We don’t know exactly when smallpox, or Orthopoxvirus variola, began infecting humans, but the earliest evidence shows it flourishing 3000 years ago in the Fertile Crescent and Indus Valley of the present-day Middle East and South Asia. Over the centuries, few people in Europe and Asia escaped this acute viral infection, which killed between 10 and 30 per cent of the people it infected. If many of the survivors were pockmarked and some badly scarred, they had at least the consolation that they would not be afflicted a second time — and in that fact lay the clue as to how the virus would ultimately be eliminated.
By the late eighteenth century smallpox was still extending its global sway. It appeared for the first time along the Pacific coast of North America in the early 1780s and around Sydney Cove in 1789, with a devastating impact on Indigenous peoples. Almost a decade after the first Australian infection, Edward Jenner, an English country doctor, published his Inquiry into the Variolae Vaccinae Known as the Cow Pox, in which he presented evidence that infection with cowpox — a rare pustular affliction on the udders of dairy cattle, and occasionally on the hands of dairy workers — provided protection against smallpox. Henceforth, he argued, cowpox should be used to vaccinate against smallpox.
Until that point, smallpox lymph had been applied under the skin of the arm in the hope of achieving a mild infection. Since it involved communicating smallpox, the procedure posed some risk to the patient; and because the patient became infective, it also posed a significant risk to the community. It’s even possible that the smallpox matter brought by British surgeons on the First Fleet for inoculation purposes may have been the source of the epidemic around Sydney Cove in 1789. Cowpox infection, by contrast, was a very mild affliction and, far from being infective, couldn’t easily be communicated.
Jenner promoted cowpox inoculation by making vaccine matter freely and widely available. Even for him, though, securing a supply of vaccine was difficult. Cowpox was rare and appeared only sporadically, and his preference was not to use cowpox directly from the cow but from a human subject who had been accidentally infected or inoculated with the disease. He would then dry some of the cowpox lymph for future use.
Unfortunately, dried cowpox had a much shorter shelf life than dried smallpox. For almost a year after the publication of his Inquiry Jenner had no cowpox to use in his own experiments or to send to colleagues to seed the practice. After the discovery of cowpox in a dairy in London, however, two physicians in the city ran inoculation trials and corroborated Jenner’s findings. In spring 1799, they began distributing samples of dried cowpox through medical networks in Britain and further afield, though initially few samples proved effective. During 1800, greater care in storing and packaging lymph made possible the establishment of the practice not only in parts of western Europe but also in Boston, Massachusetts.
Jenner’s practice of using cowpox from the vesicle, or blistering, of a vaccinated child to inoculate another batch of children pointed to another way of delivering vaccine over distances. It became common for a country doctor seeking to offer cowpox inoculation to first take a child to a town where the procedure was available, and then, on returning home, draw fresh lymph from the vaccinated child to inoculate others. This method of arm-to-arm transmission was used in summer 1800 to deliver vaccine to the Royal Navy in the Mediterranean and to introduce the vaccine in Malta, Sicily and southern Italy.
These successes stimulated interest in making vaccine available throughout the British empire. From 1800, many samples were sent to India, but none survived the voyage through the tropics. Jenner put forward a plan by which children on board ship were successively vaccinated to keep up a fresh supply of vaccine. All that was needed, he claimed, was an experienced vaccinator and ten non-immune children. A plan of this sort was approved early in 1803, only to be rendered redundant by reports that vaccine sent overland was now in service in India.
The year before, two thirteen-year-old boys born in New South Wales, John Cresswell and John Norton, had played their part in its passage through India. When a ship bound from Sydney to Calcutta, the capital of British India, called in at Madras, Dr James Anderson, the chief physician there, organised Creswell’s vaccination from an Indian boy and then arranged with the ship’s surgeon to vaccinate, at intervals, two Malay sailors and John Norton, who became the source for the beginnings of vaccination in Calcutta.
Samples of vaccine were probably sent to Australia at every opportunity. In 1800, Philip Gidley King, the newly appointed governor of New South Wales, was certainly interested in smallpox prophylaxis. He had first gone out to Australia in 1788 and, as lieutenant-governor of Norfolk Island, had written in 1791 asking Sir Joseph Banks to send smallpox matter to inoculate the children in the colony. After returning to England with a young family in 1796, he evidently took interest in Jenner’s discovery; setting out for Sydney again, he may well have taken some vaccine with him, though if he did, nothing came of it. Back in the colony, he organised an inspection of the local cattle in the hope of finding cowpox.
Not long after, in London, John Savage and William I’Anson, who were going out to Australia as surgeons, made it their business to gain experience in vaccination. Setting out on HMS Glatton early in 1802, Savage made sure he had a supply of fresh vaccine and may have secured approval to seek to maintain it on board by successive vaccinations. Once at sea, he was frustrated by the ship’s surgeon’s refusal to assist his plan and the captain’s unwillingness to “take the responsibility on himself” to intervene. After seven months at sea, his vaccine proved inert on arrival.
Governor King was increasingly concerned by smallpox’s potential impact on the “the rising offspring of the inhabitants” but also aware of the challenges in securing live vaccine. In a dispatch in May 1803, he requested that vaccine be “sent out in every possible way by a whaler,” observing that such a vessel’s voyage “will not be more than four months, which may ensure its efficacy.”
By this stage, there was even the possibility that Australia might be supplied from India. Having managed to send viable vaccine from Madras to Sumatra early in 1803, Dr Anderson recruited Indian mothers to accompany vaccinated children to Prince of Wales Island (Penang) and then dispatched samples to Sydney. In a letter to Anderson in May 1804, William Paterson, lieutenant-governor of New South Wales, expressed appreciation for his efforts in a cause so important to “the welfare and happiness of this infant colony.”
John Shoolbred, the superintendent of vaccination in Bengal, likewise drew up plans to use children from the Orphan School to carry vaccine to Penang and potentially on to the East India Company base in Canton. Aware of the needs of New South Wales, where “all attempts to introduce it had hitherto failed,” India’s governor-general, Richard Wellesley, asked him to consider the feasibility of delivering vaccine there. Having looked at the logistics, Shoolbred advised that the voyage of ten weeks or more would require more children than were available. Although vaccination could be suspended in the Orphan School until “a sufficient number [of children] shall accumulate for the purpose,” he counselled against such a move “lest the natural smallpox should make its appearance” in the interim. He assured Wellesley of his continuing efforts to deliver viable vaccine to Sydney via parcels “preserved in different ways.”
The arrival of Coromandel from England on 4 May 1804, after only 154 days at sea, raised hopes. It brought vaccine supplied by both the London Cow-Pock Institution and the recently established Royal Jennerian Society. On the ship’s arrival in Sydney, the vaccine was immediately put to use on susceptible soldiers and orphans. The Sydney Gazette provided an upbeat report of the trials and the government’s plan to make vaccination publicly available, reprinting the Royal Jennerian Society’s promotional material.
By this time, however, it was becoming evident that the samples sent to the government had failed. Sitting down to write a dispatch to Lord Hobart, Governor King expressed his disappointment with the latest failure, proposed that vaccine be maintained on the next voyage by vaccinating the “healthiest prisoners or children on the passage,” and recommended specific direction to the ship’s captain to assist the process and reward for the surgeon as “an incentive to his exertions.”
But Governor King heard good news before he sent his dispatch. In addition to the official consignment, John Ring, a leading vaccinator in London, had sent John Savage a sample of vaccine “put up in a different manner.” A little furtively, Savage used the sample on a child at Parramatta and succeeded in stimulating a vaccine response. After examining the child, Chief Surgeon Jamison confirmed the propagation of the “true vaccine pock” in the colony.
With a supply of vaccine to hand, Jamison and Savage worked to embed the practice. In the Gazette in June, they reported on the successful trials, offered free vaccination, and urged parents to embrace “so great a blessing” for their children. By August, though, with some 400 children having undergone the procedure, it was evidently becoming harder to find volunteers.
In October, Jamison penned his “General Observations on the Small-pox” — the first article on a medical topic published in Australia — in which he challenged the popular perception that “little danger is to be apprehended from [smallpox] in this climate,” affirmed the safety and effectiveness of the new prophylaxis, and expressed his concern that the “vaccine infection” would be lost if people did not avail themselves of it. “Any objection to so innocent an operation in which the very existence of our children is deeply interested,” the editor of the Gazette solemnly added, “must hereafter be considered as a flimsy absurdity.” It was evident to all that maintaining a supply of vaccine would require general and systematic practice.
By early 1805, the tally of vaccinated children had advanced only to 459. In an attempt to extend the practice more broadly, Jamison organised a vaccination tour in the colony, identifying “convenient places of attendance” where the procedure could be performed.
By this time, Governor King had organised the dispatch of vaccine to Norfolk Island and Van Diemen’s Land. The first samples sent to Hobart failed. According to lieutenant-governor David Collins, the failure “must have been occasioned by the weakness of the virus alone,” as Surgeon I’Anson “had particularly attended to the practice of inoculating for the cowpox prior to his departure from England.” In the event, the introduction of vaccination to Norfolk Island and Van Diemen’s Land was achieved by transporting children under vaccination.
Lieutenant Davis used his own children to bring cowpox “live” to Norfolk Island in 1805, and Surgeon McMillan subsequently organised a vaccination chain aboard Buffalo to deliver it to Van Diemen’s Land. McMillan was rewarded, appropriately enough, with a grant of two cows from the public stock. On 19 December 1805, I’Anson was able to report that four boys and a girl had been successfully vaccinated in Hobart, and that two other girls were undergoing the procedure. Among the vaccinees was Robert Hobart May, an Aboriginal boy who had been found at Risdon Cove after British soldiers had fired indiscriminately on his people.
The history of vaccination in Australia after 1804–05 was somewhat anticlimactic. At a little over 10,000, the population of New South Wales was small. Most of the settlers and convicts were smallpox survivors. Many parents were not disposed to have their children vaccinated. In January 1806, Surgeon Jamison made a last bid for their cooperation, warning that otherwise the “vaccine virus must inevitably be lost.” He had “used every persuasion and exertion” to establish “such a laudable system,” he said, and trusted that, “should all the evils I have pointed out occur one day,” “the public” would agree that “no reprehensibility can attach to me.” Stock from vaccine brought on Coromandel was lost shortly afterwards.
Three years later, in October 1809, Lieutenant-Governor Paterson secured a new supply, probably from India. In reporting his successful use of this vaccine, Surgeon Redfern stressed the need “to impress on the minds of the poorer orders of people, whose ignorance renders them but too susceptible of the grossest and most unfounded prejudices, the usefulness, safety, and superior advantages of this new plan of inoculation.” He also suggested the local supply of vaccine could be best secured “by inoculating but a few at a time.” The vaccine was once again lost from the lack of subjects to vaccinate. In 1818, a new supply was obtained from Mauritius and Cape Colony.
In the first quarter of the nineteenth century, several million people were vaccinated worldwide. In some places smallpox seemed to be effectively suppressed. In Australia, the disease appeared a relatively remote threat. Alarms were raised when ships arrived with recent smallpox cases on board, and smallpox-like diseases circulated among the Aboriginal population around 1830, whose source was unknown, but the relative isolation of Australia and the use of quarantine measures provided adequate security in the first half of the nineteenth century.
In this context, it is not wholly surprising that there was some neglect of vaccination except in anticipation of foreign travel. The challenge for the community was that the supply of vaccine and the capacity to respond to sudden demand during an epidemic depended on the routine vaccination of a good number of children. The Vaccination Act of 1853, which made vaccination compulsory in Britain, while formally adopted in some of the colonies, was not enforced. A smallpox outbreak in Victoria in 1857 encouraged legislative measures that had more teeth, but despite more serious scares in Sydney, the practice was never made mandatory in New South Wales.
A serious epidemic in 1881 was a call to action, with public health authorities making provision for large-scale vaccination and strengthening containment measures. Refrigeration and the use of glycerine to store vaccine made Australia less dependent on routine vaccination locally. A great deal of vaccine was imported from Britain.
Overall, the world’s first vaccine was a success story. As the understanding of microbial infection advanced from the late nineteenth century, vaccination against smallpox provided the inspiration for the development of vaccines for other diseases. In honour of Jenner and cowpox, Louis Pasteur proposed using the terms “vaccine” and “vaccination” for all interventions of this sort. Despite popular apathy and a loud anti-vaccination lobby, the practice remained in good repute. Although it was found that vaccination didn’t provide lifelong immunity, it almost always moderated the severity of the disease, and revaccination was advised.
By the early twentieth century, smallpox was largely under control in the Western world, making its last appearance in Australia in 1938. Still, global eradication appeared a distant prospect. In the middle decades of the twentieth century, the number of smallpox cases surged in Asia and Africa; in the 1950s, deaths from smallpox were still counted in millions. Although the means of preventing smallpox had been made freely available for over a century and a half, it took a massive commitment of resources by the World Health Organization, the energy and resolve of local agencies, and immense popular mobilisation to make possible the global eradication in 1979. •