Last year, scientists responded to the challenge of COVID-19 by producing vaccines with unprecedented speed and effectiveness. Now comes the hard part: vaccinating the entire world. Roughly half a year after the earliest vaccines were approved for widespread use, production shortages, logistical problems, and public concerns over vaccine safety continue to cast a shadow over global vaccination efforts.

China is no exception. In a speech earlier this month, the renowned respiratory disease expert Zhong Nanshan described China’s current vaccination rate as “a long way from achieving immunity in the whole population.”

Vaccination has never been a purely technological problem. Historically, social and cultural factors have always played an important role in the success or failure of a vaccination campaign, including distribution networks and popular attitudes toward vaccines. No country should be more familiar with these challenges than China, where inoculation — a primitive version of vaccination — was first invented roughly 400 years ago.

In 1805, a Spanish physician named Francisco Javier de Balmis led a medical team to promote smallpox vaccination in the Spanish colonies. Perhaps out of a personal interest in the region, Balmis chose not to head straight home after finishing up his scheduled trip to Manila. Instead, he traveled to Guangzhou where he set up smallpox vaccination stations. Although Balmis boasted he was the first person to bring smallpox vaccines to China, the Chinese were not strangers to the idea, only his methods. As early as 200 years previously, China had invented the world’s first method of inoculation against smallpox.

Also known as variolation, the method involved the deliberate exposure of a healthy person to smallpox material. When it first appeared in the middle of the 16th century in the eastern Anhui and Jiangxi provinces, the techniques used were primitive. For example, healthy children were given the clothes of children with smallpox to wear or had the lymph matter from smallpox lesions smeared into their nostrils. These methods were not always effective or safe, and very few people were willing to try them.

By the 18th century, however, more mature methods for inoculating people against smallpox were coming into use. These could be split into two categories: dry and wet. Scabs from children who had recovered from smallpox were removed and ground into a powder, which was then either blown directly into the nostril of the person being inoculated, or mixed with water and daubed inside the nose. Later, to further reduce the risks, wet mixtures were made from the scabs of recently variolated individuals.

It wasn’t until the late 18th century that these folk techniques were widely accepted. Partly, this was the result of their adoption by mainstream medical practitioners and inclusion in official medical textbooks. But the practice also grew more popular after it was adopted by the gentry class and started being performed in privately run charitable organizations such as orphanages.

The Kangxi Emperor (1654-1722) was particularly interested in the potential of variolation. Smallpox was a serious threat to the ruling Qing dynasty: One of the reasons the Shunzhi Emperor chose Kangxi to succeed him was because he had already survived smallpox. Kangxi was the first Chinese emperor to have children in the imperial family inoculated, but even though he recognized the value of inoculation, he did not take any concrete measures to promote the technique empire-wide. At the time, China did not have a notion of “public health” in the modern sense, and the government’s hold over rural society was relatively weak. In fact, as early as the 12th century, the Song dynasty (960-1279) had established an imperial pharmacy with the aim of linking institutions across the country to distribute medicines to people during epidemics. However, these state-run organizations rapidly declined during the ensuing centuries as the imperial court lost its interest in managing the health and hygiene of its subjects.

As the power of the central government receded, the local gentry stepped in to fill the vacuum, largely through charitable organizations. At the time, producing and storing vaccines was both difficult and expensive. Influenced by Confucian values, some southern gentry donated money to hire vaccinators and distributed vaccines free of charge to children in orphanages and other local organizations.

After Jennerian vaccination methods were introduced to China in the early 19th century, the new technique gradually replaced inoculation throughout the country. But an even more important import from the West was the idea of a modern public health system. The earliest modern public health organizations in China were established by Westerners in the concession areas of treaty ports. However, after modern quarantine measures led by Cambridge-educated Malaysian-Chinese doctor Wu Lien-teh played a key role in ending a plague outbreak in Northeast China in 1911, the Chinese government realized the importance of establishing a public health system — both as a way to guarantee the health of its people and as a means of enhancing its ability to rule.

The shift from civilian- to government-led vaccination started in 1919, when the ruling Beiyang government established the Central Epidemic Prevention Bureau in Beijing, the first centralized government agency responsible for the prevention and treatment of infectious diseases. The bureau produced vaccines for various infectious diseases, including cholera, typhus fever, dysentery, plague, and rabies. However, the prevention of epidemics was not high on the beleaguered government’s list of priorities, and vaccines were produced and distributed in extremely limited amounts. Vaccination was restricted to a few big cities, while the vast rural hinterland was left to its own devices.

During the war against Japan in the 1930s and 1940s, the Central Epidemic Prevention Bureau relocated to the southwestern city of Kunming, and the prevention and control of infectious diseases was incorporated into Chinese military strategy. Under the direction of the bureau and with international assistance, Kunming became an important base for vaccine research and production. When the surrounding Yunnan province experienced a cholera outbreak, Kunming officials worked to publicize the importance of being vaccinated, sending medical teams to promote vaccination in urban areas and villages alike before finally bringing the epidemic to an end.

After the founding of the People’s Republic of China in 1949, the lessons learned over the previous decades were adopted and propagated on a much wider scale. In 1952, the central government launched a nationwide Patriotic Health Campaign to both improve people’s living standards and consolidate the new regime. This mass campaign led to vaccines gaining in popularity among the public as a way to prevent infectious diseases. Meanwhile, the creation of an extensive network of grassroots medical stations beginning in the 1960s and the large-scale recruitment of “barefoot doctors” — individuals given basic medical training and sent to treat rural residents — allowed for a rapid rise in vaccination rates.

Hailed by the World Health Organization, this model significantly reduced the appearance and mortality of infectious diseases across China. In the first three decades after the founding of the PRC, infectious diseases such as cholera, tuberculosis, and diphtheria were effectively brought under control. In 1979, China officially declared that it had eradicated smallpox.

The lesson here is that, although research and development are important, so are publicizing the results and creating the kind of medical and health institutions capable of distributing vaccines to all levels of society.

Translator: David Ball; editors: Cai Yiwen and Kilian O’Donnell; portrait artist: Wang Zhenhao.

(Header image: “Auntie gives us smallpox vaccinations,” painted by Ma Lequn, 1974. Courtesy of Det Kgl. Bibliotek)