References
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Berche, P. (2022). Life and Death of Smallpox. La Presse Médicale, 51(3). https://doi.org/10.1016/j.lpm.2022.104117
Breman, J. (2017). Donald Ainslie (D. A.) Henderson, MD, MPH (1928–2016) smallpox eradication: Leadership and legacy. The Journal of Infectious Diseases, 215(5), 673–676. https://doi.org/10.1093/infdis/jiw640
Brink, S. (2019). What’s the real story about the milkmaid and the smallpox vaccine? Npr.org. https://www.npr.org/sections/goatsandsoda/2018/02/01/582370199/whats-the-real-story-about-the-milkmaid-and-the-smallpox-vaccine
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Diepenbrock, G. (2015, April 21). Book details misconceptions about smallpox’s role in Native depopulation. KU News. https://news.ku.edu/news/article/2015/04/20/book-details-misconceptions-about-smallpoxs-role-native-depopulation-and-european
Gibbons, A. (2016, December 8). Virus found in child mummy suggests recent rise of deadly smallpox. Www.science.org. https://www.science.org/content/article/virus-found-child-mummy-suggests-recent-rise-deadly-smallpox
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Smallpox Eradication: When Humankind Decided to Save Everyone
Intro
What is humanity’s greatest achievement? Language? Science? Space travel? I’m not sure how you define greatness, but I would offer this one for consideration: A little over 40 years ago, humankind eradicated smallpox. In today’s episode, a celebration of the knowledge, the work, and the people who made it happen. And why they deserve to be remembered and celebrated. You’re listening to “I Heart This.” I’m Ben Lord. Let’s talk about what we love.
Outro
Ideas spread much like viruses do, from one person to another, sometimes between people we know, sometimes in brief encounters with strangers. Through “I Heart This,” I’ve been committed to spreading the idea that the world is a better place for everyone when we all stop to appreciate wonderful things. If “I Heart This” has inspired you, sharing it is as easy as sending a link to a friend. And I would deeply appreciate it if you did.
Tune in next week for our very first interview with VT state representative Mike Mrowiki. “I Heart This” has new episodes every Wednesday. It’s written, edited, and produced by me, Ben Lord. Our logo was designed by Briony Morrow-Cribbs. Our website is iheartthispodcast.com. You can email me at ben@iheartthispodcast.com. And we’re on Facebook at I Heart This Podcast. Thank you so much for listening. And, as always, Be kind. Be curious, and be thankful.
Hook
There will be a last time for everything: a last time you walk the halls of your high school, a last time you will see a dear friend. One day, the last star will exhaust its fuel and leave the Universe in cold and darkness. But not every last will be sad. Take, for example, the case of Ali Maow Maalin who, in October of 1977 became the last person ever to contract a naturally occurring case of smallpox.
What Smallpox Was
You and I don’t need to think about smallpox much. If we think about it at all, we might lump it in with consumption, cholera, leprosy, or dysentery … dinosaurs of the disease world–monsters of the past whose menace no longer has the power to harm us–except, like dinosaurs, to show up as threatening specters in stories.
It can be hard to remember this in a place like the United States, but none of these other diseases are dinosaurs. None of them have had a final patient, and each of them still kills and maims and hollows out families with grief … Just as they have done for centuries. Except for smallpox. Of all the infections of humankind, smallpox is the only one that human beings have ever eradicated.
If you’d lived two centuries ago, your life would have almost certainly been touched by it. If you didn’t contract it yourself, you would at least have known someone who did. Smallpox is caused by the Variola virus … a virus that, if you caught it, you’d most likely have breathed when a nearby infected person breathed them out. For a week or two, you wouldn’t notice any symptoms as the virus incubated, multiplying in the cells of your mouth and throat. Then, the fever would strike along with head and back aches. Overcome with exhaustion, you’d probably find yourself unable to get out of bed. Only after several more days would the infection spread to your skin. A rash would evolve into small chicken pox-like bumps. The bumps would become blisters that felt like you had peas under your skin. The blisters would swell into pus-filled sores growing over and into each other. If you survived, these pustules would eventually scab over leaving your skin pitted with disfiguring and stigmatizing scars for the rest of your life. And if the infections spread to your eyes, you would go blind.
Where it came from
By most estimates smallpox killed one out of every three people who contracted it, sometimes even more. When European explorers unwittingly brought smallpox to the Americas, it wiped out entire nations. There is no way to know how many people it killed over the course of its long history, but there is no doubt that it was one of the deadliest diseases the world had ever known. It is widely estimated that between 1900 and 1977 alone, smallpox was responsible for the deaths of between 300 and 500 million people. That’s like the entire population of the United States on the low end and the population of the US and Russia combined on the other.
Numbers like this strain our ability to understand them. And they obscure the real weight of smallpox’s devastation. I know that if one of my own children died from such a disease, my grief would be infinite. How do you multiply that by 500 million?
Variolation
In the world of the past few centuries, where diseases like smallpox regularly came out of nowhere to kill loved ones of all ages, people did what they could to protect themselves. In Africa and China, this led to the practice of intentionally infecting healthy people with the Variola virus, in hopes of helping them to develop immunity. Usually this meant taking material from the smallpox pustules from infected neighbors and smearing it into a small cut in the skin of a healthy person’s skin. The resulting infection was usually much milder than smallpox caught by inhaling virus particles, but not always … People often died from these intentional inoculations, but smallpox was so feared, it was a risk that people were willing to take, even with the lives of their children. This practice was brought to the Americas by enslaved Africans and to Europe by way of the Ottoman Empire. By the late 1700s, European doctors had standardized the procedure which became known as variolation.
Vaccine
That’s when a group of country doctors from English noticed something strange about some of the patients they variolized. Usually, following a successful inoculation, a patient would become ill and pustules would grow over the site of infection. But for some people, no mark appeared. Why?
One of those doctors, John Fewster, put the pieces together when one unaffected patient, a farmer, told him that he’d not ever had smallpox but he’d had cowpox to a “violent degree.” Cowpox is a related, but much less lethal virus that infects both cows and humans. Infected cows often get a rash on their udders that readily spreads the infection to human hands. And since the virus that caused cowpox is similar enough to the virus that caused smallpox, the immune systems of those exposed to cowpox often developed an immunity to both.
This was an interesting phenomenon, but it didn’t immediately suggest any useful treatment. Getting cowpox was dangerous too. It was certainly safer to variolate patients than it was to have them go out and milk infected cows. It wasn’t until Edward Jenner, a colleague of Fewster’s, decided to combine the two paths to immunity by intentionally inoculating patients skin with the cowpox virus instead of the smallpox one.
In doing so, Jenner invented the vaccine. And not just a vaccine or the first vaccine, but THE vaccine. As a student of Romance languages will know. A vaccine isn’t just an inoculation, it is inoculation from la vache, la vacca–the cow.
Then, as today, the procedure was controversial. But as the safety and efficacy became clear through repeated trials, vaccination spread across Europe. And as it did, smallpox began to decline.
Decision to Eradicate (1959)–
You’d be forgiven for thinking that this was the climax of my story. But it’s not. Despite advances in vaccine technology and widespread use of the vaccine, smallpox continued to claim millions of lives. It wasn’t until 1872, nearly a century after Jenner’s introduction of the vaccine, that the island country of Iceland introduced mandatory smallpox vaccinations for all and became the first country in the world to eliminate it. By 1900, only two other countries had followed suit. In the United States, smallpox lasted through the entire nineteenth century, through the roaring twenties, through two world wars and the great depression and was finally eradicated in 1948, just four years before my parents were born.
In 1959, the World Health Organization accepted a resolution to eliminate smallpox worldwide. But it turned out to be little more than high-minded rhetoric. The ambitious goal was underfunded and understaffed. Having secured their own immunity, it seemed, the wealthy countries seemed to have little political will to extend the blessings of vaccination to their poorer neighbors. In 1966, two million people were still dying of smallpox every year.
That fact changed in no small part, thanks to someone you’ve probably never heard of … a doctor from Lakewood, Ohio, named Donald Ainslie Henderson, whom everyone just called D.A.
If you likened the project to eradicate smallpox to a war, D.A. Henderson was its commander-in-chief. Trained at the CDC, he was recruited in 1967 to head up the World Health Organization’s initiative to intensify and reinvigorate the languishing eradication program.
D.A. would come to be revered around the world for his leadership. He convinced a skeptical world that eradication was possible. Where others got caught in protocol or power struggles, Henderson adapted to meet the constantly changing challenges. D.A. was a master delegator who appointed people who would challenge him when he went astray and listened to them when they disagreed with him. He believed that a leader in public health had to have their boots on the ground, and so he traveled the world coordinating, talking to people, and listening. And perhaps most important of all he had a talent for making the tens of thousands of people involved in the eradication effort to feel like they were part of something remarkable … even when faced with formidable challenges.
The work to eradicate
And those challenges really were formidable. There was no road map to eradicating a disease. It had never been done before. And it literally required walking to the ends of the Earth, bringing vaccines to people who lived in places where no road had ever gone. How do you keep track of it all? How do you convince skeptics that getting jabbed with an needle by a stranger could save their life? What happens when you have to walk into a war zone? How do you keep the vaccine viable in hot climates without refrigeration? How do you get governments to keep funding the project over decades when the goal has lost its novelty and because of your earlier success the dangers of smallpox seem so far away? How do you even know if you’ve succeeded?
Even in hindsight, it seems impossible that such a project could happen. D.A. Henderson may not have the name recognition of Abraham Lincoln or Doctor King. But I think his contributions to the world will have a lasting impact that ranks with theirs. Not just because he led the effort to end smallpox, but because he showed us that something like it was even possible.
But … the eradication of smallpox wasn’t the result of any one person, however wise a leader they might be. And this is the thing I find most awe-inspiring and beautiful about it. The only way that the project happened was because the entire worked together. It took an army … a literal army of tens of thousands of health care workers to find outbreaks, conduct contract tracing, get vaccines to where they needed to go. It took the collaboration of the sworn enemies US and USSR, during some of the hottest moments of the Cold War. It took strategy. It took technological innovations like a new kind of bifurcated syringe needle. In India alone it took over a billion … a billion … home visits.
Think of all the unknown stories of heroism as people quietly, doggedly, doing the work that brought this gift to every last village in the world.
Cynics who believe that human beings are always just looking out for themselves, motivated solely by profits and self-interest, would never have predicted this. There are so many ways it could have failed. But it didn’t. Because people all over the world agreed that if we had the power to end this suffering, we should.
Climax: Eradication–The Last Case of Smallpox In the World
Which brings me back at last to Ali Maow Maalin, the last person in history to contract a natural case of smallpox. Ali was working as a cook in the hospital of a town on the coast of Somalia when he was called upon to help escort an infected family to a smallpox isolation camp. Part of that escort involved a fifteen minute car ride in a land rover. It’s believed that it was within that brief window that Ali was infected. One of the children in that vehicle, a six-year-old girl, would become the last person to die from a naturally acquired smallpox infection.
Ten days later, when Ali came down with a fever, he was treated for malaria. No one suspected smallpox because all the hospital workers were expected to be vaccinated. That was protocol. But Ali had been afraid of the needle, afraid that the injection would hurt, and so he had avoided the mandatory vaccination. When a rash appeared on his skin, he was treated for chicken pox. Even when the characteristic pustules started to form, Ali didn’t report it. A colleague had to turn him in. By the time he was diagnosed correctly, he had been out of quarantine for 14 days.
What followed was the result of a decade of practice confining outbreaks. Workers snapped into action. They identified every single one of the people that Ali had been in contact with since his infection. They tracked all of them down and vaccinated anyone who hadn’t been vaccinated already. For six weeks, they monitored hundreds of people. Then, they delivered vaccines to every person in the city ward where Ali lived.
The outbreak was completely, swiftly, and efficiently contained. And Ali made a full recovery. But that didn’t mean that he was left unscathed by infectious disease. Some time later his younger sister died of the measles–a disease that, just like smallpox, could have been prevented and even eradicated with the safe and effective vaccines widely available in the wealthy countries of the world.
In the shock after his sister’s death, Ali trained as a health worker and volunteered for the World Health Organization’s next great eradication campaign against polio. As he once said to a reporter from the BBC, “”Somalia was the last country with smallpox. I wanted to help ensure that we would not be the last place with polio too.” Ali disseminated vaccines and talked to reluctant patients and parents nervous about vaccinating their children. “I tell them my story. I tell them how important these vaccines are. I tell them not to do something foolish like me.” It was dangerous work. Somalia was not so much a country as a territory ruled by warring gangs. Vaccinators were fired upon. Militia leaders who believed the vaccine wasn’t safe, and Ali would have to try to change their minds. In 2013, he was still distributing vaccines, when he developed a fever, and died days later, on 22 July, of malaria.
Resolution: Smallpox Today
There was never and would never be any cure for smallpox. Smallpox is caused by a virus and so cannot be treated with antibiotics. Still, by the time I was born in 1977, Ali’s final case of smallpox had been clear for two months. And when I was two years old the World Health Organization officially declared that smallpox had been eradicated … the first and only eradication of its kind.
What it means
I love this story for what it says about disease: that we are not fated to have them. that even though so many exist, they don’t have to. We have the power to stop so many of them, far more than we did in 1966. Smallpox eradication showed us that this was possible. In many ways it made it possible. We spend enormous sums of money to fight cancer and ALS–worthy and important goals where we make progress one small step at a time. But we could end polio, measles, the mumps, whooping cough, guinea worm, malaria, or even tuberculosis for a fraction of the cost. That is a hope worth believing in.
But I also love this story for what it says about us, about who we can be. Look at all we overcame! That was us. That was humanity. Look at the magnitude of this work. It extended from jungles to deserts, from remote villages to war zones, all of it done without computers, without satellite communications, often without electricity or refrigeration. Look at the cooperation and trust that we were able to inspire. We crossed every boundary of race, religion, and politics. We decided that the freedom from disease that the rich had already won for themselves could and should be extended to every living person regardless of where they lived. The people who won this victory are mostly gone. Their names are mostly unknown. Their sacrifices are mostly unsung. But their legacy remains.
That monumental achievement cost the world $300 million. For comparison, the Manhattan Project cost $2 billion. The Apollo program cost $26 billion. Even adjusting for inflation, the eradication of smallpox was a staggering bargain. It is estimated that the US recoups its portion of that investment every 26 days. But that is nothing next to the fact that none of us … not you, not me, nor the poorest family in Somalia … will ever have to watch our children blinded, disfigured, or killed by smallpox agian. There is no way to put a price tag on that.