“An effective AIDS vaccine could be found as early as 2012, saving 6 million lives if the world is willing to put £10 bn a year into a new programme, the chancellor, Gordon Brown, said in a speech last night in Tanzania”. Faith in biomedical science; the conviction that new vaccines will be translated into lives saved; belief in the necessity of globally concerted action: the British minister's statement reflects views of vaccine innovation that are widely held today. New and improved vaccines seem our best hope of coping with the scourge of AIDS, of arming ourselves against the unknown threats of emergent diseases and potential bioterrorism, and of tackling the resurgence of old diseases arising once more in Europe. Global coordination, pooling our resources, seems self-evidently necessary, given the international nature of a modern epidemic. Much current discussion of vaccine development and use thus has a global character. That is to say, it is conducted under the banner of global slogans or it seeks to establish globally integrated approaches to vaccine research and development (R&D). Over the past two decades the development and rapid introduction of new vaccines have come to dominate the vaccine agenda worldwide. Social scientists and health policy analysts have been set to work, examining barriers to the implementation of international priorities at the national level. Why, for example, are national responses to the availability of new vaccines often so lethargic? A recent study of the adoption of Hemophilus influenza b (Hib) conjugate vaccine is a good example. It shows policy makers in four countries rationally weighing the burden to public health of the diseases against which the vaccine offers protection (bacterial meningitis and pneumonia), against the high cost of the vaccine. Health policy analysts tend to explain the decision to introduce a new vaccine, or to replace an existing vaccine by a new alternative, in terms of the epidemiology and seriousness of the disease, and of scientific consensus regarding the efficacy and potential risks of the vaccine and (perhaps) their costs. The studies of vaccine diffusion and adoption that they conduct have little or nothing to say about political disagreements, or the influence of commercial interests, national traditions, international relations, or global agendas. Where any attention is paid to vaccine history, it is generally in the attempt to illustrate factors (such as resistance to vaccination) that might cause deviations from the rational deployment of vaccines.

Who was to blame when a labouring woman or her unborn child died during the early modern period? How was responsibility assessed, and who was charged with assessing it? To answer such questions, this article draws on French obstetrical treatises produced by male surgeons and female midwives between 1550 and 1730, focusing on descriptions of difficult deliveries. Sometimes the poor outcome of a labour was blamed on the pregnant woman herself, but more often a particular medical practitioner was implicated. Authors of obstetrical treatises were careful to assign fault when injuries or deaths occurred in cases concerning them. Chirurgiens accoucheurs (surgeon men-midwives) regularly accused female midwives of incompetence, yet also attacked fellow surgeons as well as those male physicians officially superior to them in the medical hierarchy. Female midwives similarly condemned the actions of male practitioners, without hesitating to censure other women when their mismanagement of deliveries had tragic consequences. Part of authors' eagerness to blame others stemmed from the fear of being held accountable for mistakes preceding practitioners had made. Ascribing responsibility usually went hand-in-hand with defensive claims of innocence, or boastful declarations of having saved a suffering woman from the bungling attempts of less skilled birth attendants.

During 1923, the South African government began to issue free vaccine for the immunization of cattle against anthrax. Five years later, it introduced compulsory annual vaccination in parts of the Transkeian Territories, an area reserved for occupation by Africans. Thereafter, the state sought to extend both compulsory and discretionary vaccination. In 1942, scientists at the government's Onderstepoort Veterinary Institute announced that they had issued 6 million doses of vaccine during the previous year. Approximately half the cattle in the country were being immunized annually with a special product which scientists at the Institute had recently devised. The scale of vaccination was unprecedented within the country and the annual issue of anthrax vaccine far surpassed the amount supplied for any other animal disease. It was a major state intervention in rural society. Nevertheless, vaccination against anthrax in South Africa is absent from the historiography, while published contemporary accounts are few.

One of the animating beliefs of British health service reformers in the first half of the twentieth century was that delivery would improve if greater co-ordination was imposed over disparate providers. The fundamental divisions were between the voluntary, public and private sectors. Voluntary provision predominantly meant acute care hospitals, but also included a range of other therapeutic and clinical services. The public sector delivered general practitioner (GP) services to insured workers through the state national health insurance (NHI) scheme, while the remit of local government covered environmental health, isolation and general hospitals and a wide range of personal services addressing tuberculosis, venereal diseases, mental illness, and maternity and child welfare. Finally, the private sector provided nursing homes and GP attendance at commercial rates. Within each area there were tendencies towards independent rather than co-operative working. Voluntary hospitals often lacked any mechanism for conferring with neighbouring institutions and the competitive logic of fund-raising enforced an individualistic ethic. In the public sector health responsibilities were dispersed across various agencies: local authority health committees, advised by the county or borough Medical Officer of Health (MOH), oversaw sanitation, hospitals and personal health services; education committees were responsible for the School Medical Service (SMS), whose remit was the compulsory medical inspection and treatment of elementary schoolchildren; the Poor Law provided institutional care either in workhouses or separate infirmaries, although after the 1929 Local Government Act the boards of guardians were broken up; their powers were then transferred to the public assistance committees of local authorities, however these remained distinct from health committees. GP services accessed through the state NHI system were overseen by local insurance committees separate from local government. Private practice co-existed with NHI and doctors tended to prioritize fee-paying rather than panel patients.

Historical myths die hard: one such is of a supposed outbreak of scurvy—said by some to be the result of medical insouciance—at Millbank penitentiary in 1823. Thus, Sean McConville in his masterly account of prisons in the reform period writes: “The decision [to reduce the diet] was a major factor in the scurvy epidemic which followed shortly afterwards, causing at least thirty deaths”. Other authors take a similar line: “Fifteen months later, after 30 had died, and after the whole convict population had been evacuated from the prison, Holford was convinced that the disease had been sea-scurvy”; “there was a serious outbreak of scurvy not long after the new diet was adopted”; “In the winter of 1823, the inmates began to succumb to typhus, dysentery, and scurvy. Thirty-one died and four hundred others were incapacitated”; “The scurvy was the prevailing disease, and was seen in over half of the 860 inmates”. Joe Sim in his generally condemnatory evaluation of medical staff working in prisons states: “Millbank was at the centre of a major controversy when an outbreak of scurvy occurred and thirty-one prisoners died. The [Prison Medical Service] was deeply implicated”, and he goes on to associate the physician in charge with “experiments” on the bodies and minds of the confined.