‘There will be no compulsory vaccination. That’s not the way we do things in this country’: the journey to enforced smallpox vaccination in the 19th century

‘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’.

Form completed by the three public vaccinators in Camelford Union, for year 1845-46 (MH 12/1299)

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.

Poster from Huddersfield Union advertising the 1853 Compulsory Vaccination Act (MH 12/15073)

‘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).

Questionnaire completed by one of the vaccinators at Wakefield
(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.

Taking the Long View of Contagion, Compassion and Community Response

Temporary hospital during the Spanish Flu pandemic, 1918

In these unsettling times it might seem as though history has little comfort to offer us. When we look back for reassurance, we tend to light on the scale of the Spanish Flu pandemic, the horrors of the Black Death, or the ravages of smallpox through the ages. Yet despite the hardships and, for some, personal tragedies that have followed in the wake of Covid-19 it is important to maintain a sense of perspective, and one way we can do this is by recognising just how resilient and resourceful we are, and always have been, in the face of epidemics and communicable diseases. From the early modern period onwards, we have built on empirical observations and experimental science to understand the best ways to mitigate and even halt the spread of deadly diseases; but, individually and collectively, we also have a rich history of compassion and public spiritedness when  it comes to protecting vulnerable groups and supporting those most affected by epidemics. Nowhere are all these tendencies clearer than in the stories that emerge from the correspondence to the Poor Law Commissioners across the 19^th century.

A Ward in the Hampstead Smallpox Hospital, 1871

In 1893, for example, Charles Wills, the medical officer of health for the Southwell Rural Sanitary Authority, wrote to the Local Government Board that a case of smallpox had been discovered at the union workhouse. The affected man, Henry Jackson, had tramped from Manchester (where he was believed to have picked up the disease) and arrived on the 27 January. The authorities swiftly determined that he had shared the vagrant ward that night with a further 18 men, and this was communicated to the Local Government Board with an account (as far as possible) of their ongoing movements. The ward was then closed, and Jackson was placed in isolation with another male inmate to act as his nurse. His companion was chosen specifically because he had previously survived the disease and was therefore assumed to be immune. The Guardians took further measures to stop the spread of the disease by vaccinating or re-vaccinating all inmates over the age of 10 who would allow it. As a result of their swift action, Jackson’s was the only recorded case on this occasion: he seems to have recovered by late March, and his ‘key worker’, Robert Rushton, who nursed him for a full seven weeks, was later given a guinea by the Guardians as a reward for his efforts, which enabled him to discharge himself from the workhouse. In a postscript to the case, the Medical Officer, Charles Wills, wrote that there were many isolated cases of smallpox in Derbyshire and Yorkshire at the time, and that it was bound to be exported to neighbouring districts. In response, he proposed that some semi-detached cottages should be built on property adjacent to the workhouse in order to improve facilities for isolation if it reached Southwell again (it is not known whether the Board chose to act on his recommendation in this instance)  (TNA MH 12/8544, 9547).

If all of this sounds remarkably familiar, then it’s hardly surprising: the very fact that epidemics were a constant threat before the refinements of modern medicine meant that rapid responses and empirical methods of containment were at the forefront of everyone’s mind, and many of the public health measures that were instigated from the 1830s onwards were, of course, specifically aimed at achieving this outcome. Crucially, the newly centralised and bureaucratised structures of the poor law were an ideal forum for applying these measures. So it was that when Richard Pugh, the clerk to the Watford Union, reported in 1849 that there had been a fatal case of cholera in the town, the Guardians were well placed to put in train a series of measures to ensure that it was checked at source. These included a house-to-house visitation of infected localities, and when a case was discovered in the Workhouse Infirmary it involved daily testing and examination of all workhouse inmates to ensure that timely treatment could be applied as soon as symptoms manifested themselves (TNA MH 13/197).

Indeed, large parts of daily workhouse practice were specifically aimed at stopping the encroachment of communicable diseases from gaining a foothold in these institutions, and from spreading more widely if detected. The oft-noted practice of removing a person’s clothes for ‘purification’ (usually by boiling) when they were admitted and replacing them with workhouse dress was done for precisely this reason. It is a subject that has often caused controversy in the literature, because contemporaries, and most historians, have chosen to interpret it simply as a way of enforcing a degrading uniform; but, in fact, it was a very effective way of checking the spread of disease. As the president of the Poor Law Board explained to Parliament in 1849, “the rule now in force [was] introduced on considerations suggested by the necessity of securing cleanliness,” and he added that “by enforcing it, the cleanliness and health of the establishments [has] been very materially promoted” (Bath Chronicle, 28 June 1849). When common sense measures such as these were not followed, paupers themselves were the first to complain. In 1867, for example, J. Smith, an inmate at Bethnal Green workhouse, wrote that the nurses from the sick wards were carrying their dirty washing through the day rooms, which were used predominantly by elderly and infirm inmates, and that this laundry was likely to be contaminated from contact with infected patients. He complained that it was a practice which was “injurious to health and not to be tolerated,” and he suggested that the only reason nurses were not allowed to go the “proper way” to the laundry was because the Master was fearful lest his own children “should catch a disease, as they would have to pass his apartments” (TNA MH 12/6854).

This focus on the workhouse poor brings us back full circle to the situation we face today with Covid-19. Thankfully, here in Britain, as in many countries where it has made such rapid progress, things have begun to stabilise and, though obviously still of great concern, the overall number of cases and deaths seems to have plateaued. One of the areas of increasing anxiety, however, relates to care home residents, and we still have little understanding of just how devastating it will turn out to be for the institutional care sector as a whole. Clearly, many of the practical measures outlined above were specifically designed to protect workhouse populations from mass outbreaks. But the authorities were also acutely aware that other measures that we are now becoming all-too familiar with could make a crucial difference in preventing institutional tipping-points. So, for example, when Widow Granger, a resident at Barnet workhouse, asked permission to go out and visit her dangerously ill granddaughter, the Guardians “refused [her request] in consequence of the complaint being the small pox” (G. Gear (ed.), The Diary of Benjamin Woodcock: Master of the Barnet Union Workhouse 1836-38 (Herts. Record Society, 2008), p.98). This entry tells us that Widow Granger would, under normal circumstances, most likely have been allowed out on compassionate grounds; something that, in itself, challenges many of the standard narratives about workhouse life. But it also tells us that officials in the 19^th century were constantly grappling with the competing needs – emotional, psychological and medical – of those under their charge in exactly the same way as those who are currently trying to manage the spread of Covid-19 in care homes. The question of how to protect the physical welfare of vulnerable residents, while ensuring that they are not denied the life-affirming contact and support of loved ones, is clearly not a new one.

These are extraordinary times, unprecedented for most of us: but alongside the uncertainty and inevitable anxiety that comes with a situation like this, we also have the opportunity to reflect on the great sacrifices that ordinary people – from key workers to coordinators, and from community volunteers to self-isolaters – are making for the public good. It is, perhaps, some comfort to know that we have such deep reserves of selflessness and rapid response to draw on. This last example, from the Board of Guardians’ Minutes of Mitford and Launditch Union in Norfolk during the last great epidemic of smallpox in 1871, is a wonderful case in point (TNA MH 12/8484).

The attention of the Guardians was particularly directed to the case of William Cory, of Great Dunham, Labourer, who, with his Wife and family of six children, had recently been deprived of their usual Harvest earnings by reason of the state of Quarantine imposed upon them, for 5 or 6 weeks, in consequence of the existence of Small Pox in a Cottage adjoining his Dwelling house and under the same roof: And it being shewn to the satisfaction of the Guardians that this insulation of Cory and his family has tended to prevent the spread of the disease but that he had thereby incurred a loss of Five pounds and upwards, it is unanimously resolved that he be allowed the sum of Five Pounds, either under the provisions of the Sanitary Acts, or by way of gratuity under the special circumstances as the Local Government Board may approve.