Follow this link to read Chapter 3
1966: goodbye to death, blindness and pockmarks
Variola, the Latin name for smallpox, means spotted. People who survived smallpox were instantly recognisable. Their faces and sometimes their bodies were pitted and rasped by tiny, crowded scars. If you look at old movies – black and white and arthouse movies of the 1940s and 1950s in particular – you sometimes see faces scarred by pockmarks. These belong, usually, to the villain’s henchmen: it helped, if you had to play one of the sinister, to be disfigured. Variola is a unique disease: unique in that science can name, very precisely, the first known sufferer, and also the very last case of endemic or naturally-spread infection. The very earliest identified case was in Egypt in 1157 BC, and afflicted Ramses V, Son of Re, Pharaoh, Lord of Two Lands, Mighty Bull, Repulse of Millions, King of Upper and Lower Egypt, Golden Horus and possessor of yet a few more exalted titles. His wrapped and mummified body was found in 1898: doctors who examined the withered and dusty remains confirmed that he died at around 40 of an acute illness, and in 1979, experts permitted to examine the body from the waist up found it pitted with a ‘quite striking’ rash of blisters and pustules ‘remarkably similar to smallpox’. No virus could be identified in the fragments they were permitted to study, and tissue could not be removed for further examination, so the diagnosis remains provisional. But it remains the best judgement so far. The disease is at least as old as civilisation: a periodic contagion that brought intense suffering, blindness and high rates of death wherever it appeared. In the first three-quarters of the 20th century alone, smallpox killed between 400 and 500 million people, mostly in the poorest parts of the world. In 18th century Europe, the disease claimed an estimated 400,000 lives a year, and among these were five reigning monarchs. The most astonishing feature of the World Health Organisation’s decision to eradicate smallpox completely and forever was not its hubris, but its puny resources. It planned to wipe out one of the most terrible and indiscriminate afflictions ever known with a headquarters staff of nine, a maximum of 150 agents visiting and working in more than 180 countries and an annual budget of $2.7 million. It planned to do so in spite of a bitter stand-off between the Soviet Union and the western powers; under the auspices of an international organisation from which a quarter of the planet was excluded (because China was not a member of the WHO); in spite of a series of horrendous wars in Indo-China and bloody power struggles in colonial and post-colonial Africa, in spite of famines and sustained suffering in China and India; in spite of obstructive, heedless and ignorant governance, not just in the poorest nations, but sometimes in the wealthy world. It set about the challenge in a world in which telephones were still rare, in which telephone lines and international links were precarious and in which computer communication did not exist; in which medical services in most countries had no centralised system of information; in which many governments learned of outbreaks of cholera, bubonic plague, smallpox or other epidemic diseases only when large numbers of people were already dead, and cases had begun to appear in the capital cities; in which most people in the world lived in small villages often far from the paved roads; in which most people in the world had no regular contacts with clinics or surgeries; in which most governments had no records of people, let alone their diseases.
So to achieve eradication, the nine officials at the offices in Geneva and the 150 workers in the field had first to persuade national governments to manufacture, store and distribute vaccines; be prepared to respond to cases of an affliction that many governments and their citizens still regarded as a normal hazard, like bad weather, or late trains, or even more unhelpfully, a scourge sent by God; and – most difficult of all – to set up a nationwide system of disease surveillance and swift medical alerts. This is now considered a normal function of an effective state. But in 1966, it was for many a new idea: even in federal America, a national system of centres for disease control was only 20 years old. The second and most profound challenge involved strategy. A budget of $2.7 million could not possibly finance the supply of vaccines; there was no way to be sure of vaccinating all the people in the world; and finally the vaccines were only temporarily effective. Ten years after immunisation, a traveller – and to prevent the spread of contagion many countries imposed travel restrictions on medical grounds – had to be vaccinated again; and to cross national borders had to produce a document that recorded that his or her vaccination was up to date. So the challenge to actually remove an invisible, ubiquitous menace from a crowded world was a pretty scary one. In 1965, the World Health Organisation was presented with a set of bleak facts. One was that, in six years, only 12 countries had eradicated smallpox. Another was that in many countries there were health problems more urgent than smallpox. To conduct a campaign with any chance of success, there would have to be huge quantities of vaccine – freeze-dried and stable at atmospheric temperatures – as well as refrigeration, transport and an army of consultants. And it would cost $80 million dollars to supply vaccines for all those countries where smallpox was endemic – and that did not include Red China, which was not a WHO member.
According to Donald Henderson, one of the architects of the campaign that eliminated smallpox, even the director of the WHO was against the decision: he recalls – in a WHO publication – that the war against malaria was not succeeding, why invite another perceived failure? The sums of money available for the project wouldn’t even pay for the vaccines; most countries did not routinely collect reports of cases of smallpox; the WHO could not even arrive at a reliable count of those countries in which smallpox was endemic, because reporting was so poor. On the other hand, there were reasons why the campaign might succeed. One was that – unlike poliomyelitis – you could be sure about identification. As many as 200 people could be carrying the polio virus, but only one might develop paralysis, leaving the other 199 free to spread infection. Smallpox, however, was characterised by a distinctive rash: no mistaking that when you saw it. The polio vaccine was expensive; several doses were required and even then it might not work. Smallpox could be countered, for a decade at least, with a single immunisation. The polio virus had to be kept chilled and handled with care – in the tropical rainforests, in the impoverished shanty towns, in the arid lands of the Sahel – right up till the moment of treatment. The smallpox vaccine could survive at body temperature for at least a month and still work. Above all, when the smallpox team threw its resources at a particular outbreak in an identifiable place, they proved they could stop it. In eastern Nigeria, a WHO team identified an outbreak in 1966: they had little in the way of vaccines or transport, so they tried a new approach: they would just vaccinate in the area of the outbreaks. There were 12 million potential victims: the WHO team were able only to vaccinate 750,000. But these were the 750,000 in the pathway of the transmission, and because the virus had no new hosts to colonise, its progress was stopped. There were no more cases. Using the same approach, an outbreak in Tamil Nadu, in India – a region home to 50 million people – was stopped. A strategy emerged: find the cases promptly, get there quickly, surround the place, vaccinate everybody, and that would be the end of the local epidemic. Unexpectedly, WHO teams reported cooperation even during civil wars and international conflict. By 1973, the disease was gone from Latin America, Indonesia and most of Africa except Ethiopia.
‘The problem was in India, where we were simply not succeeding. So in late 1973, WHO and Indian government staff worked out a plan to visit every house in India in the space of 7–10 days. The concept was that if we could discover the cases more quickly than before, the containment teams could interrupt the chains of transmission,’ Henderson remembered.
‘The results were astounding. One state had been reporting about 500 cases a week, but the search teams found 10,000 cases. This was really a black day. We had no idea it was this bad. But in January and February, searches were steadily improving. India reported the largest number of cases in about 20 years. However, we sensed that we were successfully implementing the right strategy and, if we could defeat the disease in India, we could defeat it in Bangladesh, Pakistan and Ethiopia. And indeed the last case in India occurred little more than a year later.’
Just as historians have a named victim for the earliest identifiable case of smallpox –
Ramses V in 1157 BC – so there is an unassailable identity for the last known case of endemic smallpox. The last case is known with very great certainty. He was called Ali Maow Maalin, he was 23 and a cook in a hospital in Merca in southern Somalia. He had been immunised, but the immunisation had not ‘taken’: his case had not been checked. In October 1977, he had been asked to pick up two cases of smallpox and bring them to the hospital. He drove them in a Land Cruiser with the windows closed and the air conditioning in operation. He was probably exposed to infection for about five minutes. That was enough. When he fell ill with a fever and a rash, his hospital colleagues thought that – because there was a record of his inoculation – he must have chickenpox, and he was sent home. It was a visitor who reported his case to the Mogadishu health authorities as suspected smallpox. The national smallpox eradication programme team – by then they existed in every country where smallpox was endemic – rushed to the spot and established checkpoints at all entrances and exits to the town and immunised everybody not recently treated. They identified 161 possible contacts and close family members and kept them under surveillance. The team kept expecting to hear of fresh outbreaks, but there were none. There were none after that case, anywhere in the world. Ali Maow Maalin recovered, and entered the history books as the last case of random infection by smallpox. A human scourge known for more than 3,000 years had been obliterated. Smallpox is not quite gone: samples of the virus went into secure keeping, but were never destroyed, partly because, during the cold war, both sides were prepared at least to contemplate biological warfare; and because, after the end of the cold war, there were fresh fears of biological terrorism. The fears still exist. For the moment, however, an old terror has been obliterated, thanks to an unusual moment in history when enough people believed in the power of science, and the authority of sane government, to make it possible.
If you would like to read the Science that Changed the World in full now, you can purchase the ebook via the links on the Guardian Shorts website, prices from £1.99.
