When the United States green-lit two coronavirus vaccines in December, it was a rare bright spot during this pandemic: Scientists had developed a vaccine for COVID-19 far faster than any other vaccine in history. The end finally seemed at hand.
Since then, many, many things have gone wrong. In mid-December, Pfizer reported that it had millions of doses sitting around in a warehouse, and no instructions on where to send them. Medical teams trained to vaccinate masses of people have been sitting infuriatingly idle. Health departments originally stuck to banking hours instead of vaccinating around the clock. Governors have slowed things down by relying on confusing guidelines about who can get vaccinated when. Unused doses have expired and been thrown away.
Operation Warp Speed, the federal government’s plan to develop and deliver vaccines in the United States, is now sputtering. In mid-December, the federal government floated hopes of distributing 40 million vaccine doses by the end of 2020. That number soon dropped to 20 million. Twelve days into January, just about 9 million people have received vaccines, less than 3 percent of the U.S. population. Meanwhile, Israel has vaccinated 21 percent of its population. Rolling out a vaccine at this speed and scale is not easy, but health agencies have had months to prepare and were still caught off guard.
These missteps are troubling, but they’re hardly surprising. In some ways, developing vaccines has always been the easy part; getting them into people’s arms is the challenge. Vaccines have been around since the late 1700s, and the rollouts have often been precarious—full of blunders, accidental deaths, dashed hopes, and dubious ethical decisions. When the very first vaccination campaign got under way, in fact, it faced such daunting barriers—technological, geographical, and medical—that today’s distribution challenges seem minor in comparison.
At the end of the 18th century, smallpox was probably the scariest disease on Earth. It spread alarmingly quickly, and every inch of people’s skin, including their face, would erupt with thousands upon thousands of painful, pus-filled sores. Huge numbers of people died from the disease, and many survivors were struck blind, or left with severe scars. The British doctor Edward Jenner observed something strange, however: People who caught a related disease called cowpox never came down with its deadlier cousin. So in 1796, he began giving people cowpox intentionally, rendering them immune to smallpox and creating the first vaccine.
But the breakthrough introduced another dilemma: How could doctors deliver vaccines to people who needed them? Within Europe, distributing the vaccine was manageable. People with cowpox developed blisterlike sores filled with a fluid called lymph. Doctors would prick open the sores, smear the lymph on silk threads or lint, and let it dry. They would head to the next town over and mix the crusty lymph with water to reconstitute it. Then they’d scratch the fluid into the arms or legs of people there to give them cowpox. The process was straightforward but laborious.
The real trouble started when doctors tried to vaccinate people who were far away. The lymph could lose its potency traveling even the 215 miles from London to Paris, let alone to the Americas, where it was desperately needed: Smallpox outbreaks there were verging on apocalyptic, killing up to 50 percent of people who got the virus. Every so often threads of dried lymph did survive an ocean journey—a batch reached Newfoundland in 1800—but the lymph was typically rendered impotent after months at sea. Spain especially struggled to reach its colonies in Central and South America, so in 1803, health officials in the country devised a radical new method for distributing the vaccine abroad: orphan boys.
The plan involved putting two dozen Spanish orphans on a ship. Right before they left for the colonies, a doctor would give two of them cowpox. After nine or 10 days at sea, the sores on their arms would be nice and ripe. A team of doctors onboard would lance the sores, and scratch the fluid into the arms of two more boys. Nine or 10 days later, once those boys developed sores, a third pair would receive fluid, and so on. (The boys were infected in pairs as backup, just in case one’s sore broke too soon.) Overall, with good management and a bit of luck, the ship would arrive in the Americas when the last pair of orphans still had sores to lance. The doctors could then hop off the ship and start vaccinating people.
Given the era, it’s likely that no one asked the orphans whether they wanted to participate—and some seemed too young to consent anyway. They’d been abandoned by their parents, were living in institutions, and had no power to resist. But the Spanish king, Carlos IV, decided to make them a few promises: They would be stuffed with food on the voyage over to make sure they looked hearty and hale upon arrival. After all, no one would want lymph from the arm of a sickly child. Appearance mattered. And they’d get a free education in the colonies, plus the chance at a new life there with an adoptive family. It was a far better shake than they’d get in Spain.
The Royal Philanthropic Vaccine Expedition finally set sail in November 1803. Twenty-two orphans, ages 3 to 9, made the journey, accompanied by lead doctor Francisco Xavier de Balmis, his team of assistants, and Isabel Zendal Gómez, the head of the boys’ orphanage, who would care and comfort them.
Despite all the careful planning, the expedition nearly failed. When the ship arrived in modern-day Caracas, Venezuela, in March 1804, just a single sore was left on the arm of a single boy. But it was enough. Balmis immediately started vaccinating onshore, focusing on children, who were most susceptible to smallpox. By some accounts, Balmis and his team vaccinated 12,000 people in two months.
From Caracas, Balmis’s crew split into two parties. His top deputy, Jóse Salvany Lleopart, led one expedition down into what’s now Colombia, Ecuador, Peru, and Bolivia. The journey was rugged, through thick jungles and over the forbidding Andes Mountains. Still, over the next few years they managed to vaccinate upwards of 200,000 people. Many villages greeted them as saviors. Cathedral bells rang, priests said Masses of thanksgiving, and people shot off fireworks and held bullfights in their honor.
Meanwhile, Balmis marched up through Mexico, where he vaccinated on the order of 100,000 more people. Midway through the journey, he dropped off the orphans with their new families in Mexico City. Then he headed to Acapulco to prepare for another vaccine expedition, this time to Spanish colonies in the Philippines. He picked up a few dozen more boys in the town, but instead of finding orphans, he hired boys from various families, essentially renting them as vaccine mules for the journey to Asia.
The ship arrived in the Philippines on April 15, 1805, and within a few months, Balmis’s team had vaccinated 20,000 people. The expedition was so successful, in fact, that Balmis went rogue and sailed to China in the fall of 1805 to vaccinate people there. The achievement was staggering: Without any modern equipment or transportation, Balmis’s team managed to spread Jenner’s vaccine across the world in less than a decade, vaccinating hundreds of thousands of people and saving perhaps millions of lives.
The road to smallpox vaccination was messy. Spain devised the orphan plan only because prior attempts to transport the vaccine the old-fashioned way—to North America, South America, India, and elsewhere—had floundered, prolonging outbreaks that could have been stopped. If that last boy’s sore had popped before reaching Caracas, the orphan expedition would have failed as well. And while many towns hailed the vaccinators, some doctors who’d grown rich providing quack smallpox treatments were early anti-vaxxers, actively thwarting the campaign by refusing to administer vaccines. Let’s not forget the orphans, either: removed from their childhood home, injected with diseased fluid, and put on a ship for a strange land. The ordeal must have been terrifying.
No matter the era or disease, vaccine campaigns are always daunting logistical challenges, with dozens of points at which the distribution chain can, and often does, break down because of communication hiccups or weak supply-chain links. Despite health agencies the world over spending billions upon billions of dollars on campaigns to eradicate polio, the disease still has not been stamped out globally, in large part because distributing vaccines to certain areas has proved nearly impossible. A campaign for a childhood malaria vaccine erupted in controversy last year when the United Nations failed to disclose side effects to parents in Africa, including meningitis and an increased risk of death in young girls. Even in the case of measles, a disease with an established vaccine, a bungled campaign killed 15 children in South Sudan as late as 2017.
Over time, vaccines do generally reach the people who need them. That’s not an excuse for blunders: Every minute that’s wasted during this pandemic means more unnecessary death, and in this record-breaking moment, that means lots of unnecessary death. But even after two centuries of vaccines, rolling out shots is a tricky process that takes some time to get just right. Let’s just hope the missteps so far are simply a 2020 hangover, and that in retrospect our COVID-19 vaccine campaign will remind us more of Balmis’s successful orphan voyage than of the failures that preceded it.