‘There will be no compulsory vaccination. That’s not the way we do things in this country,’ the Prime Minister told a news conference on 23 November 2020, on the eve of the rollout of the Covid vaccination programme. (‘Johnson says there will be no compulsory COVID vaccination’, Reuters, 23 November 2020.) Except it was how we did things, up to 1948. From 1853 to the advent of the NHS in 1948, smallpox vaccination was compulsory in England and Wales. Systematic vaccination had been introduced in England and Wales in 1840, with the introduction of a new law requiring local authorities to facilitate (but not compel) the vaccination of children against smallpox. But uptake was low, and with repeated smallpox outbreaks around the country the government took the controversial step to make vaccination compulsory. The Compulsory Vaccination Act of 1853 required that all children be vaccinated within the first few months of birth – with fines and threat of prison for parents who refused to comply. Compulsion was finally removed nearly 100 years later, in 1948, when vaccination became a matter of parental choice once again.
The compulsion element of the 1853 Act was challenged from the outset: the Keighley case in the 1870s/80s, where a number of guardians were imprisoned for refusing to enforce the Act (see our blog of 3 October 2019), was just one of many outbreaks of public disobedience. In the end, the government bowed to pressure, inserting a clause for ‘conscientious objection’ into the Act in 1898, although the principle of compulsion remained in place.
From the beginning, many parents were reluctant to get their children vaccinated, as shown in reports on annual vaccination submitted by the Unions to the central authorities. Reports from Camelford Union, in Cornwall, were probably not unusual. In 1845-46 it reported only 12 children had been confirmed as successfully vaccinated, and only six of those were under 12 months old when vaccination took place; yet there had been 254 births during the year. The vaccinators claimed that few parents bothered to bring their children back for inspection to confirm that the operation had been a success, hence the low number of successes. But, according to their own data, they had only managed to vaccinate 23 new-borns, regardless of outcome of the operation: a paltry 9% of all births. All three vaccinators, well aware that their performance would come under scrutiny, added explanations for the low figures. Edward West, in his 1845/46 report, blamed one parish in particular for his low success rate: ‘In the parish of St Breward, one of the largest in the district, there has not been a single child vaccinated for several years notwithstanding I have frequently attended for that purpose.’ Given that two years earlier he claimed to have vaccinated 57 children out of 100 (57%), this was an odd excuse. William King had managed to vaccinate 17 babies of the 80 born in his district (21%), but none had attended their second appointment to check if the vaccination had taken. He blamed an outbreak of measles for the poor results, but he also added that ‘A great number of the children of the lower classes are left unprotected in consequence of their parents being indifferent about vaccination as the Law is not imperative’. In his earlier return, from 1844 (and in echoes of calls today for local community leaders to assist in overturning vaccine hesitancy in their communities) King urged ‘Guardians and other influential persons in the reluctant parishes to remove this prejudice’.
Disappointing vaccination rates continued in the following years. They reached a low in 1850/51, when in response to that year’s return, the Poor Law Board wrote to the Guardians, ‘The Board regret to observe that 14 persons only are returned as vaccinated during the year, and only 1 child under 1, although there are 308 births.’
While the officials in Camelford seemed to blame indifference and ignorance for their poor vaccination rates, others offered alternative explanations. In Huddersfield, a letter to a local paper (dated 6 January 1854) graphically described one obstacle to vaccination which might deter mothers from bringing their babies forward. The writer, J Clough, surgeon to the Union, wondered at a law which compelled mothers to carry their young infants, sometimes one or two miles in dreadful weather, to undergo vaccination. Clough, in righteous indignation, presented the details of a case he had come across to make his point: a poor woman had carried her child, only 3 months of age, to her nearest vaccination station. Days later the child became poorly. She returned to the station eight days later, as required by law, but without the child, explaining she ‘did dare not bring it out again’. Three days after this, the child died. Surely, Clough said, it would be better if children were vaccinated in their own homes, ‘in hope to save many a mother at Cowcliffe, Netheroyd-hills and places distant two miles from a vaccination station the trouble (to say nothing of danger to the child) of a wet, wintry, cold walk’ (MH 12/15074).
Lack of easy access to a vaccination station was a common complaint in the records. After vaccination was made compulsory, Huddersfield Union undertook a major publicity drive to ensure citizens were aware of the new law, what it entailed, and most importantly where they could get their children vaccinated. Huge posters were printed which outlined the law, fines for non-compliance and a long list of vaccination stations in the Union. The poster was displayed around the town and its outlying districts, and reproduced in local newspapers (MH 12/15073). It looks as if the people of Huddersfield were generously supplied with a wide choice of vaccination stations and hours to attend: sixteen stations were listed across the Union, many of which offered twice weekly clinics. The schedule is impressive, yet it was not enough to prevent babies dying after their mothers were forced to walk through bad weather to comply with the law. Today there has been much talk about access to vaccination centres and not everyone has found it easy to reach a centre.
‘Difficult to reach’ communities have been an ongoing focus of attention for modern day vaccinators. A report in The Guardian highlighted an initiative by two north London GPs, one Jewish and one Muslim, who set up a mobile vaccination clinic to visit places of worship, community centres and private homes in order to reduce barriers to receiving the jab. (‘UK faith leaders join to counter fears over vaccine in BAME communities’, Guardian 7 February, 2021) Similar strategies can be seen at work in Huddersfield in 1853: vaccination stations were set up in a wide range of venues. While the majority were in the vaccinators’ own surgeries, private houses of local people were used, as were school rooms, a variety of church premises (of several different denominations), the town hall and the two Huddersfield workhouses. In three places vaccination stations were established in local pubs. The choice, in some cases, may simply have been expediency, but it is also possible that church properties, school rooms and the local pub were thought to be less intimidating, and more likely to encourage attendance. In Thorne (another West Yorkshire town) the Union was reprimanded by the PLB, for using public houses as vaccination stations. The Union responded, ‘In some of the small villages … the public house is the only public space available’, but promised they would try to vaccinate children in their own homes in future, so they would not need to go to the pub (MH 12/15551).
In 1841, the PLC sent out questionnaires to local vaccinators to find out how things were going with the new Act and asking, among other things, what they thought could be done to improve uptake. Several reported they had more success if patients were visited at home, rather than being asked to attend a vaccination station. One suggested distributing hand bills in large print in the days running up to a clinic to raise awareness, while a couple raised the issue of vaccinator fees: ‘We think it would contribute to the extension of vaccination if the PLC were to fix a reasonable price for each … so as to induce medical men generally to attend to it.’ While payment of today’s vaccinators has not been raised as an issue (although GPs did wonder how they would balance their new role with their existing workload), the convenience of, and confidence in, the location of the clinics coupled with the need for good communication strikes a definite chord. However, the most common response in the 1840s was to ‘make it compulsory’. Which in 1853 is what they did.
But the fact that an Act of Parliament made vaccination compulsory did not lead to 100% compliance. From 1853 to 1898 many parents were dragged through the courts for refusing to vaccinate their children, fined and in a few cases sent to jail. There were acts of public disobedience, and mutiny by public officials – a situation which was eventually resolved, in the post war period, when compulsion to vaccinate children was finally revoked.