The Role of Smallpox Vaccination in Mortality Decline in the Great Britain through Eradicating the Disease

between XVIII-XX centuries – Facts or a Political Arithmetick?”

Mamurjon Rahimov

University of Illinois at Chicago

Department of Economics

 “Whoever would understand the political phenomenon known as ‘The Anti-Vaccination Agitation”- and its magnitude would seem to indicate it as being at least worth understanding – must remember some one or two facts, facts obvious enough indeed, but constantly forgotten.  And chief amongst them this, that every opponent of the practice, every skeptic, without exception, as to its benefits, has in the first instance approached the question in a spirit at least of impartiality, and probably all his prejudices strongly in its favor”

Alfred Milnes

Introduction

In October of 1979, The World Health Organization (WHO), officially declared smallpox, also known as variola, eradicated.  The disease that was known to mankind as early as 1122 BC in China, took millions of lives throughout the world (Britannica.com).  We all know that WHO is a branch of the United Nations Organization, and is dedicated to protect the health of the mankind.  However, UN also has many other branches dealing with issues like business, economy, culture, education, migration, to name a few, and furthermore, the eradication of smallpox is believed to be a collaborative achievement of most of these branches, both on local and on global level.  If so, this eradication must have been announced jointly with, if not all, then at least few other UN branches such as World Bank, UNDP, and UNICEF.   It would be very unfair for medical men to appropriate this great achievement of mankind all to themselves.  Although medical men do not like to mention it too much, they all recognize that eradication of smallpox was not only their merit.

Economic history has contributed significantly to the formulation of various economic theories.  Among the economists who have found history to be an important source for their ideas one can cite Adam Smith, Thomas Malthus, Alfred Marshall, John Maynard Keynes, Milton Friedman, Robert Solow, and Gary Becker.  For economists it is very important to study population history in order to come up with policies that decrease mortality and morbidity of the population.  Factors like life expectancy, infant mortality are considered to be key indicators of progress in any country.  Longer life expectancy means more manpower to move the industry, larger consumer base for products and services. 

My purpose here is to elaborate in theoretical and statistical plausibility of smallpox vaccination eradicating the disease based on papers written about the smallpox disease, and to seek whether the vaccination, if efficient at all, weighed substantially in the light of other forces that caused decline in mortality.  It is quite striking to read from Memoirs of Jacques Casanova, a contemporary, that “More people perish at the hands of doctors than are cured by them” in those centuries, and in contrast the common belief that in those centuries medical men suddenly came up with “one-size-fits-all” cure for one of the most dreadful diseases of all time, which, with little modifications, if any, continued to be administered worldwide up until the second half of the XX century.

For several centuries until now, proponents of vaccination hailed smallpox vaccination to be a proven wonder weapon in the hands of mankind in eradicating the disease in the world, although there have been a number of schools of thought that, if not disprove, then diminish the role of smallpox vaccination in fighting the disease to an insignificant level, which is the change in the virulence of smallpox.

We must remember from European history that the period in which the most drastic decline in British smallpox mortality took place coincides with the time Britain experienced industrial revolution, and thus improved standards of living must have played crucial role in reducing susceptibility of the population towards infectious diseases (Krause, 1958). A good example is a paper written by several researchers from the University of Liverpool and Manchester that used time-series analysis to study the dynamics of smallpox in Britain in 1550-1800, and found a striking correlation between wheat price fluctuations and epidemics (Duncan, 1993; also see Helleiner, 1957). 

Economists almost always try to use models in order to come up with logical interpretations of current and past events.  One such paper (Mokyr, 1993) that tries to explain decline in mortality in the light of economic forces, used standard theory  of utility maximization as a starting point: Uj = Uj (Xij…Xnj, Lj) where L is composite family life expectancy variable, subject to the usual budget constraint ∑XiPi = Y.  It further goes on and tries to estimate the rise in knowledge (in hygiene and sanitation, in particular), relative prices, public goods (convergence towards best practices), and the like and their consequent influence on decreased mortality.  Economists agree that knowledge always has indirectly influenced every single area of man’s life, however the paper attempts to go beyond indirect relationship towards autonomous causality, and since lion’s share of mortality and morbidity is attributed to smallpox at that period in history, it does seem that a general rise in the level and scope of knowledge had direct effect on mortality decline throughout Britain.

Much has been said and written about the practice of vaccination in general and smallpox vaccination in particular.  If you read a couple articles and books on how lucky we were to obtain the knowledge about vaccination, you may feel that, if not vaccines, mankind would be wiped out from the Earth by the dreadful infectious diseases of all kind.  While I am writing this paper, hundreds more new vaccines are being developed in state-of-the-art medical laboratories and millions of people, young and old, are being vaccinated, despite the growing opposition from parents, scholars, and doctors against mandatory mass vaccination. It is interesting to note that vaccination remains to be the only medical practice that has to be enforced by law (NVIC.ORG).

A Remarkable Decline in Mortality

Mortality and morbidity of a population, although closely related, are two different things.  I do not want to elaborate that in a number of developed countries, including the United States, morbidity of the population has been growing, while mortality has been rather low (NVIC.ORG statistics).  In this paper, I tried to focus on falling of mortality rates in Britain between 18^th and 20^th centuries, and the causes of this remarkable decline.  Economic gains from falling mortality can never be precisely estimated, because human life is such the most precious thing one can ever have.  Between 1750 and 1914 mortality rates went down substantially everywhere in Europe, of course not at the same pace and the same extent.  For instance, life expectancy in Britain went from 30’s in 1750 to 50’s in 1914, and crude death rate fell from about 25 per thousand in 1750 to 14-15 per thousand in 1914.  The immediate cause of this dramatic shift is undisputedly decline in infectious diseases in Europe, but deeper causes of this phenomenon have been fueling debates among three major overlapping “schools” that have emerged to explain the causes behind the mortality decline.   “Nutritionist” school stresses improvement in living standards and food consumption as a result of economic growth to be major causes, whereas “preventist” school contends that this decline in mortality can be attributed primarily to public policy such as smallpox vaccination campaigns on mass level and cleaning of sewage systems.  The third school, “exogenists”, claims that the decline in mortality can be explained by reduced virulence of major infectious diseases on microbial level and positive changes in climate (Mokyr, 1993).

First inoculation and later vaccination is cited to be plausible explanation for this decline. Inoculation, in primitive and crude way, was practiced mainly in a few Oriental and African countries.  Due to the limited scale of inoculation, its efficacy was not known well.  People of England learnt about it in 1721 when Lady Mary Wortley Montagu’s daughter was inoculated in London (Tucker, 1963).

Inoculation must be formally defined to avoid mixing it with the more recent practice of vaccination. Smallpox inoculation is the injection of smallpox virus taken from actual smallpox wound of a patient, whereas smallpox vaccination is the injection of cowpox virus.  The symptoms these two practices produce slightly differ, but they are both carried out for the same purpose – developing immunity in people against the actual smallpox disease.  Edward Jenner was the founder of smallpox vaccination in Britain, and interestingly, it was by his medical induction that he believed that exposing a person to cowpox would render the person immune to smallpox (1798).  Nobody could prove empirically that this exactly was the case, and for instance William Hewson was not able to verify through numerous experiments what Jenner supposedly achieved.  Charles Creighton, a learned anti-vaccinator, in his book Jenner and Vaccination (1889), proved that Jenner not only failed to demonstrate, experimentally or otherwise, that cowpox and smallpox were biologically related, but nobody else, until the date Creighton’s own book was published, had done so (Greenwood, 1930).  Besides, the population, which was subject to various vaccination laws and acts, stubbornly resisted to vaccination (Milnes, 1897).  The City of Leicester became a center of such resistance, and despite the gloomy prophecies of medical men about huge toll to be paid due to a large unvaccinated population, it was one of the cities that suffered least from several epidemics of 19^th century (NAVL, 1910).

Legal Side of the Story

In 1840 British Parliament passed “An Act to Extend the Practice of Vaccination”, by which smallpox inoculation that was used prior to smallpox vaccination to prevent this disease was made a penal offence.  Since the practice of smallpox inoculation dates back to 1721, it turns out this life-destroying practice lasted for a hundred and twenty years! 

The first compulsory vaccination law was Lord Lyttelton’s Act in 1853.  Lord Lyttelton is quoted to have said, “It is unnecessary for me to speak of the certainty of vaccination as a preventive of small-pox, that being a point on which the whole medical profession have arrived at complete unanimity”.  Despite a growing number of post-vaccinal morbidity and mortality cases (Krause, 1958), Britain passed another landmark vaccine law in 1867 - the vaccination law of England, which at once was put in force (Milnes, 1897).

Stakes Behind the Vaccination

Often, if not always, there are huge financial interests behind political goals.  Due to mostly qualitative information concerning the vaccination in the stated period, and inexistence of reliable statistical body for the most part of it, “There is no means of accurately gauging the amount paid for treating diseases subsidiary, or arising from vaccination” (NAVL, 1910).  However, the below brief table for Ireland will illustrate that substantial finances were committed to the vaccination practice.

 Table 1.  Annual Reports for the Local Government Board for Ireland:

Fascination vs. Repulsion with Numbers

Among all the economists of the history, I admire Adam Smith most of all.  Adam Smith’s works have been inspiring many economists throughout centuries, and many scholars can’t help mentioning him in the course of their work.  His pen did leave few stones unturned, and each time with an economic point of view.  Although most of the modern terms were inexistent at his time, he described things his own way and often cut to the core of the matter.  I had to refer to his famous book, Wealth of Nations, for many times in the past, and the most recent review of it gave me a term that has become an anchor for my paper.  That term is “Political Arithmetick”.  Adam Smith remarkably acknowledged ‘I have no great faith in political arithmetick’ (Smith, Wealth of Nations, I, p.534).  In a 1785 letter   written from Edinburgh Custom House to George Chalmers, Smith reiterated his sentiment: ‘You know that I have little faith in Political Arithmetic’ (Smith, Correspondence, p. 288).  There were serious limitations in gathering and analyzing quantitative information during the early introduction of vaccination to England, and no wonder many, like Smith, put little faith in numbers. 

Davenant gave a good definition to the term Political Arithmetick: “By Political Arithmetick, we mean the art of reasoning by figures, upon things relating to government.” (Hoppit, 1996)  The golden age of political arithmetick began in 1662 with the publication of John Graunt’s book “Natural and Political Observations upon the Bills of Mortality”, and passing with the death of its key proponents, Gregory King in 1712 and Charles Davenant in 1714.  The term itself was devised by Sir William Petty in about 1671 or 1672.  The use of statistics in policy debate became more prevalent at around the same period.  It is up to one’s imagination to count the areas which were influenced by Political Arithmetick – social order, military matters, religious affiliation, economic performance, public finances, to name a few.  Furthermore, ‘Medical Arithmetick’ was being enthusiastically championed by 1780s, though its origins are rooted in much earlier periods.  As another author put it ‘Without medical arithmetic it is impossible to reach the “grandeur of generality”, the sublime of medical divination.’(Hoppit, 1996).

Almost a century after Adam Smith’s remark about unreliability of political arithmetick, a medical man, Dr. Guy, was presenting a paper on smallpox and vaccination at The Royal Statistical Society, and to the question whether vaccination were a preventive of smallpox, he answered that “there can be no answer except such as is couched in the language of figures” (Greenwood, 1930).  An amazing contrast in faith in numbers, isn’t it?  Where does it come from?  The thing is proponents of vaccination then and now had no other way of proving the efficacy of vaccines, smallpox vaccine in particular, than talking in the language of numbers.  Even though it may sound very odd, medicine had little role in proving efficacy of vaccines. The thing is vaccines are injected mostly to people in near-perfect health, and it would be very unethical to expose control groups to the dreadful diseases in order to prove the efficacy of vaccines.  The proponents of vaccination, people with strong ties in the governments and pharmaceutical-medical industry, have been trying to prove the efficacy of vaccines through statistical study of population mortality and morbidity, often making unbelievable claims.  Having reviewed dozens of historical materials about smallpox vaccination, I saw an obvious “play with numbers” in order to reach “politically correct” conclusions.  Medical historians McKeown and Record stated that 'the data (on mortality and natality) are so treacherous that they can be interpreted to fit any hypothesis' (Razzell, 1965).

Few tables below will illustrate this point:

Table 2.  Mean Annual Rate of Mortality per million from smallpox at all ages in three groups of years, selected with reference to optional  and obligatory vaccination (Milnes, 1897).

Fascinatingly, all other infectious diseases, without any exception, decreased during this period, contributing to the falling mortality rates in Britain, a lot of them by larger percentage than smallpox.  Moreover, except smallpox, none of those infectious diseases were confronted by any inoculations and/or vaccines.  The below table will better illustrate the point:

Table 3.  Mortality compared, Smallpox with Fever Group (Typhus, Typhoid, and Simple and Ill-defined) for the Two periods, 1838-42 and 1871-75 (Milnes,1897).

Table 4.  Mortality of Smallpox and Cholera compared, on Average per million, for the Twelve Years 1838-42 and 1847-53, and the Forty-two years 1854-1895 (Milnes, 1897).

Hence, with in regards to the above two tables, it becomes clear that there is no ground to attribute decline in smallpox mortality to smallpox vaccination, because if that were the case, smallpox must have declined by far larger percentage compared to other infectious diseases.  This is not a conclusion, which has been arrived at recently, on contrary this fact has been suppressed for political purposes, and has been known from the very beginning.

Late Dr. Gryzanovski noted the strange fascination in numbers: “Not only the mathematician, and the mystic philosopher, but the artists, the physicist, the economist, all feel it alike, and even those who are unable to comprehend the real nature of numbers, have an instinctive appreciation of their conclusiveness”.  Below is a good example how numbers can be misleading if used improperly.  During an agitation in favor of compulsory vaccination in Germany at the end of 19^th century, the learned Professor Kussmaul went into great details by citing the occurrence of 3330 cases of smallpox in Marseilles in 1828.  According to the statistics that was presented by him to prove the necessity of mass vaccination, 2289 of the 3330 persons had not been vaccinated.  Out of these unvaccinated folks 420 or 18.3 per cent died, whereas the mortality among the vaccinated 1041 was only 17 or 1.7 per cent.  At first sight, it seems obvious that vaccinated folks were luckier and through saved lives smallpox vaccination caused an invaluable amount of economic gain, but that is only if we presume that data is correct and calculation is without any fault.  But now we have Dr. Lorinser’s data on Marseilles’ population in 1828, and proportion of vaccinated, 133000 and 33000 respectively.  And if now we recalculate using the correct denominators, we come up with a completely different picture.  In fact, it is the opposite of the initial finding that supported efficacy of the smallpox vaccination.  Mortality level among the vaccinated comes up to be 32 per thousand, while mortality level among the unvaccinated is 23 per thousand.  This recalculation of the data at hand not only disproves the initial claims of the efficacy of smallpox vaccination, but also shows that it was dangerous.  So who is right in this case?  Maybe both men’s conclusions were wrong, but Dr. Lorinser’s statistical methods seem to make more sense. (Gryzanovski, 1906). 

Hence, the role of smallpox vaccination in eradicating the disease in Britain seems to be exaggerated.  The first medical tool in preventing smallpox disease, inoculation, was pronounced illegal after being carried out on mass level for more than 120 years.  It is interesting to note that from the date of mandatory smallpox vaccination law in Britain in 1853 till the complete eradication of the disease in 1979, almost the same amount of time had passed as in the previous case.  One thing is different though – this time, with vaccination, medical men decided to end smallpox vaccination on a good note… After 1979, smallpox cases were spotted in a few LDCs (less developed countries) of the world, but the WHO did not re-initiate mass smallpox vaccination.

Conclusions and Directions for A Future Research

Without a doubt, eradication of smallpox disease was one of the greatest achievements of mankind.  It must be emphasized that this was the merit of combined forces of various factors, such as economic, sanitary, technological, and educational.  Arduous endeavors of certain groups to continue with inoculation long after it had been banned in 1840 were mentioned (NAVL, 1910), and this leads one to think that these groups probably had huge economic and/or political interests at stake. Estimation of economic benefits derived from smallpox immunization, both inoculation and vaccination, would shed light on the special interests behind this practice.  In case of inoculation that preceded vaccination, it seems to be a very low-cost (both start-up, and operations) and highly profitable field: all kinds of amateurs (from farmers to custom-officers) carried out inoculations throughout towns and villages, with little or no regulation; overseers of the poor paid for their parish to be inoculated.  For instance, the statement that “many gentlemen paid for inoculation of the children of the poor in their own neighborhoods” does signal huge economic spending on inoculation, but does in no way quantify the amount (Razzel, 1965).  The above description of smallpox inoculation resembles the current day Internet get-rich-instantly recipes, which also boast low-cost, huge potential markets, and little regulation. 

Vaccination replaced the arsenal of medical profession against the infectious diseases, but little has changed.  Many vaccine batches are found to be contaminated even during our days, and there is still no sure way to inspect their quality, few vaccine manufacturers work as a monopoly.  Vaccine manufacturers and doctors who carry out the vaccination practice are legally freed from liability on any consequent damage caused by vaccines (NVIC.COM).

I was not able to economically compare the weight of smallpox vaccination compared to other forces, mainly not due to the lack of data on smallpox mortality or economic and other developments in Britain between 18^th and 20^th centuries, but due to impossibility to measure things with he same units.  How would you compare sanitation, increased knowledge of safe food preparation, better economic standards of living, higher levels of vaccination, and lower mortality rates?  How much is the worth of one human being’s life?  If just one child died after vaccination, and it turns out he was a potential new Einstein, how does that change economic calculations of losses due to post-vaccine mortality?  I tried to avoid going deep into analyzing mortality rates alone, because it would become a simple body count, not economics.  However, with little surprise, I discovered that among all the forces that are believed to have played role in eradicating smallpox, smallpox vaccination remains to be the most controversial to the date.

1.  Helleiner, Karl. “The Vital Revolution Reconsidered”.  The Canadian Journal of Economics and Political Science, Vol. 23, No. 1. February 1957.

2. M. Greenwood. “The Vaccination Problem”.  Journal of the Royal Statistical Society, Vol.93, No.2. 1930.

3.  Scott, Susan.  “The Dynamics of Smallpox Epidemics in Britain, 1550-1800”. Demography, Vol. 30, No. 3, August 1993.

4.  Milnes, Alfred.  “Statistics of Smallpox and Vaccination, with Special Reference to Age-incidence, Sex-incidence, and Sanitation”.  Journal of the Royal Statistical Society, Vol. 60, No. 3. September, 1897.

5.  Gryzanovski, Ernest.  “On Collective Phenomena and the Scientific Value of Statistical Data”.  Publications of the American Economic Association, 3^rd Series, Vol. 7, No. 3.  August 1906.

6.  Encyclopedia Britannica online. http://www.britannica.com/

7.  Krause, J. T. “Changes in English Fertility and Mortality, 1781-1850”.  The Economic History Review, Vol. 11, No. 1. (1958).

8.  The National Anti-Vaccination League. (NAVL) “For and Against Vaccination”.  London, 1910.

9.  National Vaccine Information Centre. NVIC.COM

10.  World Health Organization: Smallpox Vaccination. WHO.ORG