Gareth Millward, University of Warwick.

I finished the manuscript to my new book on vaccination in late 2017. It was the culmination of my work at the Centre on Alex Mold’s Placing the Public in Public Health project. Thankfully, nothing interesting has happened on the subject since then.

Ah.

Well, as any historian will tell you, you can’t understand what is going on today without understanding its history. This week sees the publication of my new book Vaccinating Britain: Mass Vaccination and the British Public since the Second World War. It shows how vaccination policy in Britain has evolved over the twentieth and twenty-first centuries, and how the British public responded to – and shaped – the vaccination system.

Public health today is gripped with the question of why people don’t vaccinate their children. This is entirely understandable. Measles requires uptake of 95 per cent in order to ensure eradication. The last annual statistics for England showed a drop for the fourth year running – to 91.2 per cent (though it remains a little higher in Scotland. With an apparent rise in the number of parents actively rejecting immunisation, this is a potential public health crisis. Especially when you consider that non-vaccinators are often geographically concentrated in certain areas, meaning national statistics can obscure local neighbourhoods that are at a high risk of infection.

But perhaps more interesting to the historian is the opposite question. Why do people vaccinate their kids? A national rate of 91.2 per cent for any vaccine in the 1960s would have been unthinkable. And even when there have been high-profile crises over individual vaccines – such as over whooping cough vaccine in the 1970s, or MMR in the 2000s – overall vaccination rates have remained robust.

My book argues that this faith in vaccination wasn’t inevitable. Vaccination isn’t just a “rational” decision made by parents based on scientific data and expert risk assessment. It has become an accepted fact of life, the default thing to do to protect your child. This has been the result of a series of complex and inter-related developments in vaccine technology, state administration, public attitudes to science and regional, national and international politics. By understanding this, we get a longer-term, historically informed perspective on the scale and importance of public health professionals’ current vaccination worries. We also gain an appreciation that just because parents “do as they’re told” it doesn’t mean they have fully absorbed public health advice.

The volume is split into five chapters, with each considering a key theme in the history of the British vaccination system.

The first considers the diphtheria vaccination programme from around 1940 to 1960. It looks at apathy, or how the Ministry of Health understood the actions of parents who did not vaccinate. Apathy was not flat-out refusal. It represented parents who had not displayed enough effort to vaccinate because they prioritised other tasks or simply did not care enough. Of course, “caring enough” and “prioritising” were defined by the state and were clearly historically contingent.

The second chapter investigates the nation through the lens of smallpox. Routine smallpox vaccination ended in 1971. British parents had avoided it for years, with uptake much lower than for other diseases and the legacy of the Victorian Vaccination Acts looming large over the entire programme. However, when there was a localised outbreak or when foreign travellers brought the disease with them the public suddenly demanded to be protected, putting great strain on the system. This chapter shows how the “British” part of “British public health” was reflected through these debates, as well as reminding us that smallpox remained a threat to Britain well after it had been eradicated from the archipelago in the 1930s.

The third chapter looks at the development and implementation of the poliomyelitis vaccine in the 1950s and early 1960s. This shows demand. Polio vaccine was an exciting new technology to combat a childhood disease that had only become prevalent in the UK since the late 1940s. When the government was unable to meet demand, it was embarrassed by a series of epidemics and protests from parents and the general public. This shows that the British public was not simply a passive recipient of vaccination. It actively shaped public health priorities through its demands – although these did not always fit the “rational” and “scientific” aims and processes employed by those in the Ministry of Health and local health authorities.

After the period covered by the first three chapters, the British vaccination schedule as we know it today had effectively been established. It has made its scientific case and had succeeded in convincing the public to embrace it as a form of preventative health. The final two chapters, then, look at examples of where this established programme fell into crisis.

Chapter four details the pertussis (whooping cough) crisis of the 1970s, highlighting the public and governmental understandings of risk. When pertussis vaccine was linked to brain damage in children, uptake dropped dramatically. The government tried to convince people that the risks from the disease far outweighed the risks from the vaccine, but was unable to make that case convincingly until after both a detailed scientific report from the Medical Research Council and the worst outbreak of the disease since the vaccine was introduced on a national scale in the 1950s. The crisis and parental attitudes, however, cannot be separated from wider anxieties about the medical profession and the viability of the welfare state.

The final chapter, five, investigates the MMR crisis from the late 1990s to the early 2000s. Here, the themes of the previous chapters are applied to an emerging field – vaccine hesitancy. As with pertussis, contemporary concerns about the medical profession and the state loomed large. Mad cow disease, the Alder Hey organs scandal, Harold Shipman and many other disasters were fresh in the minds of parents as they weighed up whether MMR really was safe. With the internet and twenty-four hour news now in many people’s homes, the public health response took on new challenges as it reasserted the safety of the vaccine. But vaccination rates for other diseases remained high – suggesting the public still believed that vaccination was important, safe and right for their children.

Vaccinating Britain is available in hardback from Manchester University Press for £25.00. Thanks to the generous funding of the Wellcome Trust it is also available in e-book format for free.