Smallpox: The Rise and Decline of a Deadly Plague Is there something smallpox can teach us about living with contagion?

Smallpox: The Death of a Disease

By D. A. Henderson, MD (2009, Prometheus Books) 334 pages including index, sources, photos, maps, and statistical charts

Editor’s note: This review originally appeared in a 2011 issue of Belles Lettres.

 

Movie of the plague year

In 1950, Hollywood released a generally unimpressive film noir called The Killer That Stalked New York starring Evelyn Keyes, best known for her role as Scarlett O’Hara’s younger sister in the 1939 epic Gone With the Wind. (She wrote an autobiography called—what else—Scarlett O’Hara’s Younger Sister, published in 1977.)¹ It also starred Charles Colvin playing his usual two-timing scoundrel part, and a young Lola Albright before she achieved fame as the nightclub girlfriend of TV detective Peter Gunn. The plot partly revolves around Keyes, a jazz singer, who smuggles a diamond from Cuba for her husband, Colvin, who is two-timing Keyes by making doe-eyes with her sister, Albright, who winds up committing suicide. Draped over this rather standard noir situation is a story of a smallpox epidemic. Keyes unknowingly has smallpox and is spreading it all over the city as the health authorities try to hunt her down in a race against time. (A similar noir was released the same year, Elia Kazan’s Panic in the Streets with Richard Widmark as a public health doctor trying to track down criminal Jack Palance who has pneumonic plague.) The Killer That Stalked New York, which makes a point of the fact that it is taking place in 1947, was inspired by a real story.

Six million New Yorkers were vaccinated against smallpox in the spring of 1947, an enormous accomplishment by the local public health service employees and hospital personnel as shots were given around the clock to prevent an epidemic.

On February 24, 1947, Eugene Le Bar began a bus trip from Mexico City that would take him to New York. By March 1, when he arrives in New York he was not feeling very well but went sightseeing nonetheless, coming in contact with lots of people. On March 10, he died in Willard Parker hospital from the rare but extremely deadly hemorrhagic smallpox. Only five percent of smallpox cases take this intensely virulent form, so it is not surprising that Le Bar’s case was originally misdiagnosed. Overall, twelve persons were infected with traditional, not hemorrhagic, smallpox (with a much higher survival rate) from Le Bar’s ring of contacts; two died. The infection rate was low because New York embarked on a mass vaccination effort to prevent the spread of the disease. Six million New Yorkers were vaccinated against smallpox in the spring of 1947, an enormous accomplishment by the local public health service employees and hospital personnel as shots were given around the clock to prevent an epidemic.

This was the other story that The Killer That Stalked New York dramatized, much in keeping with many Hollywood documentary-style and crime films of the day that advocated public trust of trained experts, government employees and, indeed, the government itself. In effect, the film is, in part, the story of how smallpox was eradicated in New York. (The last smallpox outbreak in the United States occurred in Texas in 1949 where eight persons were affected; one died.) D. A. Henderson’s book, Smallpox: The Death of a Disease, is the story of how this dreaded disease was eradicated from the world.

 

Smallpox and how we eradicated it

The standard case of smallpox is caused by a virus called Variola major. Victims show no symptoms or ill effect for the first eight or nine days of infection. After the ninth day, they develop fever, chills, severe headache, body pain, and a rash that becomes a mass of horrible-looking pustules that cover the entire body including the soles of the feet, the scalp, and even inside the throat. There is no treatment for this disease. Typically, 30 percent of the victims of Variola major die. (The exception to this death rate was among the Amerindians of the New World—Aztecs, Mayas, and Incas—who encountered Europeans in the 16th century. They died from smallpox at a rate from 50 to 80, even 90 percent, although it killed the European settler population at the 30 percent rate. Both Indians and Europeans were infected with the same virus. Henderson offers this explanation, “Amerindian ancestors are believed to have crossed to the Americas from Asia about 25,000 years ago. Thus, it is quite possible that none had ever encountered the smallpox virus, which would not have begun spreading among humans until after the establishment of the first agricultural settlements, 10,000 years later.” All other races of people afflicted with Variola major die at the 30 percent rate.) This means that the odds are in a person’s favor to survive the disease but not without costs—usually a survivor has disfiguring scars as a result of the pustules scabbing over and the scabs dropping off. Some are left blind. Variola major was one of the scourges of the planet before any sort of vaccine was found, afflicting people from Queen Elizabeth I to Ramses V. A milder form of smallpox, Variola minor, began to appear in the latter part of the 19th century, something a bit more severe than chicken pox but with a death rate of about one percent. It is believed that this is the form of smallpox that stricken Abraham Lincoln at the time of his Gettysburg Address, although that would predate the arrival of the disease in America by 30 years. It also complicates the explanation of the death of Lincoln’s valet, William Johnson, who developed smallpox right after Lincoln and died. It is almost a certainty that Johnson had Variola major, not minor. Many of the cases in the world, in some places, most of the cases, at the time of the eradication movement of the 1960s was Variola minor, not major. Smallpox infects only humans.

A milder form of smallpox, Variola minor, began to appear in the latter part of the 19th century, something a bit more severe than chicken pox but with a death rate of about one percent. It is believed that this is the form of smallpox that stricken Abraham Lincoln at the time of his Gettysburg Address, although that would predate the arrival of the disease in America by 30 years.

The first form of inoculation against smallpox was variolation, which Henderson describes as “deliberately infecting an individual with the smallpox virus by inserting or rubbing pulverized smallpox scabs or pus into superficial scratches in the skin. Ideally, this resulted in a localized smallpox infection.” And subsequent immunity as someone who survives smallpox will never get it again. However, in many instances, variolation resulted in people getting full-blown smallpox. Another drawback was the fact that variolated persons were contagious and could spread full-blown smallpox to others, even if they did not develop full-blown smallpox themselves. Nonetheless, variolation was worth the risk as the death rate from it was much lower than that of Variola major. Puritan divine Cotton Mather introduced variolation to America in the 18th century, a technique he said he learned from an African slave. It was not without controversy and Mather was roundly condemned in some circles for practicing “heathen” medicine and trying to thwart the will of God by preventing people from getting the disease.

In 1796, Dr. Edward Jenner discovered an effective smallpox inoculation derived from cowpox, calling it Variola vaccinae, from which came the word vaccination. It was introduced in the United States in 1800. Cowpox, introduced to the human body, produces the same antibodies as if the person had been infected with smallpox but cowpox was otherwise benign. It was until the 1950s, when the vaccine could be freeze-dried to withstand great heat and thus be viable in parts of the world where there was little refrigeration, that the world could seriously think about eradicating smallpox.

Smallpox: The Death of a Disease is the story of heroes: various overworked epidemiologists from Europe, Asia, South America, Africa, and North America, traveling from country to country to head up vaccination teams and to keep records on new outbreaks, local medical staffs and teams of native workers and Peace Corp volunteers who traveled to some of the most remote and inhospitable places on the globe to vaccinate people.

D. A. Henderson, who worked as an epidemiologist for the Epidemic Intelligence Service, part of the then-modest Center for Disease Control and the United States Public Health Service, was selected in 1966 to head the global Smallpox Eradication Program. Not everyone believed that smallpox could be eradicated. At the time, the Soviet Union was much more supportive of the effort than the United States which had invested heavily in eradicating malaria, an effort that did not succeed. It seemed unthinkable to many scientists: smallpox was spread all over the globe, particularly in poor countries that had inadequate health staffs, poor roads, many isolated villages, great amounts of illiteracy, and unstable, often corrupt, governments. How could one get all of these people vaccinated? But smallpox had many features that made eradication possible, especially with the development of the freeze-dried vaccine. As Henderson writes: “Most important was that humans were the only victims of the smallpox virus; there was no reservoir in nature. No rodents, monkeys, or other animals could be infected. Each person who was infected exhibited a rash that could be identified even by illiterate villagers. No laboratory tests were required. If patients were promptly isolated, they could be prevented from spreading infection. By contrast, most infectious agents (for example, polio, tuberculosis, hepatitis) cause many sub-clinical infections as the disease spreads silently in a population. Moreover, a patient could infect others only during the two to three weeks of severe illness; on recovery, the person was immune for life.” Greater improvements in the delivery system for the vaccine, first, with jet-injector guns and then the bifurcated needle (pictured on the book’s dust jacket) made the possibility of eradication even better because it took little skill or training to vaccinate someone.

Smallpox: The Death of a Disease is the story of heroes: various overworked epidemiologists from Europe, Asia, South America, Africa, and North America, traveling from country to country to head up vaccination teams and to keep records on new outbreaks, local medical staffs and teams of native workers and Peace Corp volunteers who traveled to some of the most remote and inhospitable places on the globe to vaccinate people. Henderson and his small staff of administrators organized this great network of people who went into the field. The eradication program was always underfunded, encountered numerous obstacles from obstructionist, incompetent governments to floods, civil wars, famines, and droughts. It is a story that makes one believe that human beings are worth believing in.

In 1796, Dr. Edward Jenner discovered an effective smallpox inoculation derived from cowpox, calling it Variola vaccinae, from which came the word vaccination.

The book ends with a consideration of where we are now: smallpox still exists in laboratories in Russia and the United States and perhaps other places. The United States is adamant that it will not destroy its stock of the smallpox virus but cannot make a good case to justify keeping it other than fear that the Russians have it. (The United States was especially opposed to destroying the virus when it learned that the Russians had removed their stockpile to a biological weapons facility.) Henderson has been disappointed and frustrated by the unwillingness of Russia and the United States to destroy their stockpile of the virus. There is also the fear, because the virus still exists in vials in labs, that a terrorist could unleash it in a biological attack. Spread enough of it around so that you could infect, say, 2,000 people in the United States with Variola major and you can count on killing 600, a very good body count for a terrorist. (Moreover, suppose someone could whip up a more virulent strain of the virus!) And you could infect possibly infect a few thousand people because hardly anyone in the United States is vaccinated against smallpox anymore. Infecting a mere 600 would get you about 200 dead. So, the heroic story ends on a sobering note. Alas, human beings can never quite live up to the nobility that they possess.

¹ Keyes hardly mentions The Killer That Stalked New York in his autobiography except to ask if Columbia studio head Harry Cohn’s desire to cast her in it as well as an earlier picture where she played a deaf social worker was “a subtle scheme to set up a defective image to turn off my following.”

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