Deborah Brunton, The politics of vaccination: practice and policy in England, Wales, Ireland, and Scotland, 1800–1874, Rochester, NY, University of Rochester Press, and Woodbridge, Boydell & Brewer, 2008, pp. xi, 255, £50.00, $85.00 (hardback 978-1-58046-036-1).

Between 1800 and 1874 in Great Britain, smallpox vaccination expanded from a medical novelty to a state-mandated procedure. Deborah Brunton’s carefully researched and thoughtfully argued book details the politics that surrounded the passage of key pieces of legislation regarding vaccination in England, Wales, Ireland and Scotland. Her comparative analysis reveals remarkably different vaccination practices despite similar legislation, and underscores the importance of social, professional, and institutional cultures in the evolution of public health measures. Brunton’s work addresses a little studied period in the history of vaccination. The early history of smallpox vaccination is covered in several biographies of Edward Jenner, the English doctor who introduced the practice in 1798. Its later history in the last decades of the nineteenth century is addressed in studies about the anti-vaccination movement in Great Britain. But surprisingly little has been written about the intervening period, when smallpox vaccination became a widely adopted practice throughout Britain and the object of several pieces of legislation. The first vaccination act was passed by parliament in 1840 and established a system of public vaccination in England and Wales that placed vaccination under the supervision of the Poor Law Commission and required it to offer vaccination to everyone. Prior to the passage of this act, medical practitioners debated and contested its provisions arguing that it undermined their authority over a medical procedure. One of the themes that runs through Brunton’s analysis is the importance of the new professional identity of medical practitioners formed through shared educational experiences, medical societies and journals, and efforts to reform licensing. In the middle decades of the nineteenth century, medical professionals became increasingly involved in lobbying parliament regarding legislation about vaccination. They were unsuccessful in their attempt to shape the 1840 act, and they subsequently complained about the low fees they received for vaccinating infants under its provisions. Compulsion was not introduced until the 1853 Vaccination Act, which required that all infants be vaccinated within six months of birth otherwise parents faced fines or even imprisonment. Historians of public health have generally regarded this act as the key legislation regarding smallpox vaccination, but Brunton argues that this act did little to alter the provision of vaccination and that the system of registration put in place to record vaccinations was weak. She includes a table summarizing the number of births and the number of vaccinations in England and Wales from 1851 and 1858 drawn from the annual reports of the Poor Law Board that clearly shows that the act did not significantly increase levels of vaccination among the population. During the 1850s and 1860s, Brunton documents the growing role of experts in government, especially the role of the Epidemiological Society (established in 1850) in crafting legislation. One of the key figures in promoting expertise was the physician John Simon, a leading member of the Epidemiological Society, who authored a 280-page report on the status of vaccination and suggestions to improve its practice. Simon viewed most vaccinators as incompetent, and wanted to bring vaccination under the authority of the General Board of Health, rather than the Poor Law authorities. He promoted the use of a single technique that relied on arm-to-arm transmission of the vaccinating lymph. Brunton portrays Simon’s efforts as self-serving: “It is hard not to see Simon’s concern with the quality of vaccination as an example of the strategy of manufacturing a problem and then proffering a solution” (p. 69). In the end, Simon’s initiatives failed to garner support. Brunton has more regard for the ways vaccination developed in Ireland and Scotland. Drawing on the records of the Poor Law Commission and an Irish medical journal, Brunton shows that British efforts to impose the provision of vaccination through the Poor Law Commission failed, and that the medical charities, hospitals and dispensaries throughout Ireland that were funded by local charity and local property taxes, were mandated instead to provide vaccination free of charge to anyone. This system proved to be quite successful, and Ireland enjoyed very low levels of smallpox mortality as a result. Similarly in Scotland, local social, professional, and institutional factors shaped the provision of vaccination. Scotland had only one vaccination act—passed in 1863—that made vaccination compulsory. Unlike their English counterparts, Scottish medical practitioners were quite successful in lobbying members of Parliament in the drafting of the 1863 act. As a result, private medical practitioners retained control over the practice, vaccinating over 80 per cent of all infants, while parish medical officers vaccinated fewer than 5 per cent. (By contrast, English Poor Law authorities vaccinated between 60 per cent and 90 per cent of all infants.) As Brunton has deftly and convincingly shown, there were many paths to compulsory vaccination shaped by local and national institutions. Her study highlights the new role of the medical profession in its efforts to shape government public health policy, and the continuing role of Poor Law authorities in administering programmes directed to improve general welfare. And, for the history of vaccination, she has illuminated how a specific medical practice became a government-mandated procedure.