Much has been written about smallpox in Mexico, but Paul Ramírez has added to this impressive body of work with his important new book on efforts to prevent the disease in the last decades of Spanish government. Ramírez proposes that the conflicts between creoles and peninsular authorities have received sufficient attention elsewhere; instead, he has focused on the “realities of disease, quarantine, and vaccination” (22). His work relies on recently discovered archival documentation that he employs to tell us a great deal about the complexities of efforts to prevent smallpox in late colonial Mexico.

Ramírez has divided his work into two main sections, each containing three chapters. The first section, titled “Contagion,” begins with a chapter on how religious rituals were employed to combat infection. This was not a simple conflict between secular physicians who recommended social distancing and the ecclesiastical proponents of religious processions. Instead, Ramírez draws parallels between the penitents who flagellated themselves in the streets and the doctors who bled their patients to improve their health, concluding that “medical and technological advances might sustain, rather than delegitimize” (55) religion. Chapter 2 describes how elite medical knowledge interacted with local knowledge of natural cures that people believed had been providentially provided to remedy “diseases of the land” (61). Chapter 3 explores the efforts of royal officials to order the isolation of those infected with smallpox in distant infirmaries and the resistance of parents who rejected these attempts to separate their children (an earlier version of this chapter was published in The Americas in 2012.)

The second section is “Immunization.” Chapters 4 and 5 are the core of the book. Ramírez explains the efforts to provide immunity to smallpox, first through inoculation (with smallpox) and later through vaccination (with cowpox). Although some contended that disease was a part of the natural order of things and ultimately resulted from original sin, priests were ordered by their bishops to support the royal efforts to prevent smallpox. Mexico City's archbishop, Francisco Javier Lizana y Beaumont, even quoted Ecclesiastes on the honor due to physicians. The Royal Philanthropic Vaccination Expedition reached New Spain in 1804, but the king's plans and directions for how the vaccinations were to be carried out were modified to meet local conditions. There were also variations in who should be carrying out the procedures, where they were to do so, and how the expenses would be paid. Ramírez concludes that power was “more diffuse” and “the meanings of public health campaigns less fixed once we consider the variety of people enrolled to transport, inject, elaborate, and judge” (212).

Chapter 6 provides fascinating insights into vaccine skeptics as well as the hopes and expectations of people from all levels of society. Parents seem to have feared that their children would be kidnapped to transport the vaccine, since the expedition arrived with 22 Spanish children and left New Spain with 26 Mexican children to serve as living carriers for the vaccine on the next leg of the journey to the Philippine Islands. Oaxaca's bishop, Antonio Bergosa y Jordán, had been an active promoter of vaccination in his diocese, but he became a skeptic after he had himself vaccinated three times in the hope that the procedure was a remedio universal.

Ramírez concludes that more attention needs to be paid to the complexities and paradoxes of late colonial New Spain as the royal vaccination program moved “from the realm of theory to practice” (240). Some of these adjustments were made by the director of the expedition, Francisco Xavier de Balmis, himself. Although the royal order stated explicitly that vaccination could eventually be carried out by mothers, Balmis required that credentialed medical specialists administer the vaccine. At the same time that Bourbon policies undermined the church and priests and bishops feared their authority was being weakened, the immunization campaign had to rely on the participation of priests, as well as other unorthodox healers, in order to succeed.

The problem is complex, and the outcome is not easily summarized. As Ramírez concludes, “In the end the varieties of practical knowledge brought to bear are not easily classified as peasant, indigenous, viceregal, creole, American, Spanish, or Atlantic” (246).