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Wellcome History 46

Wellcome History 46

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Published by Wellcome Trust
Wellcome History is published three times a year: in spring (March/April), summer (July/August) and winter (November/ December).
Wellcome History is published three times a year: in spring (March/April), summer (July/August) and winter (November/ December).

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Published by: Wellcome Trust on Feb 29, 2012
Copyright:Attribution Non-commercial


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Zaire, smallpox ears and the WHO’s surveillance programme,1980–86
Issue 46, spring 2011
n May 1980, the WHO certied theglobal eradication o smallpox.In recent years, historianshave examined more closely thedierence between the public andprivate, published and unpublished,accounts o the eradication, and thediscrepancies can be revealing.Beneath the triumphant languageo the historic declaration lies evidenceo considerable scientic uncertaintyand ear that variola virus might yetlurk in some remote corner o theglobe, or that a closely related virus –monkeypox – might mutate into thevery scourge the WHO had struggledto eliminate. With this in mind, the WHO Smallpox Eradication Unitconducted a broad and intensivemonkeypox surveillance programmein central and western Arica rom1980 to 1986. An examination o unpublished papers in the WHOsmallpox eradication programmearchives in Geneva suggests that the WHO’s motives with regard to themonkeypox programme were morecomplex than generally acknowledged.Years beore the intensivemonkeypox research programme, WHO researchers had acknowledgedrepeatedly that monkeypox virus,in and o itsel, was unlikely ever tobecome a major public health threat.Instead, the WHO’s commitment tothe research was a result o the virus’sclinical and laboratory similarities tovariola virus; the interest in monkeypoxnaturally intensied as the smallpoxeradication programme drew to a close.Monkeypox virus and variolaare both members o the genusorthopoxvirus, although theirepidemiological eatures dier; itwas generally accepted that, unlikesmallpox, monkeypox had ananimal (not human) reservoir. Inhumans, monkeypox was virtuallyindistinguishable rom smallpoxinection, with a similar clinical courseo ever and pustular rash. And in the1970s, Soviet scientists even suggestedthat a variant o monkeypox, dubbed‘whitepox’, was identical to variola.In contrast to the optimisticlanguage o the smallpox eradicationannouncement, WHO scienticworking papers rom 1978–79 revealears that smallpox might return,rom either an animal reservoir orthe mutation o monkeypox. Justmonths beore the 1980 declaration,the Global Commission or theCertication o Smallpox Eradicationrecommended that the WHO giveurgent priority to the Soviet whitepoxndings. This and the subsequentresearch and surveillance activitiesdemonstrate the ears that monkeypoxwas a threat to the success o smallpoxeradication. The need or an ‘insurancepolicy’ against unexpected poxviruswould be a amiliar theme in WHOplans or a dedicated programme o monkeypox surveillance and research.In 1979, the Smallpox EradicationUnit proposed monkeypox surveillanceand research activities notable ortheir extraordinary depth and breadth.Objectives included: a more precisedenition o human monkeypoxrequency, transmissibility andgeographic distribution; determinationo the monkeypox virus reservoirand ecology; and ascertainment o whitepox virus prevalence as well asother animal orthopoxviruses thatmight cause human disease in westand central Arica. The proposedtarget countries included Zaire(as was), Nigeria, Cameroon, IvoryCoast, Liberia, Sudan and Malaysia.The scope o the monkeypoxprogramme attracted private criticismrom smallpox eradication veterans,including Dr Donald A Henderson,who was director o the smallpoxeradication programme during thecrucial years 1966–77. Medical andscientic researchers with experiencein central Arica had reservations,too, about the complex technicaland logistical challenges inherent
 An ‘insurance policy’ orsmallpox eradication
Feature: The World Health Organization’smonkeypox surveillance programme, 1980–86
Robin Fawcett 
WHO headquarters in Geneva.
Wellcome Library 
Cover image: The monkeypox programme centred on centraland western Arica, particularly Zaire.
SPRING 2011 | 3
in the proposed eld activities.The participation o local healthauthorities, particularly in Zaire, wasquestioned, as was the conservativeestimate o costs. Furthermore, animmense backlog o sera at the USCDC rom suspected smallpox caseswould mean long delays or theprocessing o animal sera and tissuesamples rom monkeypox ecologicalsurveys, and the monkeypox-specicantibody testing available at that timewas unreliable. Nevertheless, by May1980, the monkeypox surveillanceprogramme was well underway.
Operational complexitiesabounded, and there wasconict between Genevaand teams in the eld 
The monkeypox programmeoccupied an important place in the WHO agenda or more than veyears, led by some o the SmallpoxEradication Unit’s most experiencedocers. The activities covered alarge swathe o territory, with apopulation o more than 5 millionpeople. Nearly 300 cases o humanmonkeypox were detected, mostly inZaire, where the programme was mostactive. Surveillance there was mainlyhospital-based, targeted in rainorestregions. Serological surveillancewas also conducted in Zaire in areaswith the highest incidence o humanmonkeypox, mostly by collecting serarom children who had not receivedsmallpox vaccine. These eld studies, incombination with serological analysisand epidemiological research, wereconducted at great length and expense,despite considerable administrative,logistical and political challenges. Thecampaign itsel was characterised byrequent changes in research prioritiesand tactics, as the ecacy o particularstrategies, and their implementation indierent localities, was much debated.The response o Zaire’s citizens,local health ocials and governmentocers to the growing WHOpresence is not well documentedin the Geneva archives. The WHOdid make an eort in 1980–81 topersonalise the country-specicsurveillance programmes in western Arica. In Zaire, however, in keepingwith the WHO system establishedin the days o smallpox eradication,the leadership and organisation o the monkeypox programme werekept separate rom the Zairian publichealth programmes that providedboth nancial and personnel support.This caused operational challenges.The WHO surveillance protocolswere criticised by the Zaire publichealth service, or example, becausethey were incompatible withlong-established national healthmaintenance systems and containedhighly technical language unsuitableor the Zairian nursing sta to whomthe protocol was distributed.Operational complexities in Zaireabounded, and there was conict attimes between WHO administratorsin Geneva and the research teams inthe eld. Cooperation rom villagersand hunters was essential or theanimal serology surveys, but the Zairiancurrency requently experiencedmassive devaluation and was thereorenot useul or compensation. By 1985, WHO eld teams had adopted a ormo currency that was both practical andhighly eective: they paid villagers withshotgun cartridges. As correspondencebetween the eld teams and WHOheadquarters reveals, administratorswere shocked and disturbed to discovertheir researchers dealing in suchcontroversial material. The WHO eldocers were immediately instructedto use only local currency, much tothe dismay o the research team. While eld research in central andwest Arica struggled to get underway,scientic ears about whitepox viruswere being laid to rest. In late 1982,a breakthrough paper by Dr KeithDumbell, a British authority onvariola virus, discredited the Sovietwhitepox research. Dumbell comparedkey biological markers o variolastrains and demonstrated that cross-contamination o variola isolates inthe Soviet lab had been responsibleor the controversial ndings. WHOscientists have more recently suggestedthat Soviet interest in variola virusand monkeypox research may havebeen prompted in part by Sovieteorts to weaponise orthopoxviruses,and the whitepox ndings may havebeen deliberately abricated.Dumbell’s conclusions and thescientic community’s subsequentdismissal o the whitepox threat mark a major turning-point in the languageused by the WHO to justiy themonkeypox surveillance programme’sactivities. By 1983, WHO committeeworking papers reerred not to thethreat o smallpox recurrence butto helping Arican nations manageoutbreaks o human monkeypox.Tragically, it would be a dierent viralinection that would cause Arica’s nextpublic health crisis. In 1986, the WHOCommittee on Orthopoxvirus Inectionsdecided that the human monkeypoxprogramme should be discontinuedin light o the new research priority incentral and west Arica: HIV/AIDS.Sporadic cases o humanmonkeypox inection continuedin central and west Arica ater theconclusion o the active surveillanceprogramme. Signicant outbreaksoccurred in Zaire in 1996–97 andagain in 2001; extended inter-human transmission was notedin an outbreak in the Republic o the Congo in 2005. A cluster o monkeypox inections occurred in themidwestern USA in 2003, associatedwith exposure to inected prairiedogs; the outbreak was traced to theimportation o small mammals rom Arica. Today, many epidemiologistsand scientists consider monkeypoxa potential bioterrorism threat.The six-year mandate granted tothe WHO monkeypox surveillanceprogramme ollowing the globaleradication o smallpox provides abasis on which the condent rhetorico the eradication declaration can –and should – be questioned. Threedecades later, as we celebrate thismonumental achievement, the medicalworld remains wary o smallpox, bothas a disease and as a weapon. Thehistory o smallpox eradication, andits research politics and methods,remains contemporary and relevant.
Robin Fawcett MD MA was a postgraduate studentat the Wellcome Trust Centre or the History o Medicine at UCL and is now practising medicine inReston, Virginia, USA (
What is monkeypox? 
monkeys (hence the name), butmore common in rodents.
like smallpox – the two havesimilar symptoms in humans.
 Arica, but never a major killer.

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