The Politics of Vaccination: Practice and Policy in England, Wales, Ireland, and Scotland, 1800–1874 (review)

Deborah Brunton's The Politics of Vaccination is a useful addition to the historiography of vaccination in the United Kingdom during the nineteenth century. The book explores why the development of public vaccination against smallpox was so "startlingly different" (3, 106, 141) in the four major divisions of the United Kingdom. The author suggests that "the major factor that drove public vaccination along [its] different paths . . . was a debate about the relationship of medical practitioners to the state" (4). As one example, certain groups of medical men protested that the appointment of a corps of public vaccinators divided any potential unity of the profession and denied patients "the right to a free choice of practitioners" and further ignited fears about "state interfer[ence]" in the matters of the medical profession (4–5) (in this and a few other statements, Brunton's material suggests certain similarities between the nineteenth century vaccination debates and contemporary public health issues). But, she contends, the training and practice of medicine was deeply fragmented along national lines and thus there was no unified medical profession to guide an integrated scientific and legislative approach to public vaccination policy. In England and Wales, particularly under the powerful—but not uncontested—leadership of John Simon (within the Medical Office of the Privy Council), the dominant view was that the medical profession should be hierarchical, led by a small group of experts whose role would include advising government on medical matters and supervising the implementation of medical policy. Consequently, the Medical Office increasingly had the power to oversee a national system of vaccination, not just advise authorities on local sanitary improvements and specific vaccination practices (89–91, 105, 164). In contrast, in Scotland and Ireland, though in quite different and independent fashion, an alternative view dominated; there, a vision emerged of a more democratic profession in which all practitioners possessed the same qualifications and enjoyed reasonably equal access to vaccination work. In Ireland and (to a lesser degree) in Scotland, public vaccination policy and work was to be shared out among large numbers of practitioners who were, as a result of their general medical training, deemed competent to themselves decide when, where, and how to conduct vaccination (165).

Politics of Vaccination is divided into three, quite unequal, sections. The reader, whose attention is aroused by the title, finds that Scotland and Ireland receive much less attention than the comparatively well-investigated England. The first section, the largest at six chapters, chronicles the complex and contentious debates that marked the development of vaccination policy in England, and, more fleetingly, Wales. Brunton marshals evidence to demonstrate that experts centralized in government, led by Simon, ultimately prevailed over rank and file practitioners to control vaccination policy. The 1858 Public Health Act granted the Medical Office of the Privy Council powers such that Simon could, in theory, establish new training courses for vaccinators, issue new instructions on the provision and actual practice of vaccination, and organize the inspection of vaccine supplies. In actuality, however, Simon's instructions were never fully implemented due to varying degrees (in different districts) of resistance by the Poor Law Board and medical practitioners (71–90). Antivaccination sentiments and parental resistance to compulsion further complicate the picture. Brunton's second section demonstrates that the pattern of vaccination implementation in Ireland could not be a carbon copy of that in England and Wales, because the Irish poor laws were such that public medical relief operated mainly within the workhouse and the homes of the very poor. As such, the poor law authorities were not capable of providing the much more widespread duties that the 1840 Vaccination Act permitted them in principle. It was only by the late 1860s (the 1851 Medical Charities Act had initiated the wider reform of the poor laws and significantly extended the provision of public medical relief) that the Irish Medical Commissioners were able to achieve...