Chapter 8 discusses the arrival of vaccination in Portugal and Spain. An early recipient of cowpox, Portugal proved barren ground until the Prince Regent promoted the practice. Given its long rejection of smallpox inoculation, Spain moved surprisingly rapidly to embrace the new prophylaxis, with the first vaccination at the end of 1800, with vaccine sent from Paris. During 1801, vaccination was established in Madrid and other major centres and there was a flurry of publications on the procedure, some original, others customised translations. Grandees patronised vaccination in the provinces and local initiatives led to good coverage in Barcelona and Navarra. In 1803, the Royal and Philanthropic Vaccine Expedition was organised to extend the practice through the Spanish empire, beginning in the Canary Islands. War and political upheaval frustrated measures to consolidate vaccination in Spain and Portugal, but the authorities, political and medical, and some communities retained their commitment to the practice.

Chapter 12 discusses the severity of smallpox in the New World and the use of smallpox inoculation to control smallpox in the West Indies and suppress epidemics in Spanish America. Early attempts to introduce cowpox in Jamaica and elsewhere led to disappointment, but local initiatives began to bear fruit prior to the arrival of the Spanish Royal and Philanthropic Vaccine Expedition in 1804. This well documented expedition, in which children under vaccination were escorted to go arm-to-arm with others along the way, naturally commands centre stage. Projecting an image of professional expertise and imperial benevolence, Dr Balmis and his assistants brought vaccination to Venezuela and helped to set the practice on a firmer organisational footing in Cuba, Guatemala and Mexico. In the meantime, Salvany, his deputy, headed south through Colombia and Peru, vaccinating on an epic scale. Although Lima was already supplied with vaccine from Brazil by way of Buenos Aires, Salvany continued his work in the remote districts of Peru until his death in 1810. His assistant, Grajales, remained in harness in Chile until 1812.

Chapter 11 discusses the early vaccination in North America. Dr Benjamin Waterhouse pioneered the practice in Boston in August 1800, rebranded cowpox as kinepox and briefly enjoyed a monopoly of the practice. Aware of the hazards associated with smallpox inoculation, Americans welcomed the new prophylaxis. President Thomson Jefferson took up the lancet at Monticello and, largely in a private capacity, helped to entrench and extend the practice. Philadelphia emerged as a new hub of vaccination, seeding its establishment in the southern states and on the western frontier. Serviceable to individuals and communities, the new practice served to bind together the new nation, with slaves often among the first to be vaccinated and prophylaxis being offered, as opportunities arose, to Native Americans. The problem of maintaining a supply of good vaccine in sparsely populated districts and on the frontier appeared more urgent with the outbreak of war with Britain in 1812 and explains the Federal government’s unusual decision to fund a (short-lived) National Vaccine Agency in Baltimore.