The Balmis expedition

How did a simpleton king obsessed with hunting end up financing the first-ever global immunisation campaign?

The year was 1803 and the king in question was El Cazador, "the Hunter," Charles IV of Spain. One of the reluctant heroes of this story, the Bourbon heir was a masterpiece of kingly mediocrity: stout and bovine, well meaning but lacking nerve, indifferent to the affairs of the state but fiercely loyal to the institution he represented, solemn and simple-minded, a prodigious begetter of heirs and a perfectly ineffectual sovereign.

Francisco Goya’s unflattering portraits of Charles give us some insight as to how the monarch was viewed by his contemporaries. Théophile Gautier once described the king and his large family in one of these paintings as looking like “the corner baker and his wife after they won the lottery.” By 1803, his wife, Maria Luisa of Parma, and her lover, Manuel de Godoy, were running the affairs of state and the Kingdom of Spain was marching steadily towards collapse and overthrow at the hands of Napoleon’s army.

Devotion to science and enlightened philanthropy were sufficiently pervasive ideals among European elites of the epoch that even a simpleton in velvet could not ignore them. When his advisers suggested he undertake an immunisation campaign to counter the spread of smallpox in his American dominions, it is likely that their words struck close to home. The disease had already cost him a brother and a sister-in-law and had left his daughter scarred for life.

At the time, smallpox was the single greatest menace to European rulers, more dangerous than revolutionary coups or anarchist insurrections. As such it threatened to continue depriving monarchs of loved ones and monarchies of their dynastic ambitions by unpredictably shifting power from one individual or family to another. There was also the small matter of money. The Council of the Indies, convened by Charles IV in 1802 to advise him about several smallpox epidemics in his American colonies, explained that depopulation at the hands of smallpox meant fewer tributes and less mining, commerce and farming. It was therefore in the long-term interests of the state to invest in a humanitarian campaign to eradicate the disease. Science came to the rescue, in the form of three enterprising doctors and a few dozen orphans, the other reluctant heroes of this story.

The first doctor was Britain’s Edward Jenner, the country surgeon who officially discovered the smallpox vaccine. Drawing on folk tales of milkmaids becoming immune to smallpox after having contracted cowpox, Jenner decided to inoculate an eight-year-old boy with the lesser disease. In May 1796, after 10 days of convalescence, the child was inoculated again, this time with matter from a smallpox lesion. He developed no symptoms and the world gained a powerful ally against a deadly virus, as well as the term “vaccine” (from vacca, meaning “cow”).

It was a great breakthrough. Variolation, as direct smallpox inoculation was known, had been introduced in the first half of the 18th century, but it could still prove fatal.

Vaccinated subjects could be infectious and often produced unseemly infectious pustules. Jenner’s vaccination, on the other hand, entailed no risk of spreading smallpox to others. It was also simpler and cheaper since those vaccinated, unlike people directly inoculated with smallpox, did not have to be kept in isolation for two weeks.

Despite resistance and hostility from both colleagues and the general public, Jennarian vaccination gradually became the norm. By 1801, more than 100,000 people had been vaccinated in England alone. Jenner’s research meanwhile had been translated into German, French, Spanish, Dutch, Italian and Latin. By that time Charles IV had read it and so had his court physician, Dr. Joseph Flores.

Dr. Flores was a hatcher of ingenious plans. In an age where transport was grindingly slow and refrigeration and sterile containment were not yet available, he decided that the best way to keep the vaccine viable during the Atlantic crossing and beyond was through human-to-human contamination. Twenty-two orphans were selected for this purpose: each would act as a human repository for the vaccine before passing it on, in the form of vesicle fluid from the ulcerated skin of one child to the next, to the New World.

Dr. Francisco Balmis – the last doctor in this holy triumvirate – was tasked with making this happen. He set off from the port of La Coruna in Spain on 30 November 1803, returning to Portugal only in 1806 after having led a herculean campaign across the Atlantic to Puerto Rico and on to Cuba, Mexico (where he picked up a fresh batch of orphans!) and the Philippines. His deputy, Joseph Salvany, carried the campaign southwards from Puerto Rico to Colombia and eventually to Ecuador and Peru.

After 33 months of gruelling travel during which they survived illness and shipwrecks, endured rejection by some and delighted in the gratitude of many, the two expeditions succeeded in vaccinating hundreds of thousands of people. Several vaccination boards had also been formed for the continued immunisation of local populations and a hugely important precedent had been set for global humanitarian and public health initiatives.

Heroism alone could not rid two continents of smallpox's deadly threat and the Balmis Expedition was destined to be but the first chapter in the struggle. Good fortune soon ran out on the king, the three doctors and with them their idealistic campaign.

Charles IV of Spain was forced to abdicate and died in exile. Balmis would die forgotten. Even Jenner would come to a miserable end, overcome with grief at the death of his wife and a son. Only the orphans fared slightly better: in return for their services, they were educated at the king’s expense. 

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