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May 2021



Author: Isabelle Devos

The vaccination campaign against Covid-19 in Belgium is in full swing, but things are not going smoothly everywhere. There are big differences between municipalities. In Flanders, the coastal municipalities of Knokke-Heist and Koksijde are the frontrunners, with around 60 per cent of its people vaccinated; Vilvoorde, with barely 30 per cent vaccinated, lags far behind (31 May 2021). According to some, the vaccination rate can be considered a poverty indicator: vaccination coverage in the poorest municipalities is significantly lower than elsewhere. 

During the first vaccination campaign, some two centuries ago, there was also a clear link with poverty. Then it was smallpox. But the relationship was just the opposite: at that time, the poorest regions had the highest vaccination rates.

Covid-19 vaccination: large local differences

The differences in vaccination coverage are, on the one hand, related to age distribution (some municipalities have a much older population) and logistical arrangements regarding the delivery of vaccines and how people are contacted (letter, email, etc.).

On the other hand, not everyone is equally willing to have an injection. In particular, Brussels and the French-speaking part of the country have a higher proportion of people refusing the vaccine. Some say this has to do with the strong influence of the French media, where vaccination scepticism is widespread (due to several medical scandals, among other things). Religious motives or a lifestyle that is very closely bound to nature are also reasons for refusing the vaccine. Others point to a connection with socio-economic status, in particular the level of education and/or migration background. People with low educational attainment usually have less confidence in (medical) science. Also, the ability to understand information about the vaccine in a language that is not your mother tongue can have a major impact on a person's willingness to be vaccinated.​

The very first vaccination campaign

Vaccination has been around for over 200 years. In 1796, the English country doctor Edward Jenner demonstrated the link between cowpox and smallpox when he discovered that infecting people with cowpox made them immune to smallpox. 

In the early modern period, one in ten people died from the disease; children were particularly affected. Jenner’s invention spread quickly. In Belgium, the Ostend physician Roselt carried out the first cowpox inoculation in 1800, followed by the surgeon Demanet in Ghent and other doctors in other parts of the country.

Cowpox inoculation was one of the showpieces of the French enlightened administration. It tried to convince the population of its usefulness through information committees and popularising brochures, but with little success. From 1809 onwards, they used gentle coercion. 

Access to education and poor relief could now only be accessed with a vaccination certificate. Children could not attend school without a so-called ‘smallpox note’. Families who applied for poor relief received no support if their children had not been vaccinated. 

The crusade against smallpox was continued with the same zeal under the United Kingdom of the Netherlands. This was enshrined in the Royal Decree of 1818, but it was not until ca. 1823 that it was implemented on a large scale. After that, vaccination figures rose rapidly. By the end of the 1820s, an average of two-thirds of all children in the United Netherlands had been vaccinated.
Vaccination certificate (Ghent State Archives, Hollands Fonds, Box 8a (Gadeyne Collection))

Geographical patterns in vaccination coverage

This national average, however, hides large regional and local differences. The Quetelet Center has been able to reconstruct municipal vaccination maps for the years 1827-29, based on the annual ‘status of cowpox inoculation’. Although it is a snapshot and the vaccination registration had some flaws, the maps give a clear picture of the geographical patterns in vaccination. 

We calculated vaccination coverage in relation to the number of births rather than the population, because smallpox was a childhood disease and vaccinations were mainly administered to children.

In many municipalities, vaccination coverage was low: less than 13 per cent of children were vaccinated (see map 1). High rates are observed in the regions around Kortrijk, Bruges, Turnhout, Wavre, Dinant, Philippeville and Luxembourg. In the north, Drenthe, Gelderland and parts of Friesland and North Brabant stand out with above-average figures. In some municipalities, 90 per cent or more were vaccinated.

Map 1. Number of smallpox vaccinations per 100 births, the Netherlands, 1827-29

Using smoothing techniques, we can smooth out local differences and make the geographical patterns even more visible (see map 2). The regional vaccination maps clearly show that the vaccination campaigns were most successful in the northeast and the southernmost part of the United Netherlands. This is remarkable, because these were the most sparsely populated rural areas of the kingdom and the risk of infection was lower there. That they were also the poorest regions is less surprising, given the vaccination legislation. But there is more.

Map 2. Number of smallpox vaccinations per 100 births (after smoothing 10 km.), the Netherlands, 1827-29

Not an unqualified success

The map is not only the result of a series of socio-economic factors (percentage of poor people and schoolchildren in the population), but also of a mishmash of provincial and local regulations. The implementation of the central vaccination policy was in the hands of the provincial and local governments. They had great autonomy. Since there was no compulsory education at the time, a large number of children were missed. According to the Dutch historian Willibrord Rutten, the province of Drenthe was ahead of its time in this respect: it linked compulsory vaccination to general compulsory primary school education. Gelderland and Luxembourg, which like Drenthe were among the most literate regions in the United Netherlands, also kept a strict check on compulsory vaccination. By contrast, enforcement in the west of the country was less strict: many municipal schools admitted children without a smallpox note.

Vaccination scepticism

Just as not every individual was convinced of the benefits of the vaccine, this was also the case for the local authorities. There was a great deal of fear around vaccination. After all, it was not clear how the vaccine worked. Viruses and other pathogens were unknown until the late 19th century. 

The fact that healthy children were being inoculated with a cow disease also aroused a lot of suspicion. There were also dissenting voices from Catholic quarters, despite the fact that Pope Pius VII had approved the vaccination campaign. For many Catholics, smallpox and other diseases were a punishment from God. Vaccination was therefore not permitted, as it could undermine God’s work. 

Nevertheless, the well-known cultural fault line between Catholics and Protestants, below and above the Moerdijk, is not visible on our vaccination maps.

J. Gilray, The Cow-Pock—or—the Wonderful Effects of the New Inoculation!

Anti-Vaccine Society Print, 1802

Smallpox vaccination poster, 1854 (OCMW-archives Bruges. Bureel van Weldadigheid. Geneeskundige dienst. Box 191, file 292).

High vaccination coverage in the poorest, most sparsely populated and most illiterate regions

Moreover, not every local authority had sufficient means to pay for such a campaign, even though local doctors and surgeons were supplied with cowpox material by the provincial medical commissions. 

Children were vaccinated free of charge, but in many regions the physicians received a small fee for the work from the municipal coffers. In addition, gold and silver medals were awarded to those physicians who had performed the largest number of free vaccinations. Indeed, many waited until they could vaccinate a sufficient number of children to be entitled to a medal.

Due to the differences in the enforcement of the compulsory vaccination of schoolchildren and poor children, a paradoxical situation arose in which the highest vaccination rates occurred in the poorest, most sparsely populated and most literate areas of the United Netherlands. Belgium had to wait until 1946 for general compulsory vaccination. Belgium and Austria were the only European countries that did not introduce compulsory vaccination in the 19th century. Read here why.

Disaster planning

The first vaccination campaign against smallpox highlights some fundamental challenges for policymakers that still apply today. It shows that it is not possible to have an effective vaccination policy without taking into account socio-economic and regional differences. In several respects, the difficulties in the current vaccination campaign can be compared with those of 200 years ago. 

As early as 2017, the Norwegian demographer Sven-Erik Mamelund pointed out the limited attention given to social inequality in the disaster planning of international organisations such as the World Health Organization. While such disaster planning did take into account the special situation of low-income regions during epidemic outbreaks, it did not take into account the internal disparities in those countries or in high-income countries. 

Yet, as we now know, regional and social inequality in health prevention can significantly delay the fight against an epidemic. In the Belgian vaccination campaign against Covid-19, certain groups are vaccinated as a priority. These are primarily people who are at higher risk because of their age or medical history. By having policy strategies and projection models that take better account of socio-economic and cultural differences in the willingness to be vaccinated and adherence to behavioural measures, epidemics could undoubtedly be better combatted in the future.


  • National Archives The Hague, Archief van het Ministerie van Binnenlandse Zaken, Afdeling Algemene Zaken,  1823-1831, toegang 2.04.01, nrs. 821-841.
  • Agentschap Zorg en Gezondheid, Vaccinatieteller, (laatst geraadpleegd 31 maart 2021) 
  • UGent Queteletcenter, HISSTER database


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  • Gadeyne, Guy. “Variolatie en vaccinatie tegen de pokken in België sinds de 18de eeuw”.  Geschiedenis der Geneeskunde 6, nr. 6 (2000): 364-375.
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