaccination of infants. A procedure that had been made compulsory in England and Wales in 1853 was discontinued in 1971. The chief reason for the end of smallpox vaccination was fairly obvious. The disease had been all but eradicated, and had ceased to be endemic in the United Kingdom since the 1930s.2 But the timing of this decision was by no means inevitable. Full, worldwide eradication was not declared until 1980, and occasional outbreaks of the disease from foreign travel and laboratory accidents were a not-uncommon problem for post-war MOHs. The way in which these decisions were taken says much about the government's approach to the relative medical, financial and political risks of vaccination and disease. It also showed that the modern British vaccination system was forged by decisions not just about which vaccines to include, but also about which ones should be taken away.
The recurring theme in debates and policy decisions about smallpox was the nation. The discursive relationship between the public and the nation is a long-standing one. This applied to the state's – or the public sector's – provision of public health.3 Britain was a nation to be protected from foreign diseases.4 Anxieties were raised whenever an outbreak occurred – a sign of how rare smallpox had become, but also of the dread which it still elicited in the general public. Smallpox represented Britain's vulnerability to outside threats in a world of global mass transport by air and sea. And, as Roberta Bivins has shown, it came to be symbolic of Britain's relationship with her empire as attention shifted away from colonial holdings to a new Commonwealth, post-Suez.5 The specific politics around smallpox policy help to show how these anxieties manifested in the post-war era. So too do the regional, national and transnational sites of public health control. The state managed the risks to its citizens from smallpox at multiple levels. Local MOHs provided epidemic control on the ground, as well as being responsible for the administration of the routine childhood vaccination programme. The Ministry of Health provided the financial support and national policy impetus for these programmes. The medical civil service headed by the Ministry and the Scottish Office began to centralise immunisation policy further than it had done in previous decades. They did so within a global network of knowledge, coloured by the decline of the British Empire and the United Kingdom's new role in the international community. Britain's national interests therefore extended beyond the immediate medical and public health debates.
Through a series of examples, this chapter explores how concerns over the nation were expressed. First, two outbreaks in England in 1949 and Scotland in 1950 showed how the British public reacted in the face of an epidemic. The effects of smallpox were local. When the disease came to a specific area, its population sought protection via emergency vaccination, even when they had not wholeheartedly embraced routine infant vaccination. While this control worked at a subnational level, it existed to deal with an international threat – and was coordinated by the national government. Smallpox was a foreign disease, particularly prevalent in South Asia, but it was not one that was necessarily brought in by non-whites. Vaccination was therefore seen as a prophylactic that could be used in specific circumstances, such as protecting British people during an outbreak or as a disinfectant of bodies which had been contaminated by infected lands. This leads to the second section, which discusses the 1950s “propaganda” campaign for smallpox vaccination. As with diphtheria in the previous chapter, there was a sense that British parents were apathetic about smallpox, considering it a deadly but highly improbable disease. However, unlike with other forms of immunisation, the Ministry of Health and the COI did not dedicate significant resources to promoting the benefits of routine childhood vaccination. Moreover, deeper cultural and scientific misgivings about the benefits and dangers of smallpox vaccination loomed large. Instead, the Ministry relied on a limited number of materials and the cooperation of enthusiastic voluntary organisations to gently encourage British parents to present their children for the procedure. Again, the material stressed the foreign nature of smallpox. Routine vaccination was presented as something that could protect against imported disease, and as a prophylactic giving children the freedom to visit a world that was being made smaller by the growing accessibility of air travel.
The 1960s brought an end to this general laissez-faire attitude towards routine vaccination. Five cases of importation in 1961 and 1962 coincided with the Commonwealth Immigration Bill and a fierce public debate about Britain's responsibilities towards its old colonies and immigration by “coloured” Commonwealth citizens. The press coverage led to a re-examination of the science on vaccination, which in turn posed serious questions for public health officials on the relative risks of routine vaccination, mass vaccination in times of epidemic and the disease itself. The decision about whom to vaccinate and which groups were most at risk of harming themselves or the wider British population was made more difficult by the fact that vaccination had never undergone the same sorts of trials and generated the type of data that the medical civil service would have required even as early as the 1950s to make acceptable, concrete policy recommendations. In the end, the World Health Organization's (WHO) Smallpox Eradication Programme moved the prophylactic effort away from questions of national immunity and towards direct intervention in infected lands. Transnational networks of diseases surveillance, exchange of medical knowledge and movement of people became increasingly important to British public health over the latter half of the twentieth century.6 As with other European countries, Britain's position as a declining colonial power changed the dynamics of its relationship with other health ministries across the globe – as did the emergence of the WHO.7 Thus, while routine vaccination continued until 1971 and ports were monitored for signs of importation, Britain's national protection was to come from international cooperation and a battle fought well away from its own shores.
Smallpox was a deadly infectious disease which came in two forms. Variola major had a death rate of around 20 per cent, while the weaker variola minor had a death rate of around 1 per cent. All could lead to excessive scarring and complications in survivors.8 While public health measures (including vaccination) had rid economically developed nations of the disease by the end of the Second World War, it continued to afflict many parts of the world. Outbreaks in Britain were rare, but, due to increased travel by sea and air to, from and through endemic regions, they were not unheard of. Demobilisation of troops and dislocation led to a number of cases of importation directly after the war, with some indigenous cases – that is, secondary infections caught by people in Britain from the imported case. Aside from the smallpox importations in England and Wales detailed in Table 2.1, there were outbreaks in Scotland in 1937, 1942 and 1950.9
|Year||Air/sea||Country of origin||Imported cases||Indigenous cases|
a Supposed importation.
b Supposed infection from imported raw cotton.
c A further 33 cases (including 10 deaths) occurred in the Southend and Merseyside areas. It is possible that these infections were derived from these importations.
d Variola minor.
e Suspected importation. Child's mother developed modified smallpox.
Source: Adapted from TNA: MH 154/404, Importations of smallpox into England and Wales 1936–1970.
Britain's public health responses to smallpox were well established, and the medical profession was confident that it could deal with any infection that arrived.10 Vaccination had been used as a public health tool since the early nineteenth century in three distinct ways. First, routine vaccination of children was seen as the best way to prevent outbreaks from occurring. This led to compulsory childhood vaccination in 1853, causing well-publicised resistance from some quarters. Vaccination rates declined significantly after conscientious objection was permitted from 1907.11 Still, from 1948 until 1962 official policy was to vaccinate infants (children under the age of 12 months). Revaccination was then encouraged in school children and adults.12 Second, ring vaccination was used on people likely to have been exposed to the virus through contact with known cases. This was designed to stop the spread of disease by stopping the chain of transmission. Finally, mass vaccination was used across a large population during times of epidemic when other forms of public health control – such as routine and ring vaccination, quarantine and isolation – had failed.13 This was never considered necessary in the post-war outbreaks, although many people presented themselves for vaccination when smallpox was detected in their area.
Vaccination, as with other public health reforms in the nineteenth century, reflected the growing power of national government over what had traditionally been local matters, and the imposition of compulsion was resisted in many quarters.14 Conscientious objection was introduced in 1898 and made easier to obtain in 1907.15 The Vaccination Acts were repealed completely by the National Health Service Acts of 1946 and 1947. In many ways, this was an administrative clean-up – conscientious objection had effectively ended compulsion anyway, and with many health services now being pulled together it made sense to unify the legislation. But it was also a response to the success of the diphtheria immunisation programme during the war. Programmes in Britain and elsewhere had deliberately chosen to make diphtheria immunisation optional, as it was felt that education and persuasion would work better with parents.16 Practice had shown this to work, and the British government hoped that it could rehabilitate the reputation of smallpox vaccination by promoting it alongside diphtheria and the soon-to-be-available whooping cough vaccine.17 The decision to end compulsion was largely ignored by the press and Parliament and, as this chapter will show, was rarely mentioned even when outbreaks occurred.
This legacy caused some issues for the British government after 1948. Smallpox vaccination was an old technology, a product of a bygone age rather than of the new era of bacteriology and virology. Scientific debates in the 1960s showed that there was no robust statistical evidence that vaccination was the safest way of protecting the general population from smallpox importation. The medical profession and Ministry of Health remained supportive of routine infant vaccination, but had to concede that their main evidence base for this was experience and tradition rather than the modern, randomised-control trials and epidemiological analyses that they demanded for diphtheria immunisation, whooping cough vaccine and BCG.18 Although still rare, the risk of vaccine injuries was higher for smallpox than for modern, laboratory-developed immunisations. Potential hazards ranged from excessive scarring at the vaccination site up to brain swelling (postvaccinal encephalitis) and death. Given that the annual cases of smallpox could often be counted on the fingers of one hand, the number of vaccine-related injuries often exceeded the number of smallpox cases.19 Moreover, the smallpox vaccination procedure was less clean and sophisticated than modern vaccines. Instead of a simple hypodermic injection, smallpox vaccination was still performed by making small incisions in the arm. This made it unpleasant for the child and the onlooking parent, and resulted in scarring.20 Given the unlikelihood of encountering smallpox, the Ministry and local MOHs had difficulty convincing parents to present their children for the procedure. Furthermore, while central government financed the infant vaccination scheme and compelled local authorities to provide the service, MOHs had jurisdiction over how the schemes were run. This meant that local areas had developed their own traditions about how much to prioritise routine childhood vaccination. Some, such as Leicester (where the local population had strongly resisted in the nineteenth and twentieth centuries) saw uptake for infants as low as 1 per cent in 1961.21 Others regularly outpaced the national average, such as Worcester, which in the same year had uptake of 71 per cent.22 Even more so than with diphtheria immunisation, local rates varied considerably (Table 2.2).
|England and Wales||70||72||65||32|
a Percentage of children born in 1962 who were immunised at any time by 31 December 1964.
b Percentage of children under the age of two years vaccinated.
There were two different types of vaccination: routine vaccination as a preventative measure; and vaccination as a form of epidemic control. The difference in public reactions to these two types showed that the circumstances and administration of smallpox vaccination mattered. Uptake of routine vaccination was variable. In times of epidemic, however, the public were quick to present themselves for ring vaccination, whether or not they had been in contact with the disease. As the examples in this chapter show, there was a certain common-sense understanding that in times of epidemic the local authority was supposed to vaccinate the people – a legacy from the days of mass vaccination, and a perception that caused great difficulties for national and local authorities.23 There was ample evidence to suggest that primary vaccination – that is, the first time one is vaccinated – was more dangerous in adults than it was in young children. One of the reasons for routine vaccination was not simply to develop individual and herd immunity, since the effects of vaccination were known to wear off in about ten years. A secondary function was to make it safer to regularly revaccinate older children and adults to maintain their immunity; and in case of need for travel documentation, joining an at-risk profession (such as the armed forces or nursing) or during a local outbreak.24 Mass vaccination therefore posed public health risks as much as it offered potential protection. The most vivid example of this was the experience of the 1942 epidemic in Scotland, where four people died as a result of vaccinations gone wrong.25 The examples given in this chapter show that this paradox – and the relative risks as understood by the lay public – were a continual source of anxiety for the Ministry of Health.
Two examples of importation in the 1950s showed that vaccination was seen mainly as a barrier against foreign infection. Since smallpox was a foreign contagion brought in by travellers to or residents of infected areas, the government and the public showed more concern about the vaccination of at-risk groups, rather than massively expanding routine childhood vaccination. The first example is of a case of smallpox on board the SS Mooltan, which arrived in the Port of London from Australia in April 1949. Citizens, politicians and local authorities demanded stricter vaccination and quarantine controls on infected ships and for passengers from certain areas; but there was little discussion of improving Britons’ vaccination status. The second example concerns an outbreak in Glasgow in April 1950, brought in by an Indian seaman on board the SS Chitral. Here, the majority of victims worked in the city's fever hospital. Although authorities were more concerned with low routine vaccination rates among their population in the Scottish case than in the English case, more attention was paid in Scotland to the vaccination status of hospital staff. Here, anxieties were raised not just about the risk posed to nurses and doctors themselves, but also about the potential for the disease to spread beyond the fever hospital, should staff be inadequately protected.
The SS Mooltan
The secondary cases from the SS Mooltan exemplified this. Richard Allen and his wife boarded the SS Mooltan at Brisbane, Australia on 8 February 1949. On 10 March the ship docked at Bombay. Mr and Mrs Allen went ashore for a few hours, although it is unclear what they did in the city. Neither one had ever been vaccinated. On 24 March, Mr Allen complained of stomach pains, and the on-board medical staff began to suspect he may have caught chicken-pox. On 25 March the ship docked in Marseilles, but Mr Allen was too sick to disembark. Due to fog, the SS Mooltan was delayed in the English Channel, and Mr Allen died at sea on 1 April. The MOH for the City of London asked the ship company's surgeon to go aboard and check the body. He immediately diagnosed the case as smallpox. By this point, Mrs Allen was also showing signs of infection. All the ship's remaining passengers and crew were offered vaccination, but it was too late to stop the spread of the disease. As passengers disembarked and travelled to various parts of the country, the disease was found in London, North Lincolnshire, Aylesbury, Liverpool, Torquay and Cornwall. In all, there would be 16 cases and five deaths, including those of the Allens (see Table 2.1).26
Importations through seaports were not unknown. This was, however, the first epidemic in Britain since the formation of the NHS. Criticism of the decision to allow the passengers to travel across the country before the disease's incubation period was over came from many quarters.27 However, the fact that potential carriers of a dangerous disease could slip through the ports and be thousands of miles away from the place where they had contracted the disease before they showed symptoms showed that port sanitation and quarantine regulations, which had a long history in British public health, were beginning to break down.28 Local authorities, voluntary organisations and individual citizens wrote in protest to the Minister of Health, Aneurin Bevan, demanding that future cases be subject to quarantine. In Parliament, Jocelyn Lucas (Conservative, Portsmouth South) and Bessie Braddock (Labour, Liverpool Exchange) both spoke about the ‘widespread anxiety’ and urged the Ministry of Health to tighten its regulations.29 Braddock in particular called for action to be taken against contacts who refused vaccination.30 Ernest Bramall (Labour, Bexley) also enquired as to whether the decision to end compulsory vaccination would be reversed.31 Bevan resisted increasing compulsion for either the general population or smallpox contacts, and argued that the Ministry and port authorities had enough powers to ensure the safety of the population.32 In response to individual correspondence, the Ministry provided details of the International Sanitary Conventions that restricted its ability to forcibly detain passengers; and further noted that such measures probably would not have done much good.33 There were only four cases in people who had not been aboard the SS Mooltan: all of them in one family living near the isolation hospital in Liskeard, Cornwall.34
There was not an extended debate in the national press about the cases arising from the SS Mooltan. As the Ministry noted, concerns were raised in local authorities where suspected cases had arisen and from some individuals, but there is little evidence of a great national panic.35 In the Port of London, the local MOH was relaxed. ‘The public have played up very well indeed and there has been very little nervousness,’ he wrote in his annual report, ‘a fact which I think demonstrates confidence arising from the daily supervision of contact cases.’36 Discussions among health authorities focused on how to stop importation from outside rather than strengthening British immunity to the disease from within through more widespread vaccination. MOHs publicly demanded that Australian and New Zealand passengers be vaccinated if a ship was due to stop in the Indian sub-continent.37 The MOH for Lambeth, G. O. Teichmann, noted the double standard of expecting all Indian passengers to be vaccinated, but not requiring the same of ‘Australasians’ who ‘were allowed to wander about the bazaars of Bombay etc. where smallpox is endemic’.38 The Ministry related these concerns to Peninsular & Oriental, the SS Mooltan's operators, who agreed to actively discourage unvaccinated passengers from going ashore in ‘Eastern Ports’.39
Thus, foreigners and travellers to foreign lands were seen as a potential threat to British public health. This idea had grown in importance since the end of the First World War. In the nineteenth century, smallpox in India and other parts of the Empire was treated much like it was at home. As the disease ceased to be a major problem in Europe and North America, however, smallpox became viewed as a “tropical” disease, and was treated as a foreign threat.40 But while some blame for the continued presence of smallpox in the sub-continent was put on the superstitions and habits of Indians, the rhetoric around infection was not necessarily restricted to non-whites: ‘Australasians’ could themselves become contaminated because of their route through infected places and their lack of vaccination. In the meantime, there was no extended demand for more widespread routine vaccination of infants at home. Other than queues in Liskeard, there was also no great clamour for emergency vaccination. Isolated incidents appeared to grab attention, especially in local areas directly or potentially affected, but this soon died down. Unlike with the outbreaks of 1961 and 1962, the SS Mooltan cases did not become a national emergency, nor did they significantly alter attitudes towards smallpox in England and Wales. There was no major political crisis of national identity to refract the news of the outbreak.41 Instead, criticisms of policy were directed more to the ship being allowed to land than any disquiet over the epidemic controls or Britain's vaccination status.42 This was despite the ship's ability to remain in the news. A nine year old girl developed suspected smallpox on the Mooltan's return trip to Australia; and later that same year, the ship was quarantined in the Thames due to typhoid.43
The SS Chitral
Given the racial element to the 1961/62 outbreak, the SS Chitral incident provides an interesting contrast. On 5 March 1950, Lascar seaman Mussa Ali landed at Tilbury on the SS Chitral before travelling to Glasgow.44 His country of origin was smallpox endemic, and he was non-white – unlike the Allens. As a Lascar seaman, it was also unlikely that he or his shipmates had been revaccinated to maintain his immunity, unlike sailors in the Royal Navy.45 He was admitted to hospital with pneumonia and suspected chicken-pox. This was subsequently found to be smallpox. A doctor who had come into contact with Ali, Janet Fleming, died in the nearby town of Hamilton on 2 April. The outbreak would infect 19 people and kill six.46 During the epidemic, thousands queued on the streets of Glasgow and Hamilton for vaccination. The incident highlighted some of the differences between the English and Scottish health services’ experience of smallpox, but the issue of importation remained central. Here was ‘Bombay smallpox’,47 brought in by an Indian seaman and with the potential to affect Scotland's public and economic health. Yet the focus of discussion remained largely on the quality of preventative services at home rather than on concern about immigration.
The Scottish Office had already expressed its concerns with British smallpox policy in 1948. W. M. Ballantine, a Scottish civil servant, noted that ‘there is not the same tradition of vaccination in Scotland as in England and the number of vaccinated children is very low’.48 In an epidemic in 1942, mass vaccination was employed as a form of epidemic control in Edinburgh; but, due to the low rates of primary vaccinations, there were nine cases of encephalitis and four deaths.49 Ballantine asked if the COI would consider a national (British) smallpox vaccination education campaign. He felt that this would be particularly welcome in Scotland, given that ‘the risk of importation of smallpox [was] high’ and ‘the likelihood of spread [was] greater in Scotland’.50 The COI declined, as it was more concerned with promoting the new NHS; and when it did return to promoting immunisation, it was more interested in diphtheria and the soon-to-be-available pertussis vaccine. Instead, the COI recommended that local authorities should decide what was needed in their area, and the Central Council for Health Education would provide materials which could be ordered and used.51
When the disease broke out in Glasgow and Hamilton during late March and early April 1950, local MOHs offered vaccination to the public. At its peak, a special clinic in Glasgow was reportedly vaccinating 600 people per hour. By 15 April, two days before Glasgow was given the all clear, around 300,000 people had been vaccinated across Lanarkshire and Renfrewshire. The Glasgow MOH, Stuart Laidlaw, was ‘very pleased with the public response for vaccination’ and thanked the public for having ‘acted very wisely’.52 Indeed, other than demands from politicians on behalf of their constituents for public inquiries due to ‘great anxiety in the public mind’, the outbreak did not appear to create a massive scandal in the area or in the national press.53 The Daily Mail reported how Ali was cheered out of the hospital when he recovered, and that there ‘was no grudge against the man whose illness had cost six lives’.54 Instead, attention turned to what the Glasgow outbreak said about Scotland's – and Britain's – ability to deal with smallpox and its economic consequences. In this specific incident, all the victims of the disease had been in direct contact with Ali in hospital. However, while the disease had not spread into the wider community, the number of cases and deaths had caused significant harm to Scotland's and Glasgow's tourism industries during the Easter break. The MOHs of Edinburgh and of Corby in Northamptonshire, a town with a sizable Scottish diaspora, advised their residents not to travel to Glasgow, while New York City began to demand more extensive proof of vaccination before allowing travellers from Scotland to land.55 Due to the damage to the tourism industry, after the epidemic was over Scottish Office ministers called for an extensive advertising campaign to let the world know that ‘Scotland was normal again’.56 This highlighted the transnational character of the epidemic. Not only had it been imported from foreign shores, but its effects on Britain were also global.
There was also some discussion about the victims of the disease. Nine cases came from hospital staff, of whom four nurses and a laundry maid died. The sixth death was a baby; none of the six had been fully vaccinated. While importation of smallpox may have been impossible to prevent in practice, the poor vaccination records of the hospital staff caused disquiet among politicians north and south of the border. The government declined to make vaccination a condition of employment but reiterated ‘the need to ensure that vaccination is offered to all persons [working in] fever hospitals and re-vaccination is offered periodically’.57 It argued that compulsion would be difficult to justify after the repeal of the Vaccination Acts, and would jeopardise recruitment in fever hospitals that were already finding it difficult to hire staff.58 This response drew criticism in Parliament from both major parties, although the opposition Conservative politicians were most vocal. Lord (John) Llewellin (Conservative) noted that travellers from the United Kingdom were compelled to be vaccinated for their own protection, and so that they did not import smallpox on their return.59 David Gammans (Conservative, Hornsey) made a similar argument. Given the insistence of ‘almost every country in the world’ that vaccination be a condition of entry, why were fever hospital staff – the most likely group to come into contact with foreign travellers with the disease – allowed to work without being up to date? He asked the Secretary of State for Scotland, Hector McNeil, ‘have we to wait until three women die before we bring in a regulation which every other country in the world insists on?’60 In this sense, vaccination was a barrier against foreign infection, with fever hospitals acting as a buffer between the public and an infected outside world. Vaccination not only protected British medical staff, but stopped the spread of the disease out into the wider public. The government's counter arguments, however, rested on the idea that staff were themselves members of the public with the same rights to forego vaccination. If vaccination drove even more employees away from fever hospitals, that buffer might not exist at all.
1950s propaganda and education campaign
The outbreaks in 1949 and 1950 did not substantially alter the Ministry's approach to routine vaccination. The Ministry responded to individual enquiries and stressed the need for health visitors to use a ‘personal approach’ with parents to convince them of the benefits for their child.61 There was, however, no sustained propaganda campaign. The complications associated with mass vaccination and adult primary vaccination were well known. With growing travel by sea and, increasingly, by air, there was also a potential for the disease to become more common. Experts continued to write to the Ministry expressing concern that vaccination rates were steadily falling among the general public and NHS staff.62 Yet the Ministry was mindful not to engage in debates with anti-vaccination groups. Although less prominent than in previous decades, the government did continue to receive correspondence from the Anti-Vaccination League and other individuals.63 In Parliament, Samuel Viant, a Labour MP in Willesden until 1959, asked regular questions about the safety and efficacy of vaccination and the effects of trials on animals.64 However, these occasional interactions appeared to be rare and sufficiently low level as not to concern the Ministry, highlighting the declining influence of such groups since the end of compulsion and growing confidence in immunisation technologies during the inter-war years. Instead, the Ministry preferred to reiterate the benefits of vaccination and argued that since diphtheria and whooping cough immunisation had been such a success parents could possibly be persuaded at the same time to get their children vaccinated against smallpox.65
By the middle of the decade, the Ministry began to reassess its approach in light of its wider public health goals. While the government encouraged parents to immunise their children against other diseases – and appeared to be having success in these endeavours – correspondence and vaccination statistics suggested that, regardless of the intention, parents had not been convinced to take up smallpox vaccination as well.66 An officer from Essex offered some evidence from their area. When asked why mothers might not be presenting their children, home visitors replied that the women they worked with were often told when they arrived that there was not enough vaccination material and they failed to make or complete follow-up appointments. Parents also objected to waiting in a doctor's surgery with a healthy baby among sick patients. In his opinion, ‘there is not real apathy among parents but now that compulsion is no longer necessary, effective propaganda and stimulus is essential’.67 The Chief Medical Officer, John Charles, wrote in his 1954 Annual Report that it was becoming increasingly important that parents should present their children. The older generation, who had been children at the time of compulsory vaccination, were passing away. A new vaccination drive would restore immunity.68 A circular was sent to all local authorities in 1955 noting Charles's concern ‘at the current neglect of vaccination except as an emergency measure during outbreaks of smallpox, and […] the resulting lack of protection for the individual and for the community’.69 A new poster was designed, and local MOHs were encouraged to give smallpox vaccination greater priority, in the hope of raising infant uptake from a modest 36.4 per cent in 1955 to 75 per cent.70 The choice of message was revealing. The English and Welsh authorities were inspired by a long-running leaflet in Scotland which had used newspaper headlines from the 1950 outbreak to remind parents of just how dangerous the disease could be. It pulled no punches – the opening paragraph read: ‘do you want to take the risk of seeing your child's face pitted by the ugly scars of smallpox?’ This type of message was similar to the one used in the diphtheria campaign at the same time, demonstrating a coherent message about vaccination (even if the volume of material and the response to it was not equal across all programmes). Although it did not go so far as to show pictures of diseased children, it used the threat of potential damage through inaction to press home its message. It stressed that vaccination before an outbreak was safer than waiting for one to occur, and ended with the slightly dubious claim that ‘vaccination does not upset children, although in adults a first vaccination may be very painful. So have your child vaccinated now! Keep your baby safe!’71 The resulting English poster tried to emulate the visual impact of the Scottish one, with a bright yellow background and the words ‘vaccination’ and ‘smallpox’ in bright red block capitals. The text was less outwardly emotive, simply quoting the Chief Medical Officer: ‘VACCINATION of all healthy babies must be our aim if we are to protect the community against a run of SMALLPOX.’72 The foregrounding of the benefits to the community was in contrast to previous campaign messages which had very deliberately focused on the individual benefits of vaccination to the child and parent.73 The diphtheria campaign, for example, had foregrounded healthy babies and the protection that parents could gift to their child.
Despite Charles's pronouncement, this would be the extent of the Ministry of Health's propaganda mission. Both the anti-diphtheria and anti-poliomyelitis publicity efforts got far more attention from the Ministry of Health and COI.74 No major incident in the 1950s forced the government to change tack. There was also evidence to suggest that even some doctors had inferred that the end of compulsion was an admission from the government that it no longer saw routine smallpox vaccination as a priority.75 As local MOHs and other organisations wrote to the government for advice, the only other promotional offering was a 1951 film called Surprise Attack. Film had been used to promote public health messages and inform the public about public health activities for decades.76 Bermondsey in South London, for example, had established its own film department in the 1920s.77 At this time, a growing documentary film movement began to be co-opted by government departments that saw it as an effective communication tool, producing a range of materials for the promotion of health and other government activities.78 Surprise Attack starred John le Mesurier as a general practitioner and showed the story of a family whose young girl caught smallpox from a rag doll brought back from ‘the east’ by her father. In the film's tale of how the MOH tried to keep control of the outbreak, the girl survives with significant scarring. The final few moments have the MOH showing pictures of real smallpox cases to show how gruesome the disease could be – and a call to action for parents to take their children to the clinic to be vaccinated. The film stressed that while parents might think that smallpox was now rare, ‘by the time your children are all grown up, air travel will be general’.79 The dangers of travel – from both foreigners coming to Britain and unprotected Britons bringing disease back – were ever present.80 However, that Surprise Attack had not been updated or replaced by the early 1960s reflected a lack of sustained effort or resource commitment from the authorities.
While the government did not prioritise smallpox vaccination advertising, the public appeared relatively apathetic too. Vaccination rates did recover slightly in the mid-1950s, but not by enough to reach the 75 per cent target set by Charles.81 However, the government was able to lean on publicity produced by outsiders with an interest in childhood vaccination. This was not a new development. Voluntary organisations had been involved in health care from before the war, from health education to the running of hospitals.82 The National Baby Welfare Council had expressed considerable concern when it had written to the Ministry asking for a smallpox poster for an exhibition on child health and had been told that there was not one in circulation.83 The Council sought to fill the gap itself, but when outside bodies created health propaganda they could cause embarrassment for the government. The War Office complained to the Ministry about one poster which presented a returning soldier as a vector of disease and in a dishevelled uniform. Another leaflet contained inaccuracies on vaccination procedure and official government advice.84 Both pieces did, however, reinforce the “foreign threat” perception of smallpox. The returning soldier was a danger because of where he had been and how quickly he could return home. In the leaflet, a mother is urged to have her daughter ‘done’, despite the scarring from the vaccination, because ‘she may want to be an airhostess’ someday. In both pieces, the pain of the adult vaccination was stressed to convince parents that it was best to act now rather than later – deliberately drawing on the experiences of many fathers and husbands who would have been vaccinated for national service during and after the war.85 Despite the potential embarrassment, the Ministry became increasingly reliant upon these organisations to spread its message. When the Women's Voluntary Service offered to help distribute material in July 1956, the Ministry asked it to contact local MOHs instead.86 By September, however, it was responding to a national campaign by the Women's Institute by sending hundreds of copies of the yellow poster to branches across the country.87 Certain sections of the public clearly believed in the importance of routine childhood vaccination; but these were voluntary organisations of a middle-class bent concerned primarily with motherhood.88 Without central coordination and resources, the campaign never fully developed.
The 1960s – Commonwealth Immigration Bill
The campaign for improved routine smallpox vaccination rates in the 1950s did not see an appreciable increase in uptake. But this did not cause undue anxiety among staff at the Ministry of Health. There were five importations of variola major between 1951 and 1960, and all were adequately contained, despite the deaths of twelve people (see Table 2.1). There was also a variola minor outbreak in Rochdale in 1951/52, from infected raw cotton, which caused 138 cases but no deaths. It was generally accepted that routine childhood vaccination was desirable, but the Ministry had faith that its existing methods of port control, isolation and vaccination of contacts were enough to protect Britain from external threat.89 There was some concern about the level of campaigning from the British Medical Association (BMA) at its conference in 1960. Following the conference, the Association wrote to the Ministry to find what publicity material it had available and to urge it to renew the vaccination campaign. The Ministry remarked that it had little of its own material, and that other organisations’ efforts were taken into account. More broadly, it had not produced much in recent years because local authorities had shown no demand for materials.90 This low-level critique from the BMA may not have required much response; however, a major outbreak of smallpox was about to be turned into a national scandal. This saw more attention drawn to smallpox policy, and forced the Ministry to reassess its position.
From 16 December 1961 to 11 January 1962, five separate importations of variola major occurred through Britain's airports, all from Pakistani travellers.91 A smallpox epidemic was raging in Karachi, and planes were able to transport passengers to London in a matter of hours. The volume of passengers had also increased, as immigrants hoped to get to Britain to settle before the Commonwealth Immigrants Act 1962 came into force and restricted movement from Commonwealth countries. From these five, two cases resulted in local outbreaks: one in Bradford and another in Cardiff. A third outbreak then developed near to the isolation hospital in Penrhys, and spread into the Rhondda Valley, South Wales. For anti-immigration politicians, the outbreaks gave legitimacy to their claims for stricter border controls.92 For the medical profession, this new form of immigration by air raised questions about the ability of existing sanitary regulations to protect the nation from harm.93 Meanwhile, the British public expressed a range of opinions on smallpox, vaccination, race and government.94
Roberta Bivins’ work has explored in detail how British attitudes towards the new Commonwealth were manifested during the outbreak. Concerns about the social impact of immigration, particularly from South Asia, were expressed through demands for stricter health checks at ports and proof of vaccination. These were often presented as bureaucratic necessities to protect health, so as to avoid the accusation of direct racism, even though there was little epidemiological merit to the proposals.95 James Stewart has also collated a rich public history of the outbreak, including contemporary materials and oral histories with survivors.96 As these demonstrate, routine childhood vaccination was one talking point among many; and certainly not the most important.97 The outbreak became a scandal because it touched a raw nerve in British politics with regard to Commonwealth immigration, rather than because it was a medical crisis per se. Control of immigration was the main concern. It was therefore as much about protecting Britain's national character as much as its public health. As the public demanded tighter controls on foreigners entering the country, the government was forced to manage a number of risks. Any importation of smallpox at this time was even more politically sensitive than usual. Yet tighter port controls, despite being the apparent “common sense” solution, were likely to be ineffective. There was also the risk that too many draconian regulations could damage international trade, and thus the wider economy.
These issues, especially surrounding race and immigration, have been dealt with effectively by Bivins.98 However, the wider story of how the Ministry of Health dealt with the situation tells us more specifically about vaccination and the public. Three vaccination strategies emerged: mass vaccination of the indigenous public as a form of epidemic control; selective vaccination of at-risk individuals such as migrants and NHS staff; and routine vaccination of British children as a policy outside of epidemic times or locations. In each, the public and the government had a role to play. The tensions within them were not fully resolved during or in the aftermath of the crisis. Nevertheless, they did lead to a re-evaluation of policy in the years following the end of the epidemic.
The most visible show of support for vaccination came in areas that had confirmed cases of smallpox. Demand for vaccination as protection against a potential epidemic was high, but it caused headaches for national and local health authorities. As there had been in Liskeard and Glasgow in 1949 and 1950, there were queues for vaccination in Bradford, Cardiff and the Rhondda valley. One case had been taken to University College Hospital in the London borough of St Pancras, which also saw lines of concerned members of the public queueing around the block. These images were staples of press and television coverage, much to the chagrin of Chief Medical Officer George Godber. He argued that they reflected panic in epidemic areas, and also fuelled the idea that this was the correct way to behave when smallpox occurred.99 Mass vaccination was not considered an adequate form of epidemic control, and brought its own problems. Experience in the Scottish epidemic of 1942 had shown that it could lead to complications, aside from the practical undesirability of having thousands of people congregating in one spot in a city with an ongoing epidemic. Enoch Powell, the Minister for Health, declared that ‘queues were the evidence of responsibilities neglected’ by both the public, who had broken what ought to be ‘an almost universal and unquestioned code of behaviour’ (i.e. presenting for routine vaccination) and the health authorities, which had not been coordinated or effective enough to ensure that the public understood this.100
For Godber, a keen supporter of routine infant vaccination, these queues represented a paradox. As would also be seen with poliomyelitis scares in the 1950s (Chapter 3), mass vaccination enjoyed support in times of crisis that routine vaccination in normal circumstances did not. When reflecting on the 1962 epidemic, Godber remarked:
Vaccination, of course, played an important part in control … and in the circumstances of the Rhondda and Bradford the public demand is easily understood. But much vaccination was done as a matter of urgency, where no urgency existed. The population as a whole has, of course, obtained some advantage from this in increased immunity and assurance of quicker enhancement of that immunity if required in the future. Yet mass demands when smallpox occurred reflect a state of public anxiety attributable in part to the neglect of routine vaccination.101
The Ministry was not helped in some areas by its regional lieutenants, who made demands that contradicted central government advice. High demand had led to shortages of vaccine lymph and strict control by central authorities, causing consternation among members of the public as well as MOHs.102 MOHs in Yorkshire districts near to Bradford demanded more vaccine, and complained when they were not given priority access to limited supplies of lymph. In Halifax especially, the local MOH made the case that because the town had a ‘large immigrant population’, it required more vaccine to protect its people.103 This underscored the idea that foreigners were vectors of disease, and foreign lands its source. Queues in other boroughs across the country (and the subsequent shortage of lymph) were also attributed to widespread publicity about the outbreak, and fear of ‘coloured’ migrants bringing the disease into previously uninfected areas.104 For other contemporaries, however, the outbreak represented a key tension in public health policy: the fine line between acting to protect the public and being seen by the public to act. Even if mass vaccination was not considered medically justified, the MOH for Bradford and his deputy argued that it was a necessary evil to keep the general public calm.105 Allaying anxieties clearly mattered to local authorities, and, even if people were a little too keen to be vaccinated, MOHs made a point of praising citizens for their cooperation. They had come to expect this after experiences across the country during the post-war period.106
While Godber continued to promote the power of routine vaccination, many of the arguments around the 1962 outbreak focused on other forms of prophylaxis. In particular, tighter port controls, vaccination of immigrants and protection of key NHS staff were given far greater coverage in the press, Parliament and medical discourse. Some of this was politically convenient for anti-immigration politicians.107 For the Ministry, it was another example of common sense being at odds with wider economic and medical wisdom.108 Despite the panics caused by smallpox in the community, the disease burned out quickly and affected relatively few people. It was considered disproportionate, therefore, to instigate stricter border controls which would adversely affect international travel and trade.109 Enforcing vaccination or revaccination of travellers from smallpox-endemic countries was resisted, as it might be considered racially motivated, would take up too much time and would have little material effect in preventing importation.110 Some dissented: one correspondent to the British Medical Journal bemoaned that in ‘East of Suez there is far too much graft and subterfuge’, so that even those with seemingly legitimate vaccination certificates must be considered suspect.111 However, the two infected individuals who caused the local outbreaks possessed certificates of vaccination and/or showed signs of having been successfully vaccinated in the past. As for the vaccination of at-risk groups – usually taken to mean front-line NHS staff – this was considered administratively impractical. Two-thirds of the indigenous cases were contacted in hospital, affecting staff and patients (a similar pattern to Glasgow in 1950).112 Staff were prioritised during outbreaks and offered revaccination every three years, but, as in the SS Mooltan and SS Chitral incidents, it was reiterated that compulsion would have a negative effect on hiring and retention of hospital staff. The Ministry's existing protocols had not been perfect. But it was notable that there were no tertiary outbreaks in Bradford.113 The disease was promptly kept under control. And while the infectious disease hospitals in some areas were shown to be inadequate, there was never any need to invoke emergency mass vaccination measures.114 Long-standing public health measures, in line with the International Sanitary Regulations on smallpox, appeared to have worked to keep Britain safe.115
However, the level of public disquiet over the 1962 outbreak forced the Ministry to seriously reconsider its routine vaccination policies. The public's faith in vaccination and in their local health authorities during times of epidemic had been demonstrated clearly. But there was a sense in Parliament and the media that local areas had been let down by national government allowing the outbreaks to occur in the first place.116 There were also criticisms about the lymph shortages and unsatisfactory prioritisation of some areas over others – or, as one correspondent to the British Medical Journal put it, ‘bureaucratic bumbledom gone bonkers’.117 Appreciating the failures of vaccination policy, the Ministry of Health re-examined its approach and competing interpretations of the epidemiology. This would eventually lead to the end of routine vaccination in 1971.
The 1960s to 1970s: withdrawal
The Ministry remained confident in its epidemic control policies, but routine vaccination continued to be problematic. The government had consistently fallen well short of its target of 75 per cent childhood vaccination. In analysing its policy, the Ministry collated vaccination statistics, and they made grim reading for proponents of vaccination (Table 2.2). In 1964, the national average for smallpox in England remained at 32 per cent of children under the age of two. Even the most successful local authority, the city of Worcester in the Midlands, achieved only 61 per cent. This was in stark contrast to the relative successes of the pertussis, diphtheria and poliomyelitis immunisation campaigns, which were approaching childhood vaccination rates of 75 per cent, even in areas where smallpox vaccination was unpopular. The figures also suggested that parents saw smallpox vaccination as an epidemic control tool rather than a necessary immunisation for their children. In Bradford, Cardiff and Glamorgan (the epicentres of the 1962 outbreaks), uptake remained below the national average for England and Wales. Indeed, Bradford's rates were equal to the worst in England (Bristol), second only to Merthyr in Wales. The West Yorkshire boroughs which had complained to the Ministry about a lack of lymph during the heat of the crisis also had relatively weak figures. In light of this apathy towards routine vaccination, then, what was to be done? Unlike with diphtheria in the 1950s, it was not sustainable to claim that smallpox was a quotidian threat or that it could ever return as endemic and widespread, regardless of the danger posed in the rare cases of importation. By the same token, it was clear that people were not against vaccination when they felt the threat of smallpox was strong enough. The Ministry embarked on a fact-finding mission to settle these questions of how to protect the nation.
The aftermath of the 1962 outbreak caused debate in the medical press. The dangers of mass vaccination were reiterated, but new concerns were raised about the potential harm of routine vaccination.118 Three doctors in particular made the argument that routine vaccination ought to be abandoned. The first, George Dick, was Professor of Microbiology at Queen's University Belfast and had worked on oral polio vaccine trials in the early 1950s (see also Chapter 3). His work had shown the risks of cross-contamination, and this had made him very alert to the risks as well as the benefits of vaccination across a large population.119 The second, Ronald W. Elliott, was the County Medical Officer for West Yorkshire.120 Both men publicly argued that even if the country could institute 100 per cent uptake of smallpox vaccination, the resulting level of herd immunity would not be enough to prevent occasional outbreaks of smallpox. Moreover, the risk of a smallpox outbreak was low, and getting lower as a result of WHO eradication efforts.121 By contrast, it was known that between ten and twenty infants died every year from vaccination.122 In weighing these relative risks and the potential benefits of vaccination, they borrowed from a third doctor, C. W. Dixon. He had calculated that herd immunity from childhood vaccination might not even exceed 10 per cent. Because the effectiveness of the vaccine waned over time, people vaccinated as children would become vulnerable again in young adulthood. Without revaccination, this left a large section of the population vulnerable to infection. This was doubly dangerous because these people might believe themselves to be safe because they had been vaccinated in earlier life and might therefore take risks without knowing it. Dixon concluded that a childhood vaccination programme without a robust adult revaccination programme was worse than useless.123
Dick raised his concerns at the BMA's annual meeting in Belfast in July 1962.124 He was joined by William Edgar, Bradford's Deputy MOH, making a speech to the Royal Society of Health in which he claimed that mass vaccination had not contributed to controlling the outbreak there.125 The resulting debate was picked up by the popular press, highlighting the strength of feeling on the matter and causing some anxiety on the part of the Ministry of Health. It had hoped to keep the matter relatively private, a discussion between experts in government meeting rooms rather than in a public forum.126 Correspondents to the British Medical Journal were also critical that such a sensitive matter was being aired in a press prone to ‘sensationalist’ headlines, as evinced by the ‘panic’ that had followed reports of smallpox during the epidemic.127 There was a sense, therefore, that the public did not have the knowledge to be able to debate this issue properly and would act emotionally rather than logically.128 However, the British Medical Journal also cautioned its readers that they too held deep emotional positions on smallpox. An editorial quoted the noted epidemiologist Major Greenwood when he said that ‘no intelligent person supposes that logic determines practical issues’.129
To clarify Dick's comments and the organisation's position on smallpox, the BMA wrote to the Ministry arguing that a new committee should be established to advise the government on vaccination and immunisation policy.130 That the government agreed to the request shows the power and close relationship that the BMA had with the Ministry at this time.131 However, when it had requested a more intensive smallpox vaccination campaign some years earlier, this had been treated rather lukewarmly. The formation of a new committee was neither difficult nor out of line with the Ministry's pre-existing plans. The Ministry and Scottish Office's Joint Committee on Poliomyelitis Vaccine (JCPV) which reported to the Standing Medical Advisory Committee (SMAC), was about to expire following the decision to move to oral poliomyelitis vaccine (see Chapter 3).132 The Ministry had already considered something similar to the BMA's proposal, and therefore established the Joint Committee on Vaccination and Immunisation (JCVI).133 To respond directly to ‘Dick's bombshell’, a sub-committee was immediately created within the JCVI to explicitly deal with the questions raised by Dick, Dixon, Elliott and others.134 Chaired by R. E. Tunbridge, Professor of Medicine at the University of Leeds, the sub-committee's membership included MOHs, general practitioners, researchers and a paediatrician. Elliott himself was co-opted onto the sub-committee. It reported to the main JCVI which in turn reported to the Ministers responsible for health in England, Scotland and Northern Ireland.135 This reflected the growing influence of expert advice in British health matters in the post-war period.136
It also showed that immunisation policy was becoming increasingly standardised. Although the national campaign for diphtheria had begun in 1940, local MOHs were largely responsible for prioritising and administering it at the regional level. The 1950s campaigns had tried to raise uptake in areas of apathy. The JCVI, though, created a dedicated nook of the medical civil service for discussing the issues surrounding vaccination across all diseases and across all the constituent countries of the United Kingdom. Advancing immunisation technology required better planning. Conservative Minister of Health Enoch Powell promised ‘a comprehensive and planned programme of immunisation and vaccination in every part of the country’.137 By focusing on smallpox vaccination, attention had also turned back to indigenous cases – the Ministry acknowledged that importation was impossible to prevent, so it was important to ensure that Britons were best placed to deal with it if or when it arrived.138 Building on the work of previous organisations such as SMAC and JCPV, this was a national attempt to protect public health. For ‘although each outbreak’ of infectious disease had ‘a focal point of starting … each focal point [was] of National concern’.139
The sub-committee broke down Dick's main critique of vaccination into three areas. First, that ‘there is excessive mortality from vaccination’; second that ‘smallpox in infancy … is unlikely to make much contribution to herd immunity’; and third, that ‘routine public health control measures would adequately contain epidemic spread’.140 The first meeting, in April 1963, was a tense affair: the members had strong opinions on vaccination, and were frustrated at the lack of hard evidence to form any concrete advice for the JCVI.141 A second meeting was called in July to go back over the extant evidence and give Dick, who had been unavailable in April, a chance to present his case more thoroughly.142 Members seemed to be acutely aware that there was a difference between, as Dick put it, ‘paper’ and ‘de facto’ policy.143 The idea that all members of the public would behave as they were advised – 100 per cent being vaccinated in infancy and then revaccinated regularly throughout childhood and adulthood – was clearly a fantasy. In reality, primary vaccination rates in children were known to be around 40 to 50 per cent (depending on the local authority), and revaccination rates were barely one in ten. C. Kaplan, a member of the sub-committee, wrote in the British Medical Journal that this could in fact be worse than nothing, since it might give people (or the country in general) a false sense of security when there was an outbreak.144 Dick laid down the challenge that the government should either abandon the policy as unworkable, or make genuine attempts to reach the ‘paper’ policy goal – something it had clearly failed to do during the 1950s.145 But this too would have de facto problems. Even Elliott, a proponent of ending routine childhood vaccination, argued that ‘a not very well-informed public’ would see the ending of vaccination as negligent.146 There had already been a backlash in some quarters when SMAC had shifted the recommendation to vaccinate in the first year of life to vaccination between the ages of one and two years (on the epidemiological evidence that this reduced the risk of complications). H. Josephs, from the Smethwick Local Medical Committee, felt that this would reduce the number of vaccinations in his area, which was dangerous, given the number of ‘coloured’ immigrants in his borough; W. H. Crichton also argued that mothers preferred to vaccinate at around six months because the children were less mobile and therefore it was easier to deal with the scabs that developed on the arm.147 Besides, if revaccination was safer than primary vaccination in adults, there were criticisms that Dick's preferred policy of vaccinating only contacts would be unacceptable to the wider public. As the 1962 outbreaks had shown, ‘they will come in their hordes and demand protection: and no health authority will dare to them say nay’.148 Most importantly of all, the experts saw their role as one that required firm, unequivocal advice for a public considered unable to make such complex decisions for themselves. The possibility of laying out the risks for parents (and their family doctors) and allowing them to choose was considered absolutely ‘unacceptable’.149
The paradox of public attitudes to vaccination was again exposed. The public clearly welcomed, even demanded, the protections offered by vaccination in times of epidemic. Doctors working alongside parents and the general public also believed that the removal of routine vaccination would cause considerable disquiet. And yet, primary vaccination rates remained low, with revaccination rates even lower. Even if it could be epidemiologically justified, the removal of what was seen as a necessary protection was problematic. So too was the potential political fallout, should an outbreak occur in the absence of such protection (whether it was a causative factor or not). The hazard of a smallpox outbreak, even a single case, was too much to risk on the incomplete evidence so far accumulated. As the sub-committee noted, there was a general sense that current public health protection methods worked, but there was no reliable experimental evidence to suggest exactly how well they worked, as compared with routine vaccination. There was acceptance that vaccination probably did not prevent many cases, but there was no reliable epidemiological evidence on how few cases it prevented. There may have been little evidence to stop vaccination, but it was also the case that ‘smallpox vaccination [was] so much a part of ancient lore that it has not been subjected to the kind of scientific appraisal that other vaccination procedures [had] received’.150 In these circumstances, the status quo won out, while the sub-committee went in search of the evidence that would allow the JCVI to recommend concrete policy proposals to ministers. Dick's quotation of G. S. Wilson's critique of BCG vaccine was apt: ‘It is much easier to introduce a given measure into the public health practice of this country than to remove it once it has become firmly established.’151
By the late 1960s, further analyses on the vaccination programme had provided answers to questions about vaccination safety and efficacy. Expert opinion had begun to turn away from the procedure on scientific and practical grounds.152 More importantly, the smallpox landscape had changed dramatically. The intensification of the WHO Smallpox Eradication Programme from 1967 onwards significantly reduced the areas of the world in which smallpox was endemic.153 This further increased the risk of vaccine injury relative to the risk posed by the disease itself. While research had been proposed into finding a new, safer immunisation against smallpox, resistance in the WHO, a lack of suitable test populations to assess potency and risk, plus the declining need for it in economically developed nations meant that it never materialised.154 On the basis of this ‘balance of risks’, the Secretary of State, Sir Keith Joseph, announced on 28 July 1971 that routine vaccination would end.155 Both the Department of Health and Social Security (DHSS), which had replaced the Ministry of Health in 1968, and the Scottish Office accepted the JCVI's recommendation that existing public health measures would be enough to control any potential importation. Instead, people in at-risk groups (such as NHS staff, people travelling to smallpox-endemic areas and those requiring vaccination certificates for travel abroad) would be offered vaccination, as would contacts of known smallpox cases.156
The decision provoked little debate in the general press. There had not been a confirmed indigenous case of the disease via importation since the 1962 outbreak (see Table 2.1), and there was general confidence in the Eradication Programme. Where one finds isolated voices of dissent, racialised views of the disease were never far away. One concerned resident in Hayes End, Middlesex wrote to her MP that she felt very strongly that ‘in our area this is most unwise with considerable numbers of Indians and Pakistanis commuting daily and being employed in local bakeries etc, handling food’.157 Expert opinion, however, had moved on. Dick gave a summary of the arguments to the British Medical Journal and was supported by a favourable editorial in the same issue.158 A few doctors expressed doubts, but it produced far fewer letters than the original ‘Dick's bombshell’ in the summer of 1962.159 Much like when compulsory vaccination ended in 1948, the lack of public disquiet showed that the British government had formalised a paper decision that its people had already made de facto. Vaccination and revaccination rates continued to be low, even where uptake for immunisations against other diseases remained relatively robust. The decision also reflected Britain's willingness to act semi-independently from the rest of the world. In the 1960s and 1970s, many other nations, including those in the European Economic Community, continued to make vaccination compulsory for children, or at least heavily promoted it.160 The United States and Canada had taken similar action to the British government, but these Anglophone countries were outliers. There was a certain privilege to this. Britain and North America had the luxury of weighing up relative risks in a way that, say, India or Somalia could not. The economic and medical maturity of their public health structures allowed their citizens to forego the risks of vaccination at precisely the time that the Eradication Programme was aggressively intervening in the lives of people living in poorer countries.161 The protection of the British people no longer required its citizens to present themselves for vaccination – indeed, it no longer even required greater controls in Britain's ports. Instead, Britain was to be protected by fighting the sources of smallpox on other continents, rather than by insisting on prophylaxis at home.
Vaccination continued for at-risk groups, and the government maintained stockpiles of freeze-dried and liquid vaccine in case of emergency. This caused some logistical problems, notably the fact that these stores were held by a private company, Listers. Listers had financial troubles in the early 1970s and sold a million doses to Saudi Arabia. This led the government to reassess its storage policies, and highlighted that national British public health resources were not always in public hands.162 The threat of smallpox faded further during the 1970s, however, and the decision to end routine vaccination was never challenged. Two outbreaks of smallpox resulting from laboratory accidents at the London School of Hygiene and Tropical Medicine and the University of Birmingham caused scandals that led to the reappraisal of health and safety directives for infectious disease laboratories and the destruction of Britain's remaining variola samples.163 Both incidents were quickly contained to a very few people, and the Birmingham case would turn out to be the world's last smallpox victim. Stores of vaccine thus became largely symbolic. There was a general fear of bioterrorism in the West during the Cold War, and later in the post-9/11 international climate.164 Yet it was well known that it would be practically impossible to store enough vaccine and distribute it to the entire British population in the case of such an attack.165 Much like providing mass vaccination in Bradford, calling for tighter port controls and maintaining routine childhood vaccination, being seen to prioritise public health was more important than the relative balance of epidemiological risks.
In the period after 1945, smallpox vaccination had been a tool to defend the British nation from foreign contagion. The nation – Britain – was imagined both as a body to be protected and as a member of an international community. Travellers and medical knowledge moved freely into and out of this nation, creating both opportunities and difficulties. The JCVI smallpox sub-committee noted that vaccination was a ‘medical/social/political issue with international aspects and must be resolved in light of all such factors’.166 Thus, protecting the British public health required a broad view of infectious disease: vaccination was just one tool to achieve this. The British people supported the premise of smallpox vaccination, but saw it as a prophylaxis and form of epidemic control to be used when the local area had become infected. Britain could become a smallpox area – but when it was not, it was difficult to press upon its citizens the need for routine primary vaccination and revaccination. Instead, the government was implored to protect its people by ensuring that ports were properly patrolled, foreign travellers and countries were “disinfected” and, in the rare instances where this failed, to provide vaccination to any Briton who demanded it. The challenge for public health authorities was to placate these demands while stressing that epidemiological evidence might suggest a different weighting of priorities.
Indeed, demand for vaccination would put other stresses on the British government in the 1950s. The next chapter will show how these issues of national protection were stretched by periods of apathy and demand with regard to the new poliomyelitis vaccine. Britain's place within global public health and the international pharmaceutical industry would play a major role in shaping, to borrow from George Dick, ‘paper’ and ‘de facto’ policy towards the disease.167 Unlike with smallpox, the government was able to encourage young adults and parents to have themselves and their children vaccinated – however, it was not an easy process.