Smallpox: The Death of a Disease: The Inside Story of Eradicating a Worldwide Killer

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Overview

For more than 3000 years, hundreds of millions of people have died or been left permanently scarred or blind by the relentless, incurable disease called smallpox. In 1967, Dr. D.A. Henderson became director of a worldwide campaign to eliminate this disease from the face of the earth.

This spellbinding book is Dr. Henderson’s personal story of how he led the World Health Organization’s campaign to eradicate smallpox—the only disease in history to have been deliberately eliminated. Some have called this feat "the greatest scientific and humanitarian achievement of the past century."

In a lively, engrossing narrative, Dr. Henderson makes it clear that the gargantuan international effort involved more than straightforward mass vaccination. He and his staff had to cope with civil wars, floods, impassable roads, and refugees as well as formidable bureaucratic and cultural obstacles, shortages of local health personnel and meager budgets. Countries across the world joined in the effort; the United States and the Soviet Union worked together through the darkest cold war days; and professionals from more than 70 nations served as WHO field staff. On October 26, 1976, the last case of smallpox occurred. The disease that annually had killed two million people or more had been vanquished–and in just over ten years.

The story did not end there. Dr. Henderson recounts in vivid detail the continuing struggle over whether to destroy the remaining virus in the two laboratories still that held it. Then came the startling discovery that the Soviet Union had been experimenting with smallpox virus as a biological weapon and producing it in large quantities. The threat of its possible use by a rogue nation or a terrorist has had to be taken seriously and Dr. Henderson has been a central figure in plans for coping with it.

New methods for mass smallpox vaccination were so successful that he sought to expand the program of smallpox immunization to include polio, measles, whooping cough, diphtheria, and tetanus vaccines. That program now reaches more than four out of five children in the world and is eradicating poliomyelitis.

This unique book is to be treasured—a personal and true story that proves that through cooperation and perseverance the most daunting of obstacles can be overcome.

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Editorial Reviews

Publishers Weekly
In his introduction, The Hot Zone author Preston points to the fact that "in smallpox's last hundred years," 1879-1979, it killed more people than "all the wars on the planet during that time." For more than 50 years, doctor and public health expert Henderson combated the disease, first as director of the Center for Disease Control's Epidemic Intelligence Service, then (from 1965 on) as director of the World Health Organization initiative which would later be known as The Eradication. Henderson provides an overview of the painful disease, "a monster" that killed roughly a third of the unimmunized it infected. Chillingly, "variolation," the direct subcutaneous injection of a patient's pus into a healthy person, was used to spur immunity from before the 10th century. The much safer cowpox vaccination was discovered in 1796 (mandated by Washington for the Continental army); meanwhile, smallpox had decimated the Native American population. Henderson's "surveillance and containment strategy" would indeed eradicate smallpox globally; India, the last holdout, was rid of it in 1974 by 115,000 health workers, dispatched to villages throughout the country to identify, quarantine, and vaccinate. This inspiring achievement makes a stirring read for medical history fans, though readers of Preston may find it a bit dry.
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved.
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Product Details

  • ISBN-13: 9781591027225
  • Publisher: Prometheus Books
  • Publication date: 6/23/2009
  • Pages: 288
  • Sales rank: 525,362
  • Product dimensions: 6.40 (w) x 9.10 (h) x 1.00 (d)

Meet the Author

D. A. Henderson, MD is currently professor of medicine and public health at the University of Pittsburgh and a distinguished scholar at the Center for Biosecurity in Baltimore. He is a professor and former dean of the Johns Hopkins School of Public Health. He served as Life Sciences Adviser to President G. H. W. Bush and was the first director of the newly created Office of Public Health Emergency Preparedness in the Department of Health and Human Services. He is the recipient of the Presidential Medal of Freedom and the National Medal of Science plus many other awards. He has received the Japan Prize and has been knighted by the King of Thailand.
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Read an Excerpt

SMALLPOX THE DEATH OF A DISEASE

The Inside Story of Eradicating a Worldwide Killer
By D. A. Henderson

Prometheus Books

Copyright © 2009 D. A. Henderson
All right reserved.

ISBN: 978-1-59102-722-5


Chapter One

THE DISEASE, THE VIRUS, AND ITS HISTORY

"Small pox was always present, filling the churchyard with corpses, tormenting with constant fear all who it had not yet stricken, leaving on those whose lives it spared the hideous traces of its power, turning the babe into a changeling at which the mother shuddered, and making the eyes and cheeks of the betrothed maiden objects of horror to the lover." -Lord Thomas Macauley, History of England

THE OLDEST OF SCOURGES AND THE MOST DEVASTATING

No disease has ever been so instantly recognized or so widely known and feared. Smallpox was hideous and unforgettable. For me, the memory of a ward full of smallpox victims thirty-five years ago in Dhaka, Bangladesh, is still vividly etched in my mind: anxious, pleading, pock-deformed faces. The ugly, penetrating odor of decaying flesh that hung over the ward; the hands, covered with pustules, reaching out, as people begged for help. Neither water nor food offered comfort; pus-filled lesions covered the insides of their mouths, making it painful for them to even chew orswallow. Flies were everywhere, thickly clustered over eyes half-closed by the pustules. More than half the patients were dying, and there was no drug, no treatment that we could give to help them.

Dr. Nick Ward, one of my senior staff, accompanied me on the ward rounds. A veteran of medical service in Africa, he had cared for patients with the worst of tropical diseases. As we left the hospital, he placed his hands on the railing of a balcony, leaned over as he looked at the ground and said, "I don't think I can ever again walk through a ward like that. It is unimaginable." Little wonder that groups across Asia and Africa created 7 special deities such as Sopona and Sitala Mata specifically devoted to smallpox (see figure 1). No other disease warranted its own icons and in so many cultures.

Thirty years have passed since the last case of smallpox occurred. Few physicians are alive today who have seen cases outside of a textbook. Today it is impossible for anyone to comprehend what it meant to eradicate smallpox on a worldwide basis-or to envision what a devastating terrorist weapon it could be without understanding something about the disease and the virus.

A CASE OF SMALLPOX

The smallpox virus is unique among viruses in that it infects only humans-no other animals. It has survived for thousands of years by infecting one person after another in an unbroken chain of disease. Usually, transmission of the virus occurred only as a result of face-to-face contact. As soon as a patient started to develop a rash, lesions in his mouth and throat began to shed millions of microscopic virus particles into his saliva. These tiny particles would be carried into the air when he spoke or coughed. Anyone close enough to inhale them became the next link in the chain of infection.

The newly infected person felt perfectly well for the first seven to ten days. Throughout that time, however, the virus would be growing and silently establishing itself. Then it struck with the sudden onset of chills and a high fever, usually with a headache and backache so severe that the patient had to go to bed. Some people became delirious. Children sometimes had convulsions. After two or three days, the fever and symptoms temporarily ebbed. Small red spots appeared on the inside of the mouth. Angry-looking red spots cropped up on the face and, soon after, on the body; these were most dense over the face and extremities. The patient felt miserable and had trouble eating or swallowing because of lesions in the mouth and throat, which grew in size as they filled with a milky fluid and gradually became pustular. Individual pocks were buried deep in the skin and caused pain, like boils, as they expanded. There could be thousands of these pocks. Sometimes they completely covered the face, leaving scarcely a patch of untouched skin. The pustules continued to grow until nearly the end of the second week, when scabs began to replace the pustules. Among those with the severe form of smallpox found in Asia, only seven of ten unvaccinated patients survived beyond the second week.

As the scabs began to separate, symptoms disappeared and the patient was no longer contagious. Eventually, the scabs on the face went away, leaving deeply pitted scars that lasted a lifetime. Some survivors were left blind. Smallpox, in fact, was a leading cause of blindness in Europe during the seventeenth and eighteenth centuries and in India as recently as 1945 (see figure 2). All who recovered were immune for life from a second attack.

Most people had a form of the disease called "ordinary" smallpox (see plates 2 and 3). However, about one in twenty had a far more severe form, called "hemorrhagic," or "flat," smallpox, which was almost always fatal within the first week. Such patients did not develop the typical pustular lesions of smallpox, and this made diagnosis difficult. Because the rash was less distinct, these patients often infected many others before being correctly diagnosed and isolated. Another group of patients who played a significant role in transmission were those whose courses of illness were milder because of partial immunity due to previous vaccination. Having fewer symptoms, such patients could carry on many of their usual activities and would thus spread the disease to many people.

Throughout Asia, smallpox (also called Variola major) was uniformly severe, with a death rate of about 30 percent among the unvaccinated. In most of Africa, the proportion of those who died from the disease was somewhat smaller. In Ethiopia, South Africa, and Brazil, a mild form of smallpox (called Variola minor or alastrim) prevailed. Only 1 or 2 percent of those who developed this mild form died. In some endemic countries during the early twentieth century, both Variola major and Variola minor were concurrently present. However, during the eradication program no country had the two different forms occurring simultaneously.

THE VIRUS

The culprit of smallpox is called variola, a member of the orthopoxvirus family and one of the largest of all viruses. It consists of little more than a brick-shaped shell that houses a long strand of DNA, which carries the genetic instructions for making copies of itself. It has no means of locomotion and is able to multiply only by invading a human cell and then taking over its metabolism and reproducing itself.

Where or how variola originated is unknown. We believe it may have started as a mutation of a related virus of the orthopoxvirus family. Such viruses affect many animals and are especially prevalent in rodents. Presumably, the strain that first infected a human changed over time as it spread and lost its ability to infect other animals. Today, humans are the only animals that can be infected with smallpox virus and that can transmit it to others.

Only three other viruses in the orthopoxvirus family can infect humans: monkeypox, cowpox, and vaccinia. (Chicken pox is a totally unrelated virus.) Clinically, monkeypox looks much like smallpox. In Central Africa there are sporadic human cases and sometimes small outbreaks. The virus spreads so poorly from person to person that these outbreaks soon die out. The virus sustains itself in the tropical rain forest by spreading among small rodents. The name monkeypox is misleading because monkeys, in fact, are only occasionally infected. A continuing watch is being maintained to ensure that if monkeypox ever changed so as to begin spreading rapidly among humans-like smallpox-this would be detected and stopped quickly by a vaccination campaign..

The second orthopoxvirus is cowpox, which produces skin lesions on the udders of cows and causes pustules on the skin of people who milk cows or work with them. It was a pustule on the hand of a dairymaid that enabled Dr. Edward Jenner (see plate 1) in 1796 to demonstrate that those who had recovered from a cowpox infection did not get smallpox. Over time, we have learned that the primary chain of infection of the virus is sustained by small rodents. Cows become infected from the rodents but only occasionally transmit the virus to other cows.

The third orthopoxvirus is vaccinia. This was the name Jenner gave to the cowpox virus material that he used for his vaccination experiments. The name comes from the Latin vacca, meaning "cow." The immunity provided by vaccinia virus protects against all of the orthopoxviruses, including monkeypox.

How long can the smallpox virus survive?

The smallpox virus's viability under differing conditions has long been of concern. As the eradication program got under way, I heard many legends that suggested the virus was exceedingly hardy: there were stories of people being infected after spending the night in a house occupied years before by a smallpox victim; of cases of smallpox developing after a long-buried corpse was exhumed; of the disease being transmitted to the recipient of a smallpox patient's mailed letter. During the program, we made special efforts to determine the source of infection of all cases-because if such legends had an element of truth, the prospects for eradication would be dim.

We paid special attention to the outbreaks of smallpox in countries that had been free of the disease for months or years: if no source could be found, the specter of possible long-term survival of the virus somewhere in the environment would be suggested. Fortunately, during the hundreds of thousands of field investigations, we were always able to identify the sources of infection with sufficient confidence so as to declare that there was no reservoir in nature.

SMALLPOX IN ANCIENT TIMES

For the smallpox virus to survive, it needs a population large enough to enable one susceptible person after another to be infected. This could not have happened until humans established agricultural communities about 14,000 BCE.

If the first forms of smallpox were as deadly as Variola major, the disease would have taken a heavy toll as it spread along trade routes from village to village. Throughout its history, the introduction of smallpox into new "virgin soil" populations has almost always had a catastrophic impact. However, as the disease continued to spread throughout an area, fewer and fewer susceptible people would be left to sustain the chain of transmission, and eventually the outbreak would die out until reintroduced from an infected area. When a population grew large enough so that the disease could circulate continually, the impact of an outbreak in any one year was diminished, and the virus became primarily a childhood infection.

Not surprisingly, smallpox emerged first in the early centers of urban civilization in Egypt and southern Asia. In fact, the mummified bodies of three prominent Egyptians, who died between 3,000 and 3,500 years ago, provide the earliest-known evidence of the disease: their parchment-like skin is studded with telltale pustules. The mummy of the most widely known of the three, Ramses V, is on display in the Cairo Museum in Egypt (see figure 3). Since then, the virus has claimed an unbroken chain of victims extending to the last patient, Ali Maalin, who developed smallpox on October 26, 1977, in Merca, Somalia.

In India, the first references to the disease appear in Sanskrit medical texts, written before 400 CE, where descriptions from as early as 1500 BCE are recounted. An indication that smallpox was long endemic in ancient India is the existence of the Hindu goddess of smallpox, Sitala Mata. To this day there are numerous Sitala temples throughout Hindu regions of South Asia.

The history of the spread of smallpox is fragmentary. The large populations necessary for the virus to sustain itself over long periods were present in the fertile river valleys of the Nile, the Indus, and the Yangtze. With trade, migration, and wars, smallpox emerged periodically from these endemic centers to devastate more distant populations. In the newly infected areas, many would die; the survivors would be immune, and the number of susceptible people would steadily decrease until the virus could no longer be transmitted. It would die out, sometimes for many years.

Accounts of epidemics during Greek and Roman times are sparse, but two are of special interest. The first is described as the "Plague of Athens," which began in 430 BCE and continued for two or three years, killing one-fourth of the Athenian army and significant numbers in the city. The illness was characterized by a rash of small blisters or sores, with death occurring on about the seventh to ninth day. A later series of disease epidemics, described by the Greek physician Galen, was known as the "Plague of Antonius." This devastation struck the Roman Empire in 164 CE and persisted for fifteen years-reportedly killing up to two thousand victims daily in Rome during its peak periods and causing the deaths of between three and seven million people before it ended.

The lack of adequate descriptions of the early epidemics makes it impossible to state with certainty that they were due to smallpox. Historians have speculated about other possible causes, but the events, to the extent we know them, are consistent with epidemic smallpox.

There were no other population centers in Europe comparable to those around Athens and Rome at the time of those two great plagues, and there is not much early information about European smallpox epidemics. However, we know that in 451 CE, Hun invaders beheaded the bishop of Rheims-who was reported to have recovered from smallpox the preceding year. He was henceforth known as St. Nicaise, the patron saint of smallpox. At about this time, the Huns were compelled to retreat from Gaul and Italy because of famine and epidemics of what may have been smallpox.

SMALLPOX BECOMES ENDEMIC

As the world's population grew and spread, smallpox became endemic in many new areas. By the tenth century, the disease was an unwelcome fixture around urban areas in China, India, and Japan, in areas of southwest Asia, and along the Mediterranean coast. Traders and armies from these areas regularly carried the disease with them. This caused extensive outbreaks in more distant settlements, but then, starved of new victims, the disease would disappear from these outposts for decades. The full impact of smallpox on new, unprotected territories was particularly devastating. For example: in 1241, when smallpox first came to Iceland, 20,000 of the country's 70,000 people died.

Europe's population grew steadily from about 26 million in the eighth century to 80 million at the beginning of the fourteenth century-until 1346, when the Black Plague struck. This plague, caused by the bacterium Yersinia pestis, is transmitted by fleas; it wiped out between one-quarter and one-third of the population. Smallpox continued to recur. By the sixteenth century, it was well established throughout Europe, including France, Spain, Portugal, Britain, and the Netherlands-countries actively exploring the "New World" and developing colonial empires. Smallpox killed peasants and royalty alike. It supplanted plague, typhus, leprosy, and syphilis as the foremost pestilence. According to London's Bills of Mortality, which date from the mid-1600s, smallpox accounted for about 10 percent of all deaths, many of which occurred in royal families. This caused significant changes in succession to European thrones. Among those who died were Mary II of England, the last of the Tudors; Emperor Joseph I of Austria; King Luis I of Spain; Tsar Peter II of Russia; Queen Ulrika Eleonora of Sweden; and King Louis XV of France.

By the time vaccination was introduced in the early 1800s, smallpox was causing the deaths of 400,000 Europeans each year (not including those in Russia). At that time, one-third of all cases of blindness in Europe were being caused by smallpox. Separate accounts from Russia, France, and Sweden reported that at least 10 percent of all infants died each year of smallpox.

In Asia, smallpox became endemic in much of China, as well as in Burma, Siam, Japan, the Philippines, and Indonesia. Records indicate that smallpox supplanted all other pestilential diseases.

Sub-Saharan Africa was more sparsely populated than Asia or Europe, but by the twelfth century, traders from North Africa and India were regularly bringing smallpox to coastal areas. By the sixteenth century, smallpox was prevalent in tribal groups across Africa.

The only significant areas to escape smallpox were Australia, New Zealand, and the islands of the Pacific, where there were comparatively few people and contact with the endemic areas was minimal.

(Continues...)



Excerpted from SMALLPOX THE DEATH OF A DISEASE by D. A. Henderson Copyright © 2009 by D. A. Henderson. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Contents

Foreword by Richard Preston....................11
Preface....................19
CHAPTER 1. THE DISEASE, THE VIRUS, AND ITS HISTORY....................31
CHAPTER 2. THE WORLD DECIDES TO ERADICATE SMALLPOX....................57
CHAPTER 3. CREATING A GLOBAL PROGRAM....................79
CHAPTER 4. WHERE TO BEGIN? A TALE OF TWO COUNTRIES-BRAZIL AND INDONESIA....................107
CHAPTER 5. AFRICA-A FORMIDABLE AND COMPLICATED CHALLENGE....................129
CHAPTER 6. INDIA AND NEPAL-A NATURAL HOME OF ENDEMIC SMALLPOX....................157
CHAPTER 7. AFGHANISTAN, PAKISTAN, AND BANGLADESH-THE LAST STRONGHOLD OF VARIOLA MAJOR....................187
CHAPTER 8. ETHIOPIA AND SOMALIA-THE LAST COUNTRIES WITH SMALLPOX....................213
CHAPTER 9. SMALLPOX-POST-ERADICATION....................241
CHAPTER 10. SMALLPOX AS A BIOLOGICAL WEAPON....................269
CHAPTER 11. LESSONS AND LEGACIES OF SMALLPOX ERADICATION....................301
Acknowledgments....................313
Sources....................315
Index....................321
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