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World health

The first vaccination against an infectious disease was the cowpox vaccination. The English country doctor Edward Jenner (1749–1823) is considered to have discovered it. [1] That cowpox, which only causes local, mostly self-healing infections in humans, could confer immunity against the dangerous human pox, was well known in the rural population in the 18th century. Edward Jenner had also been confronted with this idea early on in his practice. In 1780 he began to collect cases of patients who were sick with cowpox and then no longer with the "Blattern", as the human pox was called at the time. The decisive attempt took place on May 14, 1796: At that time Jenner vaccinated eight-year-old James Phipps with a cowpox pustule that had formed on the arm of the cattle girl Sarah Nelmes. As expected, the boy developed a mild fever which soon subsided. After six weeks, Jenner dared to artificially infect him with human pox. The risky experiment succeeded - the boy did not fall ill. Jenner saw himself confirmed and published his discovery in 1798 in a paper on the effects of the cowpox vaccination, which quickly made him famous and which rightly went down in the annals of medical history. The "vaccination" - the term is from the Latin word vacca derived for "cow" - was invented.

Precursor to vaccination

The basic principle of any vaccination, the deliberate introduction of pathogenic material into a healthy individual to protect them from serious illness, had been known for centuries. However, this knowledge was not available in Europe until the early 18th century or had been forgotten again. Thus, in a late version of the "Regimen sanitatis Salernitanum", a health advice in verse form of the school of Salerno in today's Italy, the advice: "So that smallpox does not lead to the death of children / bring smallpox matter into the veins of healthy people . "[2] This can only mean the so-called inoculation, which was practiced in India and China. [3] For this purpose, material from a pustule was removed from people who had just survived the smallpox, usually with a small knife or a lancet. This was transmitted to healthy people by scratching the skin on the limbs. This procedure was also known among the steppe peoples of the Caucasus. The philosopher Voltaire (1694–1778) reports in one of his letters: "Since time immemorial, women in the Circassian country have used to give their children the leaves when they are six months old by opening them through the opening made by a cut put a leaf on the arm, which they have taken from the body of another child and carefully stored. This leaf placed in the arm produces the same effect that the leaven does in bread, it ferments and spreads the properties impressed on it throughout the blood The leaves of this child who has been given artificial smallpox are needed to pass this disease on to other children again. This circle is constantly maintained in Circassian land, and if unfortunately no smallpox is available in the country, one shows oneself there just as dismayed as one complains about a bad year elsewhere. "[4]

To this day, the introduction and becoming known of inoculation in Europe are associated with the name of the wife of the English ambassador to Constantinople, Lady Mary Wortley Montagu (1689–1762). She was not the first to publicize the success of Ottoman doctors with the "Blattern-Beltzen", as the method was called in German, through her letters in England. Her personal example - she had her son vaccinated in this way in 1718 - as well as her social status contributed decisively to the fact that the inoculation aroused the interest of doctors and laypeople almost everywhere in Europe. She succeeded in convincing the English King George I (1660–1727), after initial skepticism, to have his grandchildren vaccinated.

The inoculation was mostly limited to the nobility and the urban upper class. [5] The reasons for the hesitant implementation of the practice were varied. As with the vaccination later, some had religious concerns and saw in it an interference with divine providence. Others, on the other hand, had doubts about the effectiveness of the procedure, because the course of the immunization experiment was difficult or impossible to predict. Even if the vaccine came from someone whose disease was mild, the person vaccinated could still become seriously ill or even die. According to a contemporary estimate, the risk of dying from "Blatter-Beltzen" was still 1: 182. Although this was considerably lower than the risk of death in the case of a natural disease from human smallpox, which at that time died almost one in eight, it could happen that a local smallpox outbreak occurred in the first place through a vaccination. Last but not least, vaccination was associated with considerable costs in some places. In particular, the English vaccinators, who are highly praised for their expertise, demanded sometimes horrific fees.

Although in some contemporary medical writings proponents of inoculation already dreamed of the liberation of mankind from the smallpox scourge, the not exactly low-risk procedure could not meet these high expectations, if only because it was largely restricted to the social elite.

Controversial progress

Far from everyone was convinced of the benefits of the new, less dangerous vaccination. Jenner's publication sparked heated controversy which spread from England to other countries. [6] For example, the Berlin doctor and philosopher Marcus Herz (1747–1803) called the cowpox vaccination by means of a small incision on the skin using a lancet as "brutal vaccination". But the critics remained a minority among the doctors. Rather, at the beginning of the 19th century one can observe an increasing vaccination euphoria among medical professionals all over Europe. For example, the doctor Johann Immanuel Bremer (1745–1816) opened a "vaccination school" in Berlin in 1800, where he taught interested colleagues about vaccination technology. A pamphlet from 1803 shows the enthusiasm and expectations with which the positively minded doctors participated in vaccination campaigns. "Smallpox has been eradicated", announced the Erfurt medical professor August Friedrich Hecker (1763-1811) on the title page of his book of the same name. It was a bold medical utopia; it is well known that smallpox was only declared "eradicated" by the World Health Organization in 1980, almost 180 years later. In 1804 the Bückeburg doctor Bernhard Christoph Faust (1755–1842) had a large number of leaflets printed, which was to be hung in inns and other public places. [7] It was titled: "Call to the people: to eradicate the leaves by inoculating the cowpox." Even pastors participated in this vaccination propaganda in many places. Incidentally, Faust had the original idea of ​​celebrating the so-called Krengelfest on May 14th - the day on which Edward Jenner had carried out his first vaccination - at which the children held a parade in Jenner's honor. A porcelain arm with simulated inoculation pustules was carried through the place. Every child who was subsequently vaccinated by Faust received a pretzel, called "Krengel" in East Westphalia. The festival is still celebrated today, but rather folklorically and without the original clear health policy message.

The fact that such a material incentive was even necessary has to do with the resistance of broad sections of the population who, for a wide variety of reasons, did not want to be vaccinated. This was done with arguments that are still partly encountered today with anti-vaccination campaigns. Quite a few laypeople, but also doctors, were convinced that the vaccination was harmful to health. Even the proponents did not go unnoticed that the vaccination could also transmit other diseases, such as unclean lancets. Indeed, the way the vaccine was obtained at the time was highly problematic. In the first half of the 19th century, so-called over-vaccination was used, in which one used human lymph that had been obtained from the inoculation pustule of a child who had recently been vaccinated. In this way the door was opened to the transmission of diseases like syphilis. It was not until the second third of the 19th century that animal lymph was used by artificially creating inoculation pustules on the cow's skin through infection. Furthermore, intolerance reactions regularly occurred, which in individual cases even led to death or severe vaccination damage.

The other argument of the vaccination opponents, who soon formed associations not only in Germany, was: The vaccination is not only dangerous but also ineffective. In the eyes of the skeptics, this was even statistically verifiable, because although a large part of the population was already vaccinated, smallpox epidemics occurred in various places in the 19th century, claiming numerous victims. The resurgence of an epidemic that was believed to have been almost defeated was partly due to the fact that it was not recognized until the late 1820s that vaccination protection did not last a lifetime and had to be refreshed by means of revaccination.

Milestones in vaccine development

After Edward Jenner had provided evidence of the effectiveness of a vaccination against human pox with the cowpox virus, numerous researchers set out in search of bacteriology in the era of bacteriology initiated by the physician Robert Koch (1843–1910) and the chemist Louis Pasteur (1822–1895) similar protective live vaccines. [8] These have very small amounts of functional germs that are so weakened that they can still multiply, but can no longer trigger the disease due to genetic changes. It is administered either by injection or orally as an oral vaccination. One of the first hopes of early vaccine development, the "miracle drug" tuberculin, discovered by Robert Koch in the early 1890s - a mixture of weakened tubercle bacilli with glycerine and water - failed as a vaccine against tuberculosis, but still works today in the form of a skin test in diagnostics good service. It was not until the microbiologist Albert Calmette (1863–1933) and the veterinarian Camille Guérin (1872–1961) successfully developed a live vaccine against tuberculosis after experiments with a weakened virulent mycobacterium in the 1920s.

So-called dead vaccines were also experimented with in the 19th century. Some of the vaccinations that are still in use today are based on this principle. A distinction must be made between two types: on the one hand, toxoid vaccines such as those against diphtheria, pertussis (whooping cough) and tetanus, in which the respective toxin has lost its toxic properties through special processes, but the antigenic effect is retained; on the other hand, inactivated vaccines such as those against cholera, hepatitis A, rabies and polio, in which the disease-causing virus loses its infectivity under the action of various substances, but also through heat or radiation and can be used to manufacture vaccines. In 1896 Wilhelm Kolle (1868–1935), a colleague of Robert Koch, developed a cholera vaccine that was killed by heat and made preservable by adding phenol. The bacteriologist Waldemar Haffkine (1860–1930) researched from 1895 on a dead vaccine against the plague. Various clinical studies have been conducted in India and China with mixed results. In one case, tetanus spore contamination of the vaccine resulted in death of all those vaccinated and the use of Haffkine's vaccine to come to an abrupt end.

A milestone in vaccination history was a daring attempt at healing in 1885 on the nine-year-old baker's son Joseph Meister, who was bitten by a rabid dog. He was brought to Paris to see Louis Pasteur, who at that time had already carried out numerous animal experiments with the rabies pathogen. He used a weakened infectious suspension that he had obtained from the dried spinal cord of a rabbit infected with rabies. The dogs vaccinated with it then proved to be immune to the disease. In order to prevent a rabies infection after a dog bite, Joseph Meister first received an injection of a brain mass from an infected rabbit that had been dried for 14 days and then, over a period of ten days, twelve injections with ever fresher, and therefore increasingly virulent, material. The last injection was a fully virulent rabies virus, so Pasteur used to check whether the patient was immune after the treatment. After Joseph Meister showed no symptoms of rabies infection for several months, he was released from medical care. The news of the apparent success of the post-exposure vaccination established Pasteur's reputation in France. As medical history research has shown by evaluating the laboratory diaries, Joseph Meister's presumed "cure" can in no way be taken as evidence of the effectiveness of the vaccine used by Pasteur at the time. But as more and more cases of rabies were treated with the vaccine he made, it was found to be effective. [9]

Pasteur developed three other vaccines, which makes him one of the most important representatives of early vaccine research: in 1879 against avian cholera, in 1880 against anthrax, and in 1883 against swine erosion. He had thus provided convincing evidence that - at least in principle - a vaccination could henceforth protect against any infectious disease.

Jonas Edward Salk (1914–1995) conducted research on another dead vaccine in the 20th century. After the Second World War, the future Nobel Prize laureate John Franklin Enders (1897–1985) made a decisive contribution to research by cultivating viruses in cell cultures. On this basis, Salk succeeded in developing a vaccine against polio, for which the viruses were inactivated by formalin. This hit the headlines, however, after several children who had been vaccinated with a batch from the production of the Californian vaccine manufacturer Cutter-Laboratories, developed paralysis and died in 1955. A vaccine that still contained infectious material was accidentally used. The virologist Albert Sabin (1906–1993) then developed an oral vaccine on the basis of living polio viruses with weakened virulence, which was advertised in Germany with the catchy advertising message "Oral vaccination is sweet - polio is cruel".

With the discovery of the HI virus in the early 1980s, another chapter in the history of vaccine development began. When the virologist Robert Gallo was asked after the press conference in 1984, at which the discovery of the AIDS pathogen was announced, when a vaccine against the dreaded disease would be available, he replied: "In two years". More than 35 years have now passed. The big breakthrough is still not in sight, although billions have already been invested in the development of a vaccine against AIDS. The science journalist Jon Cohen believes that the search for a vaccine has long been a lack of coordinated research efforts and only secondarily of money. [10] There are also other factors that, in his opinion, are also responsible for delays and setbacks, such as the half-hearted support from politicians, who for a long time did not classify the fight against AIDS as a health policy priority, or the interests of international pharmaceutical companies who want to make money on drugs . But there are now signs that one has learned from the past and from the failures. The International Aids Vaccine Initiative has existed since 1996, a non-profit organization that strives to coordinate and financially support the almost unmanageable international research efforts. After initially taking the path of blocking the virus' path of infection with antibodies against its envelope protein, most AIDS researchers are now trying to develop vaccines that not only stimulate the antibody-based response of the human immune system, but also the cellular defense take advantage of. It is now also possible to produce hybrid viruses with which the protective effect in great apes can be tested better than previously possible, before clinical trials in humans can be considered. Because vaccination attempts on volunteers are still a big problem.

Coercion or voluntary?

The history of vaccination policy is closely interwoven with scientific progress and the debates about the pros and cons of vaccination. In some German territories, a more or less rigid compulsory vaccination was introduced just a few years after the invention of vaccination. Bavaria started in 1807 after an appeal by the king to be vaccinated against smallpox had met with little response from the population.The law stipulated that anyone over the age of three who had never had smallpox should be vaccinated by July 1, 1808. For each child who was not vaccinated in time, the parents were supposed to pay a fine of one to eight guilders, depending on their assets - the daily wage of a journeyman craftsman at that time was slightly more than one guilder. In 1815 the Grand Duchy of Baden followed the Bavarian model, in 1818 the Kingdom of Württemberg, and in 1821 the Kingdom of Hanover. Saxony and the city-state of Hamburg, on the other hand, did not issue a vaccination law until the beginning of the 1870s. Prussia did not have one either, but it put pressure on the population in other ways to get vaccinated against smallpox. Only those children were admitted to school or training who could show a vaccination certificate. When, as a result of the Franco-Prussian War of 1870/71, another large smallpox epidemic hit the population with hundreds of thousands of deaths, the newly created German Reich resorted to coercion: on February 5, 1874, the Reich Vaccination Act was adopted in the Reichstag despite resistance from circles of organized anti-vaccination groups. It not only provided for the compulsory vaccination against smallpox in infancy, but also revaccination at the age of twelve.

Even after the Reich Vaccination Act was passed, the question of the extent to which a "precautionary state" had the right to force its citizens to vaccinate by law was still heatedly debated, and the argument about compulsory vaccination kept the Reichstag busy until the Weimar Republic . The fronts went straight through the parties. Beyond the high-profile debates that were heated up by contrary opinions, vaccination practice was characterized by a "pragmatic paternalism" until 1933. [11] In other words, the state continued to insist on the compulsory vaccination, but did not enforce it with all its might. This was not least due to reports of vaccine damage that repeatedly came to the public. However, most of these did not reach the dimensions of the so-called Lübeck vaccination accident of 1930, when 77 children died as a result of the injection of a contaminated tuberculosis vaccine and a further 131 vaccinated people fell ill. [12] Because of this catastrophe, the introduction of the vaccination against tuberculosis with the Bacillus Calmette-Guérin in Germany was delayed until after the Second World War. Since this tragic event at the latest, the political discourse was no longer just about vaccination, but also about vaccinations against a variety of diseases.

Even the National Socialist regime, which placed public health above individual health, did not suppress vaccination criticism. This was not only due to the fact that some of his leading representatives, for example Rudolf Hess, were toying with alternative healing methods. The "Third Reich" pursued a pragmatic approach to vaccination policy, with the exception of the Wehrmacht. The most important reason was successful advertising campaigns by the pharmaceutical industry for voluntary vaccination using brochures, radio reports and educational films. At the end of the 1930s, for example, a vaccination quota of 90, often over 95 percent, was achieved for diphtheria vaccination, while this averaged between 60 and 80 percent for compulsory smallpox vaccination. In Germany, a development began before the middle of the 20th century that can be described as the transition from mandatory state vaccination to the privatization of health care.

After 1945, different prophylaxis concepts determined health policy in the Federal Republic and the GDR. The oral vaccination against poliomyelitis came into focus, after smallpox had not posed a threat in Germany or around the world since the late 1970s, because the successful fight against another childhood disease promised a gain in prestige in the systemic competition. The GDR was proud to be regarded internationally as the precautionary state par excellence, but that did not make it a biodictatorship. The deficits typical of the planned economy gave rise to pragmatism in the vaccination issue, even though the GDR government repeatedly boasted at the international level of the success of its state-controlled prevention program. In the Federal Republic of Germany it was mainly civil society associations, such as the German Association for Combating Polio or the German Green Cross, which organized vaccination campaigns with financial support from the health authorities. In 1972 the Standing Vaccination Commission (STIKO) was set up, and the health authorities follow its recommendations when it comes to vaccination issues. Their recommendations are now considered the medical standard. The compulsory vaccination against smallpox, which had existed since 1874, was gradually lifted a good hundred years after its introduction: From 1976, the first vaccination was discontinued. In 1983 the compulsory smallpox vaccination was finally lifted completely. At the same time, all compulsory vaccinations were eliminated.

In the unified Germany a "liberal turn of the prevention discourse" has been observed for a long time, [13] in which the individual as the "preventive self" is increasingly appealed to to orient his / her own lifestyle according to health criteria. However, since the Infection Protection Act 2001 came into force, compulsory vaccinations can be reintroduced at any time. According to Paragraph 20 Paragraph 6 and Paragraph 7 of the Infection Protection Act, all that is required is a simple ordinance to make vaccinations binding. In November 2019, for example, the Bundestag passed a nationwide compulsory vaccination against measles in all German schools, child minders and daycare centers, but also in other community facilities such as refugee accommodation and medical staff.


In view of the almost two hundred year old fight against human smallpox, there can be no doubt that there is a causal connection between the definitive disappearance of this epidemic in the early 1980s and consistent mass vaccination. For other infectious diseases, the historical evidence is not so clear. Right now the world is waiting for an effective vaccine against Covid-19. According to a recent opinion poll, a majority of 67 percent of Germans would opt for a vaccination against the novel corona virus. [14] In the group of G7 countries, however, the Federal Republic only ranks next to last.